NRSG 3420: Final Big Review

The nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for impaired tissue oxygenation resulting from hemorrhage. After 15 minutes of the transfusion, the nurse notes the client has a fever and shortness of breath. Place in order the steps the nurse should take in response to these findings. Use all options. A. Ensure the normal saline IV line is open B. Intervene for any signs and symptoms as appropriate C. Stop the transfusion D. Notify the physician E. Assess need for airway support F. Check full vital signs

Correct response: 1. Stop the transfusion 2. Ensure the normal saline IV line is open 3. Assess need for airway support 4. Check full vital signs 5. Notify the physician 6. Intervene for any signs and symptoms as appropriate Explanation: The client is experiencing an immunological transfusion reaction which will only become worse as the transfusion proceeds. The nurse's first action is to stop the transfusion. A normal saline line is always made available prior to commencing a transfusion of any blood product to promote flushing and allowing for the immediate administration of any IV medications that may be required to manage the signs and symptoms resulting from the transfusion reaction. Airway, circulation and breathing are a top priority in transfusion reactions. The client is experiencing shortness of breath which can progress to respiratory distress if not managed. The nurse must assess airway and work of breathing to determine if oxygen, repositioning or other respiratory interventions are required. The nurse must assess a full set of vital signs to determine other systemic effects caused by the transfusion. It is possible to see variations of vital signs such as hyper- and hypotension, tachycardia, fever and increased respiratory rate. Any change in the vital signs requires an intervention. This should be completed prior to contacting the physician as it is important to have this information readily available to collaborate with the physician for next steps in the client's care. The nurse must notify the physician to obtain any additional orders for interventions that may be individualized based on the client's overall clinical situation. The nurse is responsible for intervening for any other signs or symptoms such as administering antihistamines or antipyretic medications. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Fluid Replacement, p. 2165.

The nurse is evaluating the effectiveness of discharge teaching for a client with an oxalate urinary stone. Which statement by the client indicates the need for further teaching by the nurse? Select all that apply. A. "I need to take allopurinol." B. "Tylenol is best to control my pain." C. "I will never have another urinary stone again." D. "I need to drink eight to ten glasses of water every day." E. "I'm so glad I don't have to make any changes in my diet."

Correct response: A. "I need to take allopurinol." B. "Tylenol is best to control my pain." C. "I will never have another urinary stone again." E. "I'm so glad I don't have to make any changes in my diet." Explanation: Nonsteroidal anti-inflammatory drugs are used to treat renal stone pain. Oxalate-containing foods should be avoided. Fluid intake should total 2 to 3 liters, if not contraindicated. Allopurinol (Zyloprim) is prescribed for uric acid stones. Recurrence of stones occurs in about half of individuals. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Chart 55-12, p. 1633.

Hypertension is diagnosed when the client demonstrates a systolic blood pressure greater than ______ mm Hg or a diastolic blood pressure greater than _____ mm Hg over a sustained period. A. 130, 80 B. 120, 70 C. 140, 90 D. 110, 60

Correct response: A. 130, 80 Explanation: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 31: Assessment and Management of Patients With Hypertension, Hypertension, p. 885.

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

Correct response: A. Apply antiembolism stockings. B. Initiate passive exercises. C. Avoid elevating the knees on the bed. Explanation: Preventive measures used to prevent venous stasis include application of sequential pneumatic compression devices; discouraging crossing of legs; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; and beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 27: Management of Patients with Coronary Vascular Disorders, p. 787.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply. A. At bedtime B. When bronchospasms occur C. When secretions have mobilized D. Before meals E. After meals

Correct response: A. At bedtime D. Before meals Explanation: The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. It is important to perform chest physiotherapy before meals to prevent nausea, vomiting, and aspiration. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 519.

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. A. Minimize lights and noise disturbances B. Provide airway support and ventilation C. Apply warming blankets D. Follow the unit seizure protocol E. Administer antipsychotic medication

Correct response: A. Minimize lights and noise disturbances B. Provide airway support and ventilation D. Follow the unit seizure protocol E. Administer antipsychotic medication Explanation: Anticipated interventions for client who have experienced cardiovascular collapse secondary to overdose with methamphetamines include prioritizing airway support, ventilation, cardiac monitoring and intravenous access. The nurse should attempt to provide a calm environment that is as private as possible. Lights and noise disturbances should be kept to a minimum because external stimulation can produce overactivity and overstimulation. Due to the hallucinations and/or delusions that can be caused by the illicit substance overdose, the client may require antipsychotic medication such as haloperidol. Clients can experience seizures after illicit substance overdose and withdrawal. The nurse should anticipate the need to employ a seizure protocol in accordance with unit policy. Clients with methamphetamine overdoses experience hypertension and hyperthermia. Warming the client potentiates amphetamine toxicity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1 Emergency Management of Patients With Drug Overdose (continued), p. 2182.

A nurse is assessing a client who is suspected of having bronchiectasis. The nurse should consider which of the following potential causes? Select all that apply. A. Pulmonary infections B. Genetic disorders C. Atelectasis D. Pulmonary hypertension E. Airway obstruction

Correct response: A. Pulmonary infections B. Genetic disorders E. Airway obstruction Explanation: Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the new definition of COPD, it is considered a disease process separate from COPD. Bronchiectasis may be caused by a variety of conditions, including airway obstruction, diffuse airway injury, pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections, or genetic disorders such as cystic fibrosis. Bronchiectasis is not caused by pulmonary hypertension or atelectasis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Management of Patients with Chronic Pulmonary Disease, Bronchiectasis, p. 648.

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? A. Record the observation B. Report the finding to the physician immediately C. Measure the patient's pulse oximetry D. Apply a compression dressing to the area

Correct response: A. Record the observation Explanation: The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders, p. 631.

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. A. Red wine B. Exposure to flashing light C. Menstruation D. Prolonged positioning E. Change in environmental temperature F. Nausea

Correct response: A. Red wine B. Exposure to flashing light C. Menstruation Explanation: Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation), exposure to flashing light, and particular food/beverages and alcohol can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to changes in environmental temperature does not trigger a migraine headache. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 67: Management of Patients With Cerebrovascular Disorders, Migraine Headaches, p. 2006.

A client has been classified as status asthmaticus. The nurse understands that this client will likely initially exhibit symptoms of: A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

Correct response: A. Respiratory alkalosis Explanation: There is a reduced PaCO2 and initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Management of Patients with Chronic Pulmonary Disease, Assessment and Diagnostic Findings, p. 664.

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. A. Venous pooling B. Hypothermia C. Tachypnea D. Hypotension E. Tachycardia F. Diaphoresis

Correct response: A. Venous pooling B. Hypothermia C. Tachypnea D. Hypotension Explanation: The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Spinal and Neurogenic Shock, pp. 2053-2054.

What normal change due to aging does the nurse expect in the heart of an older client? A. Widening of the aorta B. Decreased connective tissue in the SA and AV nodes and bundle branches C. Thinning and flaccidity of the cardiac values D. Decreased left ventricular ejection time

Correct response: A. Widening of the aorta Explanation: Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection time (prolonged systole). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessment of Cardiovascular Function, Table 25-1, p. 679.

Nursing students are reviewing various procedures that can be used to obtain a tissue biopsy of the breast. They demonstrate understanding of the material when they identify which of the following as being done using local anesthesia and intravenous (IV) sedation? Select all that apply. A. Wire needle localization B. Stereotactic biopsy C. Excisional biopsy D. Fine-needle aspiration E. Core needle biopsy

Correct response: A. Wire needle localization C. Excisional biopsy Explanation: Surgical biopsies are usually performed using local anesthesia and IV sedation. Types of surgical biopsies include excisional biopsy and wire needle localization. Fine-needle aspiration, core needle biopsy, and stereotactic biopsy are examples of percutaneous biopsies. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Table 58-1, p. 1726.

The nurse is admitting a client who has been exposed to the botulinum toxin during a terrorist attack. What should the nurse include in the client's immediate interdisciplinary care? Select all that apply. A. Administration of immunoglobulins B. Administration of antitoxin C. Negative pressure isolation D. Respiratory support E. Positive pressure isolation

Correct response: B. Administration of antitoxin D. Respiratory support Explanation: There is an antitoxin for botulism poisoning, which often causes respiratory failure. Immunoglobulins do not affect the neurologic etiology of the infection. It is not communicable, so isolation is not a priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Table 73-5, p. 2205.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. A. Trauma B. Dehydration C. Vomiting D. Diarrhea E. Burns

Correct response: B. Dehydration E. Burns Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Chart 14-3, p. 308.

Positive client outcomes are the ultimate goal of nurse-client interactions, regardless of the particular setting. Which of the following factors has the most direct influence on positive health outcomes? A. Client's ethnic heritage B. Health education C. Outcome evaluation D. Client's age

Correct response: B. Health education Explanation: Health education is an influential factor directly related to positive client care outcomes. The other options are incorrect because ethnicity, the client's age, and outcome evaluation are less influential factors related to positive client care outcomes, though each factor should be considered when planning care. Outcomes should be evaluated, but this does not cause them to be successful, but rather identifies if they were achieved. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Introduction, p. 46.

