NURS 322 Exam 1

Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.) a. Anemia b. Joint pain and swelling c. Hair loss d. Fever e. Fatigue f. Facial redness

a. Anemia b. Joint pain and swelling c. Hair loss d. Fever e. Fatigue f. Facial redness

The nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters will the nurse choose most often? a. Cephalic vein of the forearm b. Palmer side of the wrist c. Back of the hand d. Subclavian vein

a. Cephalic vein of the forearm

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) a. Environment of care b. Taking a client's temperature c. Availability of electronic health records d. Time pressures within the unit e. Individual nursing knowledge

a. Environment of care c. Availability of electronic health records d. Time pressures within the unit e. Individual nursing knowledge

The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? (Select all that apply.) a. Establish trust and explain the postoperative pain management plan. b. Consult the pain management team if needed and available. c. Plan continuing pain management after discharge. d. Use multimodal and alternative pain management modalities. e. Identify at-risk clients preoperatively using a comprehensive assessment.

a. Establish trust and explain the postoperative pain management plan. b. Consult the pain management team if needed and available. c. Plan continuing pain management after discharge. d. Use multimodal and alternative pain management modalities. e. Identify at-risk clients preoperatively using a comprehensive assessment.

Which nursing actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) a. Obtain cultures as needed. b. Remove unnecessary medical devices. c. Monitor the red blood cell (RBC) count. d. Inspect the skin for coolness and pallor. e. Promote sufficient nutritional intake. f. Encourage fluid intake, as appropriate.

a. Obtain cultures as needed. b. Remove unnecessary medical devices. e. Promote sufficient nutritional intake.

The nurse provides client-centered care for an older client who was admitted from an assisted living facility. What attributes would the nurse demonstrate when providing care for this client? (Select all that apply.) a. Physical comfort b. Emotional support c. Client respect d. Communication and education e. Care coordination f. Transition and continuity of care

a. Physical comfort b. Emotional support c. Client respect d. Communication and education e. Care coordination f. Transition and continuity of care

The nurse is caring for a client who was bitten by a spider and has cellulitis. What signs and symptoms would the nurse expect? (Select all that apply.) a. Redness b. Discomfort c. Necrosis d. Warmth e. Swelling

a. Redness b. Discomfort d. Warmth e. Swelling

The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? a. The client does not need to have labs drawn for PT or INR. b. The client only needs to take the drug while in the hospital. c. The client is not at risk for bleeding or bruising. d. The client does not need to wear sequential compression devices.

a. The client does not need to have labs drawn for PT or INR.

The nurse is assessing a young adult client who missed multiple work days this winter due to having pneumonia or other respiratory infection four times. What question would be most appropriate for the nurse to ask as part of the health interview? a. "Have you received your pneumonia vaccines?" b. "Do you have any environmental concerns at work?" c. "Did you have the flu before developing pneumonia?" d. "Do you travel out of the country a lot?"

b. "Do you have any environmental concerns at work?"

The nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatestconcern during this procedure? a. "It hurts when you are inserting the line." b. "My hand tingles when you poke me." c. "My IV lines never last very long." d. "I hate having IVs started."

b. "My hand tingles when you poke me."

Which client laboratory response indicates to the nurse that granulocyte colony-stimulating factor therapy is successful? a. Increased lymphocytes b. Increased white blood cells c. Increased platelets d. Increased red blood cells

b. Increased white blood cells Granulocyte colony-stimulating factor is a growth factor that stimulates the increased production and maturation of neutrophils. This action increases the circulating number of neutrophils and has minimal effect on other blood cell types.

The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? a. "When did your bony nodules develop?" b. "How do you feel about having these bony nodules?" c. "Are you able to independently perform ADLs?" d. "Are your bony nodules painful or tender?"

c. "Are you able to independently perform ADLs?"

The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? a. Rheumatoid arthritis b. Infectious arthritis c. Gouty arthritis d. Osteoarthritis

c. Gouty arthritis Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints.

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) a. Designing nursing care with a focus on keeping the client safe b. Participating on a committee that is evaluating the newest bar-code scanner c. Including the client in discussions about dietary choices d. Respecting the client's preference about treatment options e. Referring to a nursing journal to consider trends in care f. Using data collected over the past quarter to determine if and how nursing care should change

c. Including the client in discussions about dietary choices d. Respecting the client's preference about treatment options

Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed? a. "My friend and I are going to start walking 2 miles daily." b. "Taking my temperature every day can help me recognize when a flair is starting." c. "If I still have a lot of pain after taking an NSAID, I can also take acetaminophen." d. "At the first sign of a flare, I will begin taking my medication again."

a. "My friend and I are going to start walking 2 miles daily."

What is the nurse's best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided? a. "Nicotine reduces blood flow to your organs and increases the risk for permanent damage." b. "Using nicotine in any form reduces the effectiveness of drug therapy for lupus." c. "Nicotine promotes muscle cell loss, increases joint inflammation, and reduces functional mobility." d. "Smoking or vaping increases your risk for lung cancer development."

a. "Nicotine reduces blood flow to your organs and increases the risk for permanent damage."

Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? a. Water retention b. Partial airway obstruction c. Nasogastric suction d. Diabetic ketoacidosis

c. Nasogastric suction

Which information does the nurse include when teaching a client about antibiotic therapy for infection? a. Take antibiotics until symptoms subside, and then stop taking the drugs. b. Share antibiotics with family members who develop the same infection. c. Take all antibiotics as prescribed, unless adverse effects develop. d. Take antibiotics when symptoms of infection develop.

c. Take all antibiotics as prescribed, unless adverse effects develop.

Which of these hospital staff members will the nurse manager request to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? a. The primary health care provider assigned as the client's medical resident b. The physical therapist who developed the client's exercise program c. The nurse responsible for the client's case management d. The unit-based RN who has cared for the client during the hospital stay

c. The nurse responsible for the client's case management

Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed? a. "If I inject myself, I will still go immediately to the emergency department." b. "When needed, I can inject the drug right through my clothing." c. "My wife and I will both practice putting the device together." d. "If I keep the injector in the refrigerator, the drug will not expire as quickly."

d. "If I keep the injector in the refrigerator, the drug will not expire as quickly."

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

ANS: A, B, C, D Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self- administer the medication. The other options are not appropriate for etanercept.

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

ANS: A For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.

An increase in platelet stickiness can lead to: a. hypercoagulability b. thromobocytopenia c. embolus d. atrial fibrillation

ANS: A Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive plately stickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to form adequate clots, which often occurs when there is an inadequate number of circulating platelets or a reduction in platelet stickiness.

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

ANS: C Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.

Acid-base balance occurs when the pH level of the blood is between: a. 7.3 and 7.5 b. 7.35 and 7.45 c. 7.4 and 7.5 d. 7.25 and 7.35

ANS: B Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production and elimination.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Re-position the client into the Trendelenburg position.

ANS: B An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

Signs and symptoms of __________ thrombosis include localized redness, swelling, and warmth: a. arterial b. venous c. partial d. atrial

ANS: B Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed locally.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B Vomiting after surgery has several complications, including aspiration. The nurse should listen to the clients lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old

ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.

Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.

ANS: D Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

A client is being admitted to the burn unit from another hospital. According to the client's medical record, the client has an intraosseous IV that was started 2 days ago. Which nursing action is most appropriate? a. Start an epidural IV. b. Call the previous hospital to verify the date. c. Anticipate an order to discontinue the intraosseous IV. d. Immediately discontinue the intraosseous IV.

c. Anticipate an order to discontinue the intraosseous IV.

The nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What will the nurse do first? a. Check connections. b. Check the infusion rate. c. Assess the insertion site. d. Discontinue the IV and start another.

c. Assess the insertion site.

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? a. "I do not know how long my wife will be able to take care of me at home." b. "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." c. "I do not know how much longer my neighbor can continue to help clean my house." d. "The bus is coming to pick me up from the senior center three times a week so I can play cards."

d. "The bus is coming to pick me up from the senior center three times a week so I can play cards."

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? a. Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia. b. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. c. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. d. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

d. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. What syringe should the nurse use to draw up and administer the heparin?

Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC.

Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management? a. See your ophthalmologist for visual field testing every 6 months. b. Report a reduction of joint swelling to your rheumatology health care provider immediately. c. Report a worsening of joint swelling to your rheumatology health care provider immediately. d. See your ophthalmologist for intraocular pressure measurement every 6 months.

a. See your ophthalmologist for visual field testing every 6 months.

The nurse is documenting peripheral venous catheter insertion for a client. What will the nurse include in the note? (Select all that apply.) a. Vein used for insertion b. Client's response to the insertion c. Date and time inserted d. Client's name and hospital number e. Type of dressing applied f. Type and size of device

a. Vein used for insertion b. Client's response to the insertion c. Date and time inserted e. Type of dressing applied f. Type and size of device

Which nursing action reflects systems thinking? a. Giving report to the next shift including client status b. Developing a quality improvement initiative for respiratory assessment c. Documenting the client's lung sounds each shift d. Reviewing best practice for respiratory assessment

b. Developing a quality improvement initiative for respiratory assessment

The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? a. Massage and hypnosis. b. Hot compresses or moist heating pad. c. Glucosamine and chondroitin combination. d. Ice packs used every 3 to 4 hours during the day.

b. Hot compresses or moist heating pad.

A 22-year-old client presents with appendicitis and is preparing for surgery. What gauge catheter will the ED nurse select for this client? a. 22 b. 14 c. 18 d. 24

c. 18

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent b. Gives the client accurate information when questioned c. Keeps the promises made to the client and family d. Treats the client fairly compared to other clients

ANS: A Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care b. Ensures that all the client's basic needs are met c. Tells the client and family about all upcoming tests d. Thoroughly orients the client and family to the room

ANS: A Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, client education, and empowerment. By assessing the effect of the client's culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care.