The nurse is caring for a 12-year-old client. When teaching the client, what tone of teaching should the nurse implement? A. Serious B. Relevant C. Abstract D. Relatable

Correct response: B. Relevant Explanation: Teaching to an adolescent client should be fun and relevant. Teaching should not be abstract or serious. Being relatable may seem appropriate; however, an adolescent often does not feel like they can relate to an adult and teaching would not be as effective if this is what the nurse is basing teaching on. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, p. 58.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. A. institute vital signs every 4 hours B. administer pantoprazole IV daily C. monitor urine output every hour D. obtain a urine specimen for culture E. maintain the IV site inserted on admission

Correct response: B. administer pantoprazole IV daily C. monitor urine output every hour D. obtain a urine specimen for culture Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole (Protonix), would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 315.

The nursing profession and nurses as individuals have a responsibility to promote activities that foster well-being. What factor has most influenced nurses' abilities to play this vital role? A. Nurses possess a baccalaureate degree as the entry to practice. B. Nurses possess an authentic desire to help others. C. Nurses are seen as nurturing professionals. D. Nurses have long-established credibility with the public.

Correct response: D. Nurses have long-established credibility with the public. Explanation: Nurses, by virtue of their expertise in health and health care and their long-established credibility with consumers, play a vital role in health promotion. Nurses are not necessarily seen as nurturing and a baccalaureate entry to practice is not in place in all jurisdictions. Not every nurse has a genuine desire to help others. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Nursing Implications of Health Promotion, p. 58.

A nurse has been working with a client whose poorly controlled type 1 diabetes has led to numerous health problems. Over the past several years the client has had several admissions to the hospital medical unit, and the nurse has often carried out health promotion interventions. Who is ultimately responsible for maintaining and promoting this client's health? A. The community health nurse who has also worked with the client B. The medical nurse C. The client's primary care provider D. The client

Correct response: D. The client Explanation: Society places a great importance on health and the responsibility that each of us ultimately has to maintain and promote our own health. Therefore, the other options are incorrect, even though each actively participates in promoting the client's health. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Supporting Informed Decision Making and Self-Care, p. 47.

A recent nursing graduate is aware that the nursing scope of practice goes far beyond what is characterized as "bedside care." Which of the following is a nurse's primary responsibility? A. To encourage individuals' self-awareness B. To promote activities that enhance community cohesion C. To influence individuals' social interactions D. To promote activities that foster well-being

Correct response: D. To promote activities that foster well-being Explanation: As health care professionals, nurses have a responsibility to promote activities that foster well-being, self-actualization, and personal fulfillment. Nurses often promote activities that enhance the community and encourage self-awareness; however, they are not a nurse's central responsibility. As professionals, nurses do not actively seek to influence social interactions. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Nursing Implications of Health Promotion, p. 58.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as A. 18%. B. 36%. C. 9%. D. 27%.

Correct response: A. 18%. Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1848.

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps? A. Reassess pulses and neurovascular status B. Establish airway and start ventilation C. Start peripheral intravenous insertion and infusion of fluids D.Examine client for additional injuries to the body E. Application of pressure to control abdominal bleeding F. Assess for head and neck injuries

Correct response: 1. Establish airway and start ventilation 2. Application of pressure to control abdominal bleeding 3. Start peripheral intravenous insertion and infusion of fluids 4. Assess for head and neck injuries 5. Examine client for additional injuries to the body 6. Reassess pulses and neurovascular status Explanation: The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. Any injury interfering with a vital physiologic function (e.g., airway, breathing, circulation) is an immediate threat to life and has the highest priority for immediate treatment. Essential lifesaving procedures are performed simultaneously by the emergency team. Establishing the airway and performing ventilation is necessary to support airway and breathing. Hypovolemic shock is prevented by applying pressure to bleeding sites and initiating a peripheral IV and immediate start of infusion of intravenous fluids. As soon as the client is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. The physical assessment should prioritize head and neck injuries and then injuries over the rest of the body. Ongoing examination, assessment and diagnostic evaluation are necessary. The health care team will continue to assess vascular and neurological status as these can change quickly. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Multiple Trauma: Chart 72-5 Priority Management in Patients With Multiple Injuries, p. 2169.

A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options. A. Remove constricting clothing B. Clean the wound C. Have the patient lie down D. Cover the wound with a light sterile dressing E. Immobilize the injury below the level of the heart F. Provide warmth

Correct response: 1. Have the patient lie down 2. Remove constricting clothing 3. Provide warmth 4. Clean the wound 5. Cover the wound with a light sterile dressing 6. Immobilize the injury below the level of the heart Explanation: Initial first aid for a snake bite includes having the person lie down, removing constrictive items, providing warmth, cleaning the wound, covering the wound with a light and sterile dressing, and immobilizing the injured body part below the level of the heart. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Management, p. 2176.

The nurse is educating a client about allergy management at home. What client statements indicate no further teaching is required? Select all that apply. A. "I bought a wooden chair for my living room." B. "I picked out a new tufted bedspread for my bed." C. "I will vacuum my floors once a week." D. "I only let my dog sleep with me every other day." E. "I have pull shades on all of my windows."

Correct response: A. "I bought a wooden chair for my living room." E. "I have pull shades on all of my windows." Explanation: Using pull shades on windows and using steam for heating will help reduce environmental allergens such as dust. Rugs on floors will hold allergens in and floors need to be vacuumed every day. Dogs may bring allergens into the client's home, especially when in close proximity while sleeping. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, 37-5, p. 1073.

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply. A. "I will watch my urine output to be sure that the medication is not affecting my kidneys." B. "If I take my digoxin I should have limited episodes of shortness of breath." C. "Digoxin therapy requires monthly drug levels." D. "The digoxin will increase my appetite, so I should weight myself daily." E. "The medication will increase my heart rate and my blood pressure."

Correct response: A. "I will watch my urine output to be sure that the medication is not affecting my kidneys." B. "If I take my digoxin I should have limited episodes of shortness of breath." Explanation: Digoxin is excreted by the kidneys and causes renal failure, so the client should monitor urine output. Digoxin therapy will increase ventricular output, so it can be effective in decreasing heart failure symptoms like shortness of breath. Digoxin toxicity may can anorexia, not increased appetite. Digoxin therapy will slow AV conduction, not increase heart rate or blood pressure. A client taking digoxin therapy will have levels drawn if symptoms of toxicity or renal function changes are present. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 29: Management of Patients With Complications from Heart Disease, p. 826.

A client is diagnosed with polycystic ovarian syndrome. Which of the following findings would the nurse expect to assess? Select all that apply. A. Impaired glucose tolerance B. Hirsutism C. Menorrhagia D. Sleep apnea E. Emaciated appearance

Correct response: A. Impaired glucose tolerance B. Hirsutism D. Sleep apnea Explanation: Polycystic ovarian syndrome is associated with obesity, insulin resistance, impaired glucose tolerance, dyslipidemia, sleep apnea, and infertility. In addition, menstrual periods may be irregular. Menorrhagia (excessive bleeding) is more commonly associated with fibroids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Ovarian Cysts, p. 1703.

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply. A. Administer diphenhydramine. B. Give intravenous fluids. C. Check for hematuria. D. Ask the client if they are lightheaded. E. Prepare for insertion of an endotracheal tube. F. Give metoprolol.

Correct response: A. Administer diphenhydramine. B. Give intravenous fluids. D. Ask the client if they are lightheaded. E. Prepare for insertion of an endotracheal tube. Explanation: Diphenhydramine would be administered because it reverses the effect of histamine. Lightheadedness is a symptom of anaphylactic shock. Intravenous fluids will be given to treat hypotension. Metoprolol is used to treat hypertension or chest pain. An endotracheal tube would be inserted if a respiratory arrest is imminent. Hematuria would be seen in urinary problems, such as bladder or kidney stones, enlarged prostate, kidney infection or urinary tract infection. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Basic Physical Care.

A nurse is teaching a client about bronchodilators. What bronchodilator actions that relieve bronchospasm should the nurse include in the client teaching? Select all that apply. A. Alter smooth muscle tone B. Increase oxygen distribution C. Decrease alveolar ventilation D. Reduce airway obstruction E. Reduce inflammation

Correct response: A. Alter smooth muscle tone B. Increase oxygen distribution D. Reduce airway obstruction Explanation: Bronchodilators relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation. Inflammation would be reduced by corticosteroids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Management of Patients with Chronic Pulmonary Disease, Bronchodilators, p. 640.

A public health nurse reviews data on chronic illness in the community over time and notes that chronic illness rates are climbing. Which factors may contribute to the increased chronic illness rates? Select all that apply. A. An increase in obesity rates B. A decrease in mortality from infectious diseases C. A decrease in global awareness of chronic illness D. An increase in infectious disease rates E. A decrease in client education regarding chronic illness

Correct response: A. An increase in obesity rates B. A decrease in mortality from infectious diseases Explanation: Chronic illness rates are climbing due in part that there is a decrease in mortality from infectious diseases and an increase in obesity rates. There is not an increase in infectious disease rates, a decrease in client education about chronic illness, or a decrease in global awareness of chronic illness. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 9: Chronic Illness and Disability, p. 143.

The nurse is assessing a patient upon admission to the hospital. What significant nursing assessment data is relevant to renal function? Select all that apply. A. Any voiding disorders B. The presence of hypertension or diabetes C. The patient's financial status D. The ability of the patient to manage activities of daily living E. The patient's occupation

Correct response: A. Any voiding disorders B. The presence of hypertension or diabetes E. The patient's occupation Explanation: When obtaining the health history, the nurse should inquire about the following: dysuria (painful or difficult urination), as well as when during voiding (i.e., at initiation or at termination of voiding) this occurs; occupational, recreational, or environmental exposure to chemicals (plastics, pitch, tar, rubber); hypertension; or diabetes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Table 53-1, p. 1555.

The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply. A. Arterial occlusion B. Bleeding at the insertion site C. Retroperitoneal bleeding D. Abrupt closure of the coronary artery E. Venous insufficiency

Correct response: A. Arterial occlusion B. Bleeding at the insertion site C. Retroperitoneal bleeding D. Abrupt closure of the coronary artery Explanation: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute kidney injury. Venous insufficiency is not a postprocedure complication of a PTCA. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 27: Management of Patients with Coronary Vascular Disorders, Complications, p. 772.

A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Body mass index B. Weight history C. White blood cell count D. Serum albumin level E. Blood urea nitrogen (BUN) level

Correct response: A. Body mass index B. Weight history D. Serum albumin level E. Blood urea nitrogen (BUN) level Explanation: Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the client's ability to purchase and prepare food is assessed. Weight history (i.e., changes over time); anthropometric measurements; and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status. White cell count is not a typical component of a nutritional assessment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Nutritional Status, p. 1043.

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply. A. Increases lean muscle mass B. Decreases the levels of high-density lipoproteins C. Decreases total cholesterol D. Increases resting metabolic rate as muscle size increases E. Increases glucose uptake by body muscles

Correct response: A. Increases lean muscle mass C. Decreases total cholesterol D. Increases resting metabolic rate as muscle size increases E. Increases glucose uptake by body muscles Explanation: All of the options are benefits of exercise except the effect of decreasing the levels of HDL. Exercise increases the levels of HDL. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 51: Assessment and Management of Patients With Diabetes, Exercise, p. 1465.

A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply. A. Check for low back pain. B. Dispose of the blood container and tubing. C. Notify the health care provider. D. Discontinue the intravenous line the blood was transfusing through. E. Assess for anxiety and mental status changes.

Correct response: A. Check for low back pain. C. Notify the health care provider. E. Assess for anxiety and mental status changes. Explanation: The intravenous line is needed to give fluids and medications through. The blood container and tubing need to be sent back to the blood bank for repeat typing and culture. Low back pain is a symptom of acute hemolytic reaction. Anxiety and mental status changes are symptoms of acute hemolytic reaction. The health care provider needs to be notified because he/she may need to see the client and order further treatments. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Basic Physical Care.

A group of nursing students have been asked to break into groups of four and complete a health-promotion teaching project and present a report to their fellow students. What project most clearly demonstrates the principles of health promotion teaching? A. Discussing the importance of preventing sexually transmitted infections (STI) to a group of high school students B. Demonstrating an injection technique to a client for anticoagulant therapy C. Instructing an adolescent client about safe and nutritious food preparation D. Explaining the side effects of a medication to an adult client

Correct response: A. Discussing the importance of preventing sexually transmitted infections (STI) to a group of high school students Explanation: Health promotion encourages people to live a healthy lifestyle and to achieve a high level of wellness. Discussing the importance of STI prevention to a group of high school students is the best example of a health promotion teaching project. This proactive intervention is a more precise example of health promotion than the other cited examples. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Health Promotion, p. 53.

A nurse is working with a client who has recently received a diagnosis of human immunodeficiency virus (HIV). When performing client education during discharge planning, what goal should the nurse prioritize? A. Encourage the client to adhere to his therapeutic regimen. B. Encourage the client to exercise within his limitations. C. Encourage a disease-free state. D. Appraise the client's level of nutritional awareness.

Correct response: A. Encourage the client to adhere to his therapeutic regimen. Explanation: One of the goals of client education is to encourage people to adhere to their therapeutic regimen. This is a very important goal because if clients do not adhere to their therapeutic regimen, they will not attain their optimal level of wellness. In this client's circumstances, this is likely a priority over exercise or nutrition, though these are important considerations. A disease-free state is not obtainable. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Promoting Adherence to the Therapeutic Regimen, p. 47.

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. A. Extravasation B. Air embolism C. Hematoma D. Phlebitis E. Infection

Correct response: A. Extravasation C. Hematoma D. Phlebitis E. Infection Explanation: Local complications of intravenous therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Infections can be local or systemic. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, and febrile reaction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 291.

A nurse works in an employee health department of a hospital. She was asked to treat a staff nurse who was exposed to blood from a patient with an HIV infection. The nurse practitioner instituted a PEP protocol that includes which of the following actions? Select all that apply. A. Finish postexposure testing at 6 months. B. Start prophylaxis medications between 3 to 6 hours after exposure. C. Continue HIV medications for 4 weeks postexposure. D. Practice safe sex for 2 weeks (time for HIV medications to reach a satisfactory blood level). E. Initiate postexposure testing after 4 weeks.

Correct response: A. Finish postexposure testing at 6 months. C. Continue HIV medications for 4 weeks postexposure. E. Initiate postexposure testing after 4 weeks. Explanation: Refer to Box 37-4 in the text Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Post-Exposure Prophylaxis for Health Care Providers, p. 1029.

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. A. Heart rate B. Urine output C. Blood pressure D. Oxygen saturation

Correct response: A. Heart rate B. Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1854.

A client with AIDS has developed cytomegalovirus (CMV) retinitis and is receiving treatment with foscarnet. The nurse would monitor for which possible adverse drug effects? Select all that apply. A. Hyperphosphatemia B. Hypercalcemia C. Seizures D. Hypomagnesemia E. Neutropenia

Correct response: A. Hyperphosphatemia C. Seizures D. Hypomagnesemia Explanation: Adverse reactions associated with foscarnet include nephrotoxicity, including acute renal failure, and electrolyte imbalances such as hypocalcemia, hyperphosphatemia, and hypomagnesemia, which can be life-threatening. Seizures also may occur. Neutropenia is an adverse effect associated with ganciclovir. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Cytomegalovirus Retinitis, p. 1042.

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. A. Indigestion B. Nausea C. Anxiety D. Chest pain E. Shortness of breath

Correct response: A. Indigestion B. Nausea Explanation: Many women experiencing coronary events including--unstable angina, MIs, or sudden cardiac death events--are asymptomatic or present with atypical symptoms including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among clients of all ages and genders. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 27: Management of Patients with Coronary Vascular Disorders, Clinical Manifestations, p. 752.

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. A. MRI B. Cranial radiography C. Cerebral angiography D. Electromyography (EMG) E. Transcranial Doppler flow study

Correct response: A. MRI C. Cerebral angiography E. Transcranial Doppler flow study Explanation: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Medical Management, p. 1989.

The nurse is working in a health clinic. Which statements are correct regarding characteristics of chronic conditions? Select all that apply. A. Managing chronic conditions must be an individual process. B. The health care team needs to focus on preventing complications. C. Managing chronic conditions is becoming less costly. D. Keeping chronic conditions under control requires occasional adherence to therapeutic regimens. E. Difficult ethical issues arise in the care of people with chronic conditions.

Correct response: A. Managing chronic conditions must be an individual process. B. The health care team needs to focus on preventing complications. E. Difficult ethical issues arise in the care of people with chronic conditions. Explanation: Managing chronic conditions involves the individual. The health care team must focus on prevention of complications. Ethical issues can be part of the care of people with chronic conditions. Managing chronic conditions is costly, involving multiple services and treatments. Keeping chronic conditions under control requires adherence to therapeutic regimens. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 9: Chronic Illness and Disability, p. 145.

The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia? Select all that apply. A. Monitor respiratory rate and sensation every 2 hours or as per ordered. B. Turn the client from side to side at least every 2 hours, if permitted. C. Encourage the client to increase activity if complaining of a headache. D. Assist the client to a sitting position at the side of the bed. E. Instruct the client to stay in bed until sensation and movement returns.

Correct response: A. Monitor respiratory rate and sensation every 2 hours or as per ordered. B. Turn the client from side to side at least every 2 hours, if permitted. D. Assist the client to a sitting position at the side of the bed. E. Instruct the client to stay in bed until sensation and movement returns. Explanation: The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit. If client complains of a headache, the client should not be encouraged to increase activity. The client may have to remain lying flat for a longer period of time. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Intraoperative Nursing Management, Spinal Anesthesia, p. 445.

An older client underwent a lumpectomy for a breast lesion that was determined to be malignant. Which factors increase the risk for breast cancer? Select all that apply. A. Nulliparity B. Increased age C. Daily alcohol intake D. Obesity E. Silicone breast implants

Correct response: A. Nulliparity B. Increased age C. Daily alcohol intake D. Obesity Explanation: Being female, being older than 50 years of age, and having a family history of breast cancer are the most common risk factors. Additional factors include obesity and having no children or having children after 30 years of age. Consuming 2 to 5 alcoholic drinks per day increases breast cancer risk. There is no evidence to support increased breast cancer risk with silicone breast implants. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1731.

During an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the client's plan of care? Select all that apply. A. Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development. B. Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. C. The immune system is integrated with other psychophysiological processes and is regulated by the brain. Aging of the brain can have immunologic consequences and can affect neural and endocrine function increasing the risk of cancer development. D. Education about the importance of adhering to a recommended vaccine schedule should be initiated to boost the immune system function. E. The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early.

Correct response: A. Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development. B. Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes; therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. E. The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early. Explanation: Large tumors can release antigens into the blood, and these antigens combine with circulating antibodies and prevent them from attacking the tumor cells. Furthermore, tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes. During the early development of tumors, the body may fail to recognize the tumor antigens as foreign and subsequently fail to initiate destruction of the malignant cells. The incidence of autoimmune diseases also increases with age, possibly from a decreased ability of antibodies to differentiate between self and nonself. Failure of the surveillance system to recognize mutant or abnormal cells also may be responsible, in part, for the high incidence of cancer associated with increasing age. Vitamin D deficiency has been associated with increased risk of common cancers. Evidence shows that nutrition plays a role in the development of cancer and that diet and lifestyle can alter the risk of the development of cancer and other chronic diseases. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 35: Assessment of Immune Function.

The nurse is teaching a local community group about the importance of disease prevention. Why is the nurse justified in emphasizing disease prevention as a component of health promotion? A. Prevention is emphasized as the link between personal behavior and health. B. The external environment affects the outcome of most disease processes. C. International organizations emphasize prevention as the main criterion of health care. D. Most individuals die of preventable causes.

Correct response: A. Prevention is emphasized as the link between personal behavior and health. Explanation: Most deaths are not classified as being preventable. HMO priorities do not underlie this emphasis. The external environment affects many disease processes, but the course of illness is primarily determined by factors intrinsic to the client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Health Promotion, p. 53.

A client is being seen by an urologist for perineal pain, low back pain, fever lasting 5 days, and painful urination. The diagnosis of prostatitis is confirmed. What teaching should the nurse include? Select all that apply. A. Regularly drain the gland. B. Complete the prescribed antibiotic treatment C. Avoid prolonged sitting. D. Avoid caffeine products. E. Apply heat to the prostate area.

Correct response: A. Regularly drain the gland. B. Complete the prescribed antibiotic treatment C. Avoid prolonged sitting. D. Avoid caffeine products. Explanation: The nurse instructs the client to comply with antibiotic therapy, use a mild analgesic for pain, regularly drain the prostate gland through masturbation or intercourse, and avoid caffeine, prolonged sitting, and constipation. The application of heat is not used, but sitz baths may help with discomfort. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, p. 1762.

Which of the following are the immediate complications of spinal cord injury? A. Respiratory arrest B. Paraplegia C. Autonomic dysreflexia D. Spinal shock E. Tetraplegia

Correct response: A. Respiratory arrest D. Spinal shock Explanation: Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Other Complications, p. 2054.

An older adult in the hospital with a fractured hip is being prepared for surgical repair. The bilateral hearing aids were forgotten at the client's home and the client is having difficulty hearing. To promote communication, which of the following actions should the nurse perform? Select all answers that apply. A. Talk directly to the client. B. Use a deeper tone of voice. C. Ask the client to repeat what was stated. D. Speak in a loud voice. E. Allow the television to remain on while talking to the client.

Correct response: A. Talk directly to the client. B. Use a deeper tone of voice. C. Ask the client to repeat what was stated. Explanation: Actions that a nurse can take to help a client with hearing loss include the following: talk directly to the client; use a deep tone rather than a high tone; and ask the client to repeat what was stated to ensure understanding. The nurse does not speak in a loud voice, because in doing so, the nurse would use a higher tone, which is more difficult to hear. The nurse should minimize background noises in the room by turning off the television. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 9: Chronic Illness and Disability, p. 155.

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply. A. The 70-year-old client who takes no routine medications. B. The 27-year-old client with non-insulin dependent diabetes. C. The 47-year-old client who stopped smoking 4 years ago. D. The 25-year-old client who occasionally smoked marijuana in high school. E. The 43-year-old client with past surgeries.

Correct response: A. The 70-year-old client who takes no routine medications. B. The 27-year-old client with non-insulin dependent diabetes. Explanation: The client with diabetes is at risk for complications during the intraoperative or postoperative period. Hypoglycemia can develop during anesthesia or from inadequate carbohydrate intake or excess insulin administration postoperatively. Hyperglycemia can increase the risk for wound infection and delay wound healing. The older adult is at risk for complications because of his or her advanced age. The client with past surgeries is not at more risk for complications. Smokers are encouraged to stop 4 to 8 weeks before surgery. Recent illicit drug use can increase the risk for adverse reactions to anesthesia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 19: Postoperative Nursing Management, p. 427.

A nurse has just come on duty and has received the end-of-shift report. One of the nurse's clients newly diagnosed with diabetes was admitted with diabetic ketoacidosis. Which behavior best demonstrates this client's willingness to learn? A. The client requests a visit from the hospital's diabetic educator. B. The client wants a family member to meet with the dietician to discuss meals. C. The client sets aside a dessert brought in by a family member. D. The client readily allows the nurse to measure his blood glucose level.

Correct response: A. The client requests a visit from the hospital's diabetic educator. Explanation: Emotional readiness also affects the motivation to learn. A person who has not accepted an existing illness or the threat of illness is not motivated to learn. The client's willingness to learn is expressed through the action of seeking information on their own accord. Seeking information shows an emotional readiness to learn. The other options do not clearly demonstrate a willingness to learn. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Learning Readiness, p. 49.

A nurse is caring for a client from another country. How might the client's culture impact his or her readiness to learn when the nurse attempts teaching? Select all that apply. A. The manner in which the client learns is impacted. B. The severity of disease or injury impacts learning. C. The information in which the client learns is impacted. D. The client's present lifestyle impacts learning. E. The client's previous life experience impacts learning.

Correct response: A. The manner in which the client learns is impacted. C. The information in which the client learns is impacted. Explanation: Clients with different cultural backgrounds have different values and lifestyles, which varies choices about health care. Culture may impact the manner in which the client learns as well as the information in the client learns. Lifestyle, severity of disease or injury, and life experience all impact readiness to learn; however, these are not directly related to culture. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, p. 51.

A patient has a suprapubic catheter inserted postoperatively. What would be the advantages of the suprapubic catheter versus a urethral catheter? Select all that apply. A. The patient can void sooner than with a urethral catheter. B. The patient is not at risk for a UTI with a suprapubic catheter. C. The suprapubic catheter permits measurement of residual urine without urethral instrumentation. D. The suprapubic catheter can be kept in longer than a urethral catheter. E. The suprapubic catheter allows for more mobility.

Correct response: A. The patient can void sooner than with a urethral catheter. C. The suprapubic catheter permits measurement of residual urine without urethral instrumentation. E. The suprapubic catheter allows for more mobility. Explanation: Suprapubic drainage offers certain advantages. Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Suprapubic Catheters, p. 1629.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply. A. To facilitate removal of tracheobronchial secretions B. To support connecting to mechanical ventilation C. To bypass an upper airway obstruction D. To provide airway support to a client with facial trauma E. To support ventilation in a client with basal skull trauma

Correct response: A. To facilitate removal of tracheobronchial secretions B. To support connecting to mechanical ventilation C. To bypass an upper airway obstruction Explanation: Endotracheal intubation is indicated to establish an airway for a client who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the client to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Establishing an Airway, p. 2163.

An elderly client with chronic osteoarthritis has difficulty ambulating and is seeking a prescription for a walker. How should the nurse categorize the client's disability? A. acquired B. developmental C. age-associated D. sensory

Correct response: A. acquired Explanation: Acquired disabilities may be progression of a chronic disorder, such as arthritis. Developmental disabilities are those disabilities that occur any time from birth to 22 years and may result in impairment of physical or mental health, cognition, speech, language, or self-care. Sensory disabilities affect hearing or vision. Age-related disabilities are conditions from age, not a chronic disease. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 9: Chronic Illness and Disability, p. 150.

A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply A. aging B. aortic valve stenosis C. hypertension D. mitral valve stenosis E. diabetes mellitus

Correct response: A. aging B. aortic valve stenosis C. hypertension Explanation: Major factors that determine afterload are the diameter and distensibility of the great vessels (aorta and pulmonary artery) and the opening and competence of the semilunar valves (pulmonic and aortic valves). If the client has significant vasoconstriction, hypertension, or a narrowed valvular opening, resistance or afterload increases. Aging causes muscle stiffness, thus increasing afterload. Diabetes mellitus and mitral valve stenosis do not directly affect afterload. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 29: Management of Patients With Complications from Heart Disease, p. 819.

The nurse is administering medications to a client with pericarditis. What medications will be commonly prescribed to treat pericarditis? Select all that apply. A. colchicine B. indomethacin C. ibuprofen D. prednisone

Correct response: A. colchicine C. ibuprofen D. prednisone Explanation: Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, may be prescribed for pain relief during the acute phase. Indomethacin is contraindicated because it may decrease coronary blood flow. Corticosteroids (e.g., prednisone) may be prescribed if the pericarditis is severe or the patient does not respond to NSAIDs. Colchicine may also be used as alternative therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 28: Management of Patients with Structural, Infectious and Inflammatory Cardiac Disorders, Medical Management, p. 814.

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? A. deep tissue cooling B. continuing inflammatory process C. protein cell coagulation D. All options are correct.

Correct response: A. deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Chart 62-3, p. 1850.

The nurse is conducting an assessment on a client that has acute irritant contact dermatitis. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply. A. edema B. blisters C. rhinitis D. cracked skin E. redness

Correct response: A. edema E. redness Explanation: Edema is an acute symptom of irritant contact dermatitis. Cracked skin is a chronic symptom of irritant contact dermatitis. Blisters are symptoms of allergic contact dermatitis. Redness is an acute symptom of irritant contact dermatitis. Rhinitis is a symptom of latex allergy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, p. 1069.

The nurse working in the medical intensive care unit is caring for a client admitted with mitral stenosis. What will the nurse assess is related to the pathophysiology of mitral stenosis? Select all that apply. A. low-pitched murmur B. high-pitched murmur C. fatigue D. shortness of breath with activity E. history of endocarditis

Correct response: A. low-pitched murmur C. fatigue D. shortness of breath with activity E. history of endocarditis Explanation: Clients with mitral stenosis can have fatigue, a low-pitched murmur due to turbulent blood flow, shortness of breath from poor cardiac blood flow, and decreased cardiac output. A history of endocarditis can cause valve damage from vegetation break off. The high-pitched murmur is seen with mitral valve regurgitation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 28: Management of Patients with Structural, Infectious and Inflammatory Cardiac Disorders, Clinical Manifestations, p. 794.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply. A. place the client in an upright position B. instruct the client to cough C. perform chest physiotherapy D. have the client take deep breaths E. administer oxygen

Correct response: A. place the client in an upright position E. administer oxygen Explanation: An upright position, such as high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen as prescribed to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in the expectoration of secretions, which isn't the primary problem in pulmonary edema. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 29: Management of Patients With Complications from Heart Disease, Pulmonary Edema, p. 833.

For a cancerous tumor, a client must undergo modified radical mastectomy, which includes axillary node removal and immediate reconstruction. The nurse explains to the client that the axillary nodes will be removed to: A. provide prognostic information. B. prevent metastasis. C. facilitate postoperative recovery. D. facilitate breast reconstruction.

Correct response: A. provide prognostic information. Explanation: Lymph node dissection provides prognostic information by helping to determine if chemotherapy is indicated. Although removal of lymph nodes may assist in prevention of metastasis, lymph node dissection isn't a guarantee that metastasis won't occur. This procedure doesn't affect breast reconstruction and may actually make postoperative recovery more difficult. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Modified Radical Mastectomy, p. 1733.

A client is in the ED after being struck in the left eye with a baseball, leaving a large ecchymosis and edema. In client education, the nurse explains to the client the functions of the various structures of the eye. What are functions of the eyelids? Select all that apply. A. spread tears B. eliminate dust C. impact ocular light D. produce tears

Correct response: A. spread tears C. impact ocular light Explanation: The eyelids adjust the amount of light that enters the eye and spread tears over the surface of the eye. The eyelids do not produce tears. The eyelids protect against foreign bodies but do not eliminate them. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1877.

The nurse recognizes what conditions cause elevated prostate-specific antigen (PSA) levels in the absence of prostate cancer. Select all that apply. A. transurethral resection of the prostate (TURP) B. acute prostatitis C. erectile dysfunction D. acute urinary retention E. benign prostatic hyperplasia (BPH)

Correct response: A. transurethral resection of the prostate (TURP) B. acute prostatitis D. acute urinary retention E. benign prostatic hyperplasia (BPH) Explanation: Acute urinary retention, acute prostatitis, BPH, and recent TURP can cause elevated PSA levels in the absence of prostate cancer. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, p. 1756.

A nurse is caring for a client newly diagnosed with cancer. Which therapies are used to treat cancer? Select all that apply. A. electroconvulsive therapy B. hyperthermia C. surgery D. chemotherapy E. radiation therapy

Correct response: B. hyperthermia C. surgery D. chemotherapy E. radiation therapy Explanation: Cancer is frequently treated with a combination of therapies using standardized protocols. The basic methods used to treat cancer are surgery, radiation therapy, hyperthermia, and chemotherapy. Electroconvulsive therapy is a method of treatment for mental distress or illness. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Management of Patients with Oncologic Disorders, p. 334.

The nurse is providing discharge teaching to a client with recurrent endocarditis. What are prevention strategies will be included with the teaching? Select all that apply. A. use a nail clipper for fingernail care B. notify dentist of the history of endocarditis with any planned dental procedures C. use a toothpick to keep food from accumulating in the mouth D. report recurrent fever lasting longer than 7 days to the health care provider E. body piercing can be done in a clean area

Correct response: A. use a nail clipper for fingernail care B. notify dentist of the history of endocarditis with any planned dental procedures D. report recurrent fever lasting longer than 7 days to the health care provider Explanation: The client at high risk for endocarditis should report recurrent fever lasting longer than 7 days to the health care provider, avoid nail biting, and notify the dentist of the history of endocarditis before any planned dental procedures. Body piercing and using toothpicks can provide an entry for infection for high-risk clients. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 28: Management of Patients with Structural, Infectious and Inflammatory Cardiac Disorders, p. 810.

The nurse is preparing to begin a pelvic examination of a female client in the health clinic. The client states, "These exams make me feel so nervous and out of control." How should the nurse respond? Select all that apply. A. "The exam takes about 20 minutes but I will make sure you are comfortable the entire time." B. "Many people feel nervous before and while having this examination." C. "It can help you relax if you use deep breath and meditation during the exam." D. "If you like, I can give you a mirror so you can watch the examination." E. "If you feel pain let me know because this is not something you should expect."

Correct response: B. "Many people feel nervous before and while having this examination." C. "It can help you relax if you use deep breath and meditation during the exam." D. "If you like, I can give you a mirror so you can watch the examination." E. "If you feel pain let me know because this is not something you should expect." Explanation: The nurse should tell the client that she may have a feeling of fullness or pressure during the examination, but that she should not feel pain. The client should be encouraged to speak up if she experiences pain. This can help the client feel more in control of the examination. The nurse should reassure the client that it is normal to feel uncomfortable and apprehensive during the examination. To promote a sense of control for the client, the nurse can offer for the client to use a mirror to be able to fully view the examination as it is taking place. The nurse should tell the client that it is important to relax because if she is very tense, she may feel discomfort. Offering the client strategies to relax such as deep breathing and meditation can put the client at ease. It would be incorrect to tell the client to expect that the examination will take about 20 minutes. Typically, a pelvic examination should last about 5 minutes. Knowing what duration to expect can help minimize the client's anxiety. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Physical Assessment. Chart 56-7--The Pelvic Examination, p. 1660.

A nurse is performing a health assessment on a client. In order to learn more about the client's interpersonal environment, which questions will the nurse ask the client? Select all that apply. A. "What is the most important thing in your life?" B. "What practices do you use to keep in good health?" C. "Do you have a place of worship?" D. "What spiritual support do you desire?" E. "What language do you speak at home?"

Correct response: B. "What practices do you use to keep in good health?" E. "What language do you speak at home?" Explanation: Part of assessing a client's interpersonal environment is taking into account their ethnicity because attitudes and beliefs about health and wellness can vary by ethnicity. The beliefs, customs, and practices that have been shared from generation to generation are called ethnic patterns. The questions, "What language do you speak at home?" and "What practices do you use to keep in good health?" best assess the ethnic patterns of the client. Asking the client about places of worship, spiritual support, and the most important thing in his or her life are all questions related to a client's spirituality. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 5: Adult Health and Nutritional Assessment, pp. 68-69.

Following a recent history of dyspareunia and lower abdominal pain, a client has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address what topics? Select all that apply. A. The need for a Pap smear every 3 months B. Appropriate use of antibiotics C. Use of condoms to prevent infecting others D. Taking measures to prevent pregnancy E. The importance of weight loss in preventing symptoms

Correct response: B. Appropriate use of antibiotics C. Use of condoms to prevent infecting others Explanation: Clients with PID need to take action to avoid infecting others. Antibiotics are frequently required. Pregnancy does not necessarily need to be avoided, but there is a heightened risk of ectopic pregnancy. Weight loss does not directly alleviate symptoms. Regular follow-up is necessary, but Pap smears do not need to be performed every 3 months. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Nursing Management, p. 1696.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. A. Diuresis B. Bradycardia C. Numbness and tingling in the extremities D. Confusion E. Chest pain F. Shortness of breath

Correct response: B. Bradycardia D. Confusion Explanation: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 29: Management of Patients With Complications from Heart Disease, Digitalis, p. 823.

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply. A. A repeat multiple-puncture skin test B. Drug susceptibility testing C. Complete blood count D. A chest radiograph E. Complete history and physical examination

Correct response: B. Drug susceptibility testing D. A chest radiograph E. Complete history and physical examination Explanation: Once a client had a positive skin test or a positive sputum culture for acid-fast bacilli, additional tests such as complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing are done. The nurse does not need to teach about a complete blood count or a repeat multiple puncture skin test, as the initial positive skin test will serve as the indicator of tuberculosis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders, p. 602.

The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply. A. Assess the client using the CIWA-A scale B. Ensure the head of the bed remains elevated C. Assess respiratory rate every 4 to 6 hours D. Monitor naloxone intravenous infusion E. Apply warming blankets to client

Correct response: B. Ensure the head of the bed remains elevated D. Monitor naloxone intravenous infusion Explanation: Interventions in the urgent care of a client who has overdosed on an opioid narcotic focuses on reversal of the effects of the narcotic agent and supporting oxygenation. The nurse should ensure the client has the head of the bed elevated to aid respirations and monitor the intravenous infusion of naloxone, an opioid narcotic reversal agent. Applying a warming blanket to a client in this state should not be considered an immediate intervention as the blanket may interfere with the nurse's ability watch respirations closely. This may also risk causing the client hyperthermia. The CIWA-A scale would be appropriate in assessing withdrawal from alcohol. Respirations need to be assessed more closely than every 4 to 6 hours when immediate, more urgent care is being provided to prevent respiratory depression. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Substance Abuse, p. 2180.

The nurse is working with a male client who has diagnoses of coronary artery disease and angina pectoris. During a clinic visit, the nurse learns that he has only been taking his prescribed antiplatelet medication when he experiences chest pain and fatigue. What nursing diagnosis is most relevant to this assessment finding? A. Confusion related to mismanagement of drug regimen B. Ineffective health maintenance related to inappropriate medication use C. Ineffective role performance related to inability to manage medications D. Acute pain related to myocardial ischemia

Correct response: B. Ineffective health maintenance related to inappropriate medication use Explanation: This client's actions suggest that by taking his medications incorrectly he is not adequately maintaining his health. Role performance is not directly applicable to the client's actions and confusion suggests a cognitive deficit. Pain is not central to the essence of the problem. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Nursing Diagnosis, p. 50.

The nurse is planning to teach a 75-year-old client with coronary artery disease about administering her prescribed antiplatelet medication. How can the nurse best enhance the client's ability to learn? A. Exclude family members from the session to prevent distraction. B. Make the information directly relevant to the client's condition. C. Use color-coded materials that are succinct and engaging. D. Provide links to websites that contain evidence-based information.

Correct response: B. Make the information directly relevant to the client's condition. Explanation: Studies have shown that older adults can learn and remember if the information is paced appropriately, relevant, and followed by appropriate feedback. Family members should be included in health education. The nurse should not assume that the client's color vision is intact or that the client possesses adequate computer skills. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Gerontologic Considerations, p. 48.

The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply. A. Pulmonary hypotension B. Polycythemia C. Insomnia D. Evening headaches E. Loud snoring

Correct response: B. Polycythemia C. Insomnia E. Loud snoring Explanation: Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, , polycythemia, and enuresis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 22: Management of Patients with Upper Respiratory Tract Disorders, Chart 22-4, p. 568.

The nurse educator is teaching about reproductive health to a group of nursing students. The nurse educator is correct in stating which information about the menstrual cycle? A. Estrogen production decreases during the follicular phase B. Progesterone production is low during ovulation C. Follicle stimulating hormone (FSH) is high during the luteal phase D. The endometrium stops growing during the ovulation phase

Correct response: B. Progesterone production is low during ovulation Explanation: Progesterone production is low during ovulation. Progesterone plays a role in regulating uterine changes during the menstrual cycle and prepares the endometrium for ovulation. Follicle stimulating hormone production is low during the luteal phase. Estrogen production increases during the follicular phase. The endometrium continues to grow during ovulation in preparation for implantation or shedding of the lining in the case of menstruation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Menstrual Cycle, Table 56-1 Hormonal Changes and Menstrual Cycle, p. 1654.

The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply. A. White blood cell casts in the urine B. Red blood cells in the urine C. Proteinuria D. Polyuria E. Hemoglobin of 12.8 g/dL

Correct response: B. Red blood cells in the urine C. Proteinuria Explanation: The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts may be present, indicating glomerular injury. Acute glomerulonephritis does not present with white blood cell (WBC) casts. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Complications, p. 1571.

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply. A. Put some of the tablets in a small metal or plastic pillbox that can be easily carried at all times and be accessible quickly, when needed. B. Renew the supply every 6 months. C. Take the tablet in anticipation of any activity that can produce pain. D. Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. E. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists. F. Keep the tablets at home on the kitchen counter or bedside table so they can be reached quickly.

Correct response: B. Renew the supply every 6 months. C. Take the tablet in anticipation of any activity that can produce pain. D. Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. E. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists. Explanation: Nitroglycerine is very unstable and should be carried securely in its original container (capped, dark, glass bottle). The tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerine is also volatile and is inactivated by heat, moisture, air, light, and time. Therefore, storage and replacement is recommended every 6 months. Refer to Box 14-3 in the text. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 27: Management of Patients with Coronary Vascular Disorders, nitroglycerin, p. 759.

Compliance to a renal diet is a difficult lifestyle change for a patient on hemodialysis. The nurse should reinforce nutritional information. Which of the following teaching points should be included? Select all that apply. A. Limit protein to 1.6 g/kg/day. B. Restrict sodium to 2,000 to 3,000 mg daily. C. Eat foods such as milk, fish, and eggs. D. Restrict fluid to daily urinary output plus 500 to 800 mL. E. Increase potassium to prevent cardiac problems.

Correct response: B. Restrict sodium to 2,000 to 3,000 mg daily. C. Eat foods such as milk, fish, and eggs. D. Restrict fluid to daily urinary output plus 500 to 800 mL. Explanation: With hemodialysis, protein should be limited to 1.2 to 1.3 g/kg/24 hr. Potassium, along with sodium and phosphorus should be restricted. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 54: Management of Patients With Kidney Disorders, Promoting Nutritional and Fluid Therapy, p. 1592.

A nurse on a medical unit is conducting a spiritual assessment of a client who is newly admitted. In the course of this assessment, the client indicates that she does not eat meat. Which of the following is the most likely significance of this client's statement? A. The client does not understand the principles of nutrition. B. This is an aspect of the client's religious practice. C. This constitutes a nursing diagnosis of Risk for Imbalanced Nutrition. D. This is an example of the client's coping strategies.

Correct response: B. This is an aspect of the client's religious practice. Explanation: Because this datum was obtained during a spiritual assessment, it could be that this is an aspect of the client's religious practice. It is indeed a personal choice, but this is not the primary significance of the statement. This practice may not be related to health-seeking if it is in fact a religious practice. This does not necessarily constitute a risk for malnutrition or a misunderstanding of nutrition. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 5: Adult Health and Nutritional Assessment, Spiritual Environment, p. 65.

The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply. A. Region of country lived in B. Tobacco C. Industrial pollutants D. Age E. Alcohol

Correct response: B. Tobacco C. Industrial pollutants D. Age E. Alcohol Explanation: Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is not associated with laryngeal cancer as a specific risk factor. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 22: Management of Patients with Upper Respiratory Tract Disorders, Cancer of the Larynx, p. 572.

A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply. A. Apply lubricating lotion to the wound bed. B. Wash the wound with soap and water. C. Take pain medications daily. D. Continue physical therapy exercises. E. Report increased redness and wound drainage to the healthcare provider.

Correct response: B. Wash the wound with soap and water. D. Continue physical therapy exercises. E. Report increased redness and wound drainage to the healthcare provider. Explanation: The client being discharged with burn wound care needs to demonstrate wound care technique; take prescribed pain medications if needed 30 minutes prior to wound care to achieve maximum effectiveness; use mild soap, water, and a clean washcloth to clean wounds; apply prescribed topical medications( not lubricating lotions to the wound bed) and dressings as instructed; inspect wounds carefully with each dressing change for signs of infection, including increased redness, swelling, drainage, or foul odor; and state aspects of activities of daily living as per therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, p. 1871.

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply. A. milrinone B. epinephrine C. norepinephrine D. vasopressin E. phenylephrine

Correct response: B. epinephrine C. norepinephrine D. vasopressin E. phenylephrine Explanation: The vasopressive agents that may be used in managing a client with cardiogenic shock include norepinephrine (Levophed), vasopressin (Pitressin), and phenylephrine (Neo-Synephrine). The vasopressive agents increase blood pressure by constriction. Milrinone (Primacor) is an inotropic agent that improves contractility. Epinephrine is both a vasopressor and an inotropic agent. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

An occupational health nurse is in the planning stages of a new health promotion campaign in the workplace. When appraising the potential benefits of the program, what will the nurse consider most participants depend on for success? A. self-awareness B. taking responsibility for themselves C. time and task management skills D. desire to expand knowledge

Correct response: B. taking responsibility for themselves Explanation: Taking responsibility for oneself is the key to successful health promotion, superseding the importance of the desire to learn information, self-awareness, or time and task management skills. The desire to learn is part of taking responsibility for oneself. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Self-Responsibility, p. 55.

Lately, a 75-year-old man is having difficulty emptying his bladder. He is unable to empty it completely and yet it feels full, causing discomfort. The physician suspects prostate cancer. Which question(s) would you expect the physician to ask the client? Select all that apply. A. "Do you leak urine involuntarily?" B. "Do you feel thirsty often?" C. "Do you have a burning sensation during urination?" D. "Do you pass blood in your urine?" E. "Do you have a family history of prostate cancer?"

Correct response: C. "Do you have a burning sensation during urination?" D. "Do you pass blood in your urine?" E. "Do you have a family history of prostate cancer?" Explanation: The symptoms of prostate cancer include a slow urinary stream; hematuria, which is passing blood with urine; urinary hesitancy; incomplete bladder emptying; and dysuria (painful urination). A family history of prostate cancer would increase the client's risk of developing it himself. Urine leakage is a symptom of cervical cancer. Thirst is not related to prostate cancer. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, p. 1764.

A nurse is educating a client about the benefits of fruit versus fruit juice in the diabetic diet. The client states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What are the best responses by the nurse? Select all that apply. A. "Eating the fruit is more satisfying than drinking the juice. You will get full faster." B. "Eating the fruit will give you more vitamins and minerals than the juice will." C. "Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." D. "The fruit has less sugar than the juice." E. "Eating the fruit will lead to hyperglycemia and the fruit juice will not lead to hyperglycemia."

Correct response: C. "Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." D. "The fruit has less sugar than the juice." Explanation: Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption. A serving of juice has more sugar than a serving of fruit. Whether a fruit is more satisfying and has more vitamins and minerals than the fruit's juice are dependent on the types of fruit and juices. Eating fruit does not lead to hyperglycemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 51: Assessment and Management of Patients With Diabetes, p. 1464.

The nurse is assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. The nurse observes bruising to the client's upper arm that corresponds to the outline of fingers as well as yellow bruising around her left eye. The client makes minimal eye contact during the assessment. How should the nurse best inquire about the bruising? A. "Tell me about your relationships." B. "Do you want to see a social worker?" C. "Is anyone physically hurting you?" D. "Is there something you want to tell me?"

Correct response: C. "Is anyone physically hurting you?" Explanation: Few clients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, "Is anyone physically hurting you?" The other options are incorrect because they are not the best way to elicit information about possible abuse in a direct and appropriate manner. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 5: Adult Health and Nutritional Assessment, Risk for Abuse, p. 69.

A nurse is teaching a client about the functions of the larynx. What should the nurse include in the teaching? Select all that apply. A. Preventing infection B. Acting as a passage way for the respiratory tract C. Facilitating coughing D. Protecting the lower airway from foreign objects E. Producing sound

Correct response: C. Facilitating coughing D. Protecting the lower airway from foreign objects E. Producing sound Explanation: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. The larynx assists in protecting the lower airway. Facilitating coughing is a function of the larynx. Preventing infection is the main function of the tonsils and adenoids. The pharynx is a passageway for the respiratory tract. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 20: Assessment of Respiratory Function, pp. 481-482.

The nurse is preparing discharge teaching for an adult client diagnosed with urinary retention secondary to multiple sclerosis. The nurse will teach the client to self-catheterize at home upon discharge. What teaching method is most likely to be effective for this client? A. A list of clear instructions written at a sixth-grade level B. A short video providing useful information and demonstrations C. A discussion and demonstration between the nurse and the client D. An audio-recorded version of discharge instructions that can be accessed at home

Correct response: C. A discussion and demonstration between the nurse and the client Explanation: Demonstration and practice are essential ingredients of a teaching program, especially when teaching skills. It is best to demonstrate the skill and then give the learner ample opportunity for practice. When special equipment is involved, such as urinary catheters, it is important to teach with the same equipment that will be used in the home setting. A list of instructions, a video, and an audio recording are effective methods of reinforcing teaching after the discussion and demonstration have taken place. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Teaching Techniques and Resources, p. 50.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. What pin site assessments would the nurse report to the healthcare provider? Select all that apply. A. Inability to turn head from side to side B. Crust around the pin insertion site C. A small amount of yellow drainage at the left pin insertion site D. Pain at the insertion site after administration of medication E. A redness of the skin surrounding the insertion site

Correct response: C. A small amount of yellow drainage at the left pin insertion site D. Pain at the insertion site after administration of medication E. A redness of the skin surrounding the insertion site Explanation: The areas around the four pin sites of a halo device are cleaned at least daily and observed for redness, drainage, and pain. The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. A client with skeletal tongs will not be able to turn the head, so this does not need to be reported. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, p. 2056.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. A. Keep the nasal packing in place for 72 hours to help reshape the form of the nose. B. Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. C. Check for any unusual changes in breathing during the first 48 hours. D. Restrict from sports activities for 6 weeks. E. Observe for any clear drainage from either nostril. F. Elevate the head of the bed for sleeping during the first week.

Correct response: C. Check for any unusual changes in breathing during the first 48 hours. D. Restrict from sports activities for 6 weeks. E. Observe for any clear drainage from either nostril. F. Elevate the head of the bed for sleeping during the first week. Explanation: Ice or cold compresses are applied four to six times a day, for several days, until the swelling is decreased. Packing is inserted to control bleeding. It would not be used to reshape the nose. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 22: Management of Patients With Upper Respiratory Tract Disorders, p. 571.

An elderly female client has come to the clinic for a scheduled follow-up appointment. The nurse learns from the client's daughter that the client is not following the instructions she received upon discharge from the hospital last month. What is the most likely factor causing the client not to adhere to her therapeutic regimen? A. Ethnic background of health care provider B. Presence of a learning disability C. Costs of the prescribed regimen D. Personality of the primary provider

Correct response: C. Costs of the prescribed regimen Explanation: Variables that appear to influence the degree of adherence to a prescribed therapeutic regimen include gender, race, education, illness, complexity of the regimen, and the cost of treatments. The ethnic background and personality of the health care provider and the personality of the physician are not considered variables that appear to influence the degree of adherence to a prescribed therapeutic regimen. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Factors Affecting Adherence, p. 47.

A gerontologic nurse has observed that clients often fail to adhere to their therapeutic regimen. What strategy should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care? A. Delegate the dressing change to a trusted family member. B. Provide a detailed pamphlet on a dressing change. C. Demonstrate a dressing change and allow the client to practice. D. Verbally instruct the client how to change a dressing and check for comprehension.

Correct response: C. Demonstrate a dressing change and allow the client to practice. Explanation: The nurse must consider that older adults may have deficits in the ability to draw inferences, apply information, or understand major teaching points. Demonstration and practice are essential in meeting their learning needs. The other options are incorrect because providing written instructions is not a substitute for a comprehensive teaching plan. Having a family member change the dressing when the client is capable of doing it impedes self-care and independence. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Gerontologic Considerations, p. 48.

The nurse assisting at the scene of a terrorist bombing is assessing bystanders for quinary effects from the blast. The nurse assesses for which signs and symptoms? Select all that apply. A. Fractures B. Asthma exacerbation C. Hyperpyrexia D. Diaphoresis

Correct response: C. Hyperpyrexia D. Diaphoresis Explanation: Quinary effects to bystanders ( near to the blast) include hyperpyrexia and diaphoresis. Fractures occur during the secondary and tertiary phases of blast injuries. Asthma exacerbation is seen during the quaternary phase. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing, Table 73-3, p. 2203.

A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply. A. Risk for infection B. Knowledge deficit C. Ineffective airway clearance D. Disturbed body image E. Impaired gas exchange

Correct response: C. Ineffective airway clearance E. Impaired gas exchange Explanation: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude or plug the airway, requiring frequent suctioning. Impaired gas exchange and airway clearance are priority nursing concerns. Infection, knowledge deficit, and disturbed body image are concerns, but not priorities. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 22: Management of Patients with Upper Respiratory Tract Disorders, Complications, p. 524.

When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply. A. Increased urine output B. Hypertension C. Irregular heart rate D. Diaphoresis E. Cyanosis F. Muscle rigidity

Correct response: C. Irregular heart rate D. Diaphoresis E. Cyanosis F. Muscle rigidity Explanation: Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Intraoperative Nursing Management, p. 451.

In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk occupations? Select all that apply. A. Mechanic B. Banker C. Miner D. Nurse E. Stone cutter F. Rock quarry worker

Correct response: C. Miner E. Stone cutter F. Rock quarry worker Explanation: A quarry worker and stone cutter are exposed to rock dust and silica. A miner can inhale dust, causing silicosis or pneumoconiosis. A banker, nurse, and mechanic may have work hazards, but none specific to the development of an occupational lung disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 23: Management of Patients with Chest and Lower Respiratory Tract Disorders, Occupational Lung Diseases: Pneumoconioses, p. 619.

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply. A. Negative sputum culture B. Increased viscosity of lung secretions C. Relief of dyspnea D. Increased respiratory rate E. Increased expiratory flow rate

Correct response: C. Relief of dyspnea D. Increased respiratory rate Explanation: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 24: Management of Patients with Chronic Pulmonary Disease, Achieving Airway Clearance, p. 645.

A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to erectile dysfunction? Select all that apply. A. The client is 66 years old. B. The client has been treated for a UTI twice in the past year. C. The client has a history of hypertension. D. The client drinks five to six alcoholic drinks per day. E. The client leads a sedentary lifestyle.

Correct response: C. The client has a history of hypertension. D. The client drinks five to six alcoholic drinks per day. Explanation: Past history of infection and lack of exercise do not contribute to impotence. With advancing age, sexual function, and libido and potency decrease somewhat, but this is not the primary reason for impotence. Vascular problems cause about half the cases of impotence in men older than 50 years; hypertension is a major cause of such problems. Heavy alcohol use can contribute to the problem as well. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Erectile Dysfunction, p. 1756.

The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, established national standards to protect individuals' medical records and other personal health information. It applies to health plans, health care clearinghouses, and health care providers who conduct certain health care transactions electronically. Which of the following actions demonstrates an understanding of HIPAA? Select all that apply. A. The nurse allows the client's son or daughter to view the medical record. B. The nurse shares her computer password with a peer to help her prepare a chart. C. The client requests a correction to the medical record on file. D. The hospital provides a copy of the medical record to the client. E. The nurse informs the client that the therapist will have access to his EMR. F. The nurse allows the client to view his or her electronic medical record (EMR) at the bedside.

Correct response: C. The client requests a correction to the medical record on file. D. The hospital provides a copy of the medical record to the client. E. The nurse informs the client that the therapist will have access to his EMR. F. The nurse allows the client to view his or her electronic medical record (EMR) at the bedside. Explanation: HIPAA includes the rights of clients to obtain and examine a copy of their health records, and to request corrections. HIPPA provides the client the right to know why requested information is sought and how it will be used. The act requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information. Sharing client information with the client's children or sharing computer passwords is a violation of this privacy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 5: Adult Health and Nutritional Assessment, p. 63.

A nurse is obtaining health histories from clients at a busy low-income clinic. Which clients should the nurse follow more closely as being at the highest risk for developing breast cancer? Select all that apply. A. The client who is over 50 years of age B. The client who is African American C. The client who has relatives with the BRCA1 mutated gene D. The client with a mother who had breast cancer E. The male client with a family history of prostate cancer

Correct response: C. The client who has relatives with the BRCA1 mutated gene D. The client with a mother who had breast cancer Explanation: There are several risk factors that the nurse must identify; however, the most important risk factor to be identified is the presence of the mutated BRCA1 gene, which makes the client "very likely" to develop breast cancer. Breast cancer family history is another significant risk factor. Other risk factors include being female and being older than 50 years, but these clients are not at as high a risk for the development of breast cancer. Males are not a high-risk group. White women are at a higher risk than African Americans. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1731.

The PACU nurse is caring for a client who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply. A. The identities of the staff in the OR B. The names of the anesthetics that were used C. The presence of family and/or significant others D. The client's full name E. The client's preoperative level of consciousness

Correct response: C. The presence of family and/or significant others D. The client's full name E. The client's preoperative level of consciousness Explanation: The PACU nurse is responsible for informing the floor nurse of the client's intraoperative factors (e.g., insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of unexpected events), preoperative level of consciousness, presence of family and/or significant others, and identification of the client by name. The PACU nurse does not tell which anesthetic was used, only the type and amount used. The PACU nurse does not identify the staff that was in the OR with the client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Chart 17-1, p. 420.

A nurse cares for a client who has recently been diagnosed with cancer. While hospitalized, the client has also been diagnosed with diabetes. When will the nurse determine is the best time to assess the client's readiness to learn about health promotion with diabetes? A. When the nurse notices family support at the client's bedside B. When the client tells the nurse he or she is ready to learn C. When the nurse initiates a conversation about motivation to learn D. When the client expresses acceptance of the diagnosis

Correct response: C. When the nurse initiates a conversation about motivation to learn Explanation: While it is true that client must be emotionally ready to learn in order to learn, the client may not be fully ready to learn based on emotional state. A client diagnosed with cancer may likely still be focused on that diagnosis and may never be ready to engage in additional learning unless the nurse first initiates a conversation about it. The client may never tell the nurse that he or she is ready to learn or that he or she accepts the current diagnosis. Family at the bedside may promote learning; however, many times this is not the case and is not the best time to initiate readiness to learning. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, p. 51.

A client has cancer of the neck and is receiving external beam radiation therapy to the site. The client is experiencing trauma to the irradiated skin. The nurse does all of the following. (Select all that apply.) A. applies an over-the-counter ointment to the skin B. uses cool water to wash the neck area C. assesses the client for any sun exposure D. inspects for skin damage of the chest area E. avoids shaving the irradiated skin

Correct response: C. assesses the client for any sun exposure E. avoids shaving the irradiated skin Explanation: The client receiving external beam radiation therapy may experience trauma to the irradiated skin. To prevent further skin damage, the client is to avoid sun exposure and shaving the irradiated skin area. Other skin areas are not damaged, only the irradiated skin. Lukewarm water is to be used to bathe the area. Water of extreme temperature should be avoided. Many over-the-counter ointments contain metals and may cause additional skin damage. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Management of Patients with Oncologic Disorders, Chart 15-7, p. 359.

A client reports "bloody" urine to the nurse. What causes would the nurse relate the hematuria? Select all that apply. A. lithium toxicity B. hypertension C. renal stones D. acute glomerulonephritis E. extreme exercise

Correct response: C. renal stones D. acute glomerulonephritis E. extreme exercise Explanation: Hematuria may be caused by cancer of the genitourinary tract, acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasias, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, or sickle cell trait or disease. Lithium toxicity and hypertension are not related causes of hematuria. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, p. 1556.

The nurse is teaching a client about the symptoms of anaphylaxis. Which client statements indicate no further teaching is needed? Select all that apply. A. "Sneezing a lot can be a concern if it continues and does not let up." B. "A feeling of fullness in my mouth is okay as long as it does not increase." C. "If I experience recurrent diarrhea after eating, I will need to call my doctor." D. "Peripheral tingling is a symptom of anaphylaxis reaction." E. "If I start having difficulty breathing, I need to get help right away."

Correct response: D. "Peripheral tingling is a symptom of anaphylaxis reaction." E. "If I start having difficulty breathing, I need to get help right away." Explanation: Difficulty breathing is a life-threatening symptom of anaphylaxis and requires help right away. Peripheral tingling is a symptom of anaphylaxis reaction. Recurrent diarrhea is not a symptom of anaphylaxis. Sneezing is not a symptom of anaphylaxis reaction. A feeling of fullness in the mouth is a symptom of anaphylaxis reaction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, p. 1069.

An adult client will be receiving outpatient intravenous antibiotic therapy for the treatment of endocarditis. The nurse is preparing to perform health education to ensure the client's adherence to the course of treatment. What assessment should be the nurse's immediate priority? A. Quality of the client's relationships B. Client's understanding of the teaching plan C. Client's previous medical history D. Characteristics of the client's culture

Correct response: D. Characteristics of the client's culture Explanation: Before beginning health teaching, nurses must conduct an individual cultural assessment instead of relying only on generalized assumptions about a particular culture. This is likely a priority over previous medical history and relationships, though these are relevant variables. The teaching plan would not be created at this early stage in the teaching process. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Learning Readiness, p. 49.

A nurse is working with a teenage boy who was recently diagnosed with asthma. During the current session, the nurse has taught the boy how to administer his bronchodilator by metered-dose inhaler. How should the nurse best evaluate the teaching-learning process? A. Ask the boy specific questions about his medication. B. Assess the boy's respiratory health at the next scheduled visit. C. Ask the boy whether he now understands how to use his inhaler. D. Directly observe the boy using his inhaler to give himself a dose.

Correct response: D. Directly observe the boy using his inhaler to give himself a dose. Explanation: Demonstration and practice are essential ingredients of a teaching program, especially when teaching skills. It is best to demonstrate the skill and then give the learner ample opportunity for practice. By observing the client using the inhaler, the nurse may identify what learning needs to be enhanced or reinforced. Asking questions is not as an accurate gauge of learning. Respiratory assessment is a relevant, but indirect, indicator of learning. Delaying the appraisal of the client's technique until a later clinic visit is inappropriate because health problems could occur in the interval. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Teaching Techniques and Resources, p. 50.

A nurse has been studying research that examines the association between stress levels and negative health outcomes. Which relationship between stress and other factors should inform the nurse's teaching plan? A. Stress decreases concentration. B. Stress increases weight. C. Stress increases weight. D. Stress decreases immune function. E. Stress impairs sleep patterns.

Correct response: D. Stress decreases immune function. Explanation: Studies have shown the negative effects of stress on health and a cause-and-effect relationship between stress and infectious diseases, traumatic injuries (e.g., motor vehicle crashes), and some chronic illnesses. It is well known that stress decreases the immune response, thereby making individuals more susceptible to infectious diseases. The other options can also be correct in certain individuals, but they are not those that best support stress-reduction initiatives. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, Stress Reduction and Management, p. 55.

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following are causes of secondary brain injury? Select all that apply. A. Cerebral edema B. Infection C. Hyperthermia D. Seizures E. Ischemia

Correct response: (ALL) A. Cerebral edema B. Infection C. Hyperthermia D. Seizures E. Ischemia Explanation: Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Pathophysiology, p. 2034.

A nurse prepares to teach an individual regarding the client's admitting diagnosis. Which does the nurse do when preparing to assess the client for individualized client education? Select all that apply. A. Determine the client's readiness to learn. B. Summarize the collected client data. C. Ask what the client's expectations are. D. Ask what the client wants to learn.

Correct response: (ALL) A. Determine the client's readiness to learn. B. Summarize the collected client data. C. Ask what the client's expectations are. D. Ask what the client wants to learn. Explanation: Assessment related to individualized client education involves determining the client's readiness to learn, asking what the client wants to learn, asking what the client's expectations are, and summarizing the collected client data. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 4: Health Education and Health Promotion, p. 54.

The nurse recognizes that causes of acquired seizures include what? Select all that apply. A. Hyponatremia B. Cerebrovascular disease C. Metabolic and toxic conditions D. Brain tumor E. Drug and alcohol withdrawal

Correct response: (All) A. Hyponatremia B. Cerebrovascular disease C. Metabolic and toxic conditions D. Brain tumor E. Drug and alcohol withdrawal Explanation: The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (e.g., renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Clinical Manifestations, p. 1996.

A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system. *Picture of water seal chest tube drainage system*

Your selection and the correct area, market by the green box. *LEFT SIDE OF DRAINAGE SYSTEM-LABELED "A"* Explanation: Suction control is determined by the height of instilled water in that chamber. The suction control chamber is on the left side. In the middle of the closed drainage system is the water-seal chamber. The drainage chamber is on the right side of the closed drainage system. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 541.