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the doctors phone number by the telephone. c. Make sure all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

ANS: A Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes.

ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting the rapid care to the client.

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching? a. Avoid carrying your grandchild with the arm that has the central catheter. b. Be sure to place the arm with the central catheter in a sling during the day. c. Flush the peripherally inserted central catheter line with normal saline daily. d. You can use the arm with the central catheter for most activities of daily living.

ANS: A A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

A major serum protein that is below normal in patients who have inadequate nutrition is: a. Albumin b. Globulin c. Fibrinogen d. Transferrin

ANS: A A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

ANS: A All activities would be beneficial for the older population in the community. However, failure in performing ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

ANS: A All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

ANS: A All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed.

ANS: A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion.

A clients chart indicates anisocoria. For what should the nurse assess? a. Difference in pupil size b. Draining infection c. Recent eye trauma d. Tumor of the eyelid

ANS: A Anisocoria is a noticeable difference in the size of a persons pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

A serious condition which is not locally observable and is typically manifested by decreased blood flow to a distal extremity is known as thrombosis. a. arterial b. venous c. partial d. atrial

ANS: A Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For example, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood to the leg. This is an emergent condition and requires immediate intervention.

Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta or through breast milk is called: a. natural passive b. artifical passive c. natural active d. artifical active

ANS: A Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or immunization.

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow

ANS: A Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

A group of nursing students has entered a futuristic science contest in which they have developed a cure for cancer. Which treatment would most likely be the winning entry? a. Artificial fibronectin infusion to maintain tight adhesion of cells b. Chromosome repair kit to halt rapid division of cancer cells c. Synthetic enzyme transfusion to allow rapid cellular migration d. Telomerase therapy to maintain chromosomal immortality

ANS: A Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.

The process to control cellular growth, replication, and differentiation to maintain homeostasis is called: a. cellular regulation. b. cellular impairment. c. cellular reproduction. d. cellular tumor.

ANS: A Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function within the body.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

ANS: A Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction? a. I always lose my sunglasses, so I dont wear them. b. I have diabetes and get an annual eye exam. c. I will not share my contact solution with others. d. I will wear safety glasses when I mow the lawn.

ANS: A Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

ANS: A Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

ANS: A Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? a. Maybe; preservatives, dyes, and preparation methods may be risk factors. b. No; research studies have never shown those things to cause cancer. c. There are other things you can do that will more effectively lower your risk. d. Yes; preservatives and dyes are well known to be carcinogens.

ANS: A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer- promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the clients question.

The nurse reads on a clients chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? a. Bulging eyes b. Drooping eyelids c. Sunken-in eyes d. Yellow sclera

ANS: A Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

ANS: A Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem.

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

ANS: A Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. I have had the same best friend for decades. b. I think I am coping very well on my own. c. My kids come to see me every weekend. d. Oh, I have lots of friends at the senior center.

ANS: A Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I cant be exposed to the sun, I have been using a tanning bed.

ANS: A Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct? a. Inspect the clients distal finger joints. b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes. d. Perform range of motion on the clients wrists.

ANS: A Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

ANS: A If a postoperative clients oxygen saturation (SaO2) drops below 95% (or the clients baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. Drink 1 to 2 liters of water each day. b. Have 10 to 12 ounces of juice a day. c. Liver is a good source of iron. d. Never eat hard cheeses or sardines.

ANS: A Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

ANS: A Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the clients end-tidal carbon dioxide level. b. Document the findings in the clients chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

ANS: A Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

ANS: A Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Bakers cysts. b. Inspect the clients feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

ANS: A Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Hydrogen ions. b. Bicarbonate. c. Oxygen. d. Phosphate.

ANS: A Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen and phosphate are not characteristic of respiratory acidosis.

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic. c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.

ANS: A Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.

ANS: A The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this expertise. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

ANS: A The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg.

ANS: A The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the clients culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

ANS: A The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

ANS: A The nurse needs to conduct further assessment of the clients anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the clients feelings.

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

ANS: A The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.

While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a. Grade 3 phlebitis at IV site b. Infection at IV site c. Thrombosed area at IV site d. Infiltration at IV site

ANS: A The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls th surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

ANS: A This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the clients chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. Avoid large crowds or people who are ill. b. Stay upright for 1 hour after taking this drug. c. This drug may cause your hair to fall out. d. You may double the dose if pain is severe.

ANS: A This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

ANS: A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the clients functional abilities.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the clients white blood cell count. c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively.

ANS: A To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

ANS: A With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.) a. State Nurse Practice Act b. The facilitys Policies and Procedures manual c. The LPNs level of education and experience d. The Joint Commissions goals and criterion e. Client needs and prescribed orders

ANS: A, B The state Nurse Practice Act will have the information the RN needs, and in some states, LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it may be difficult and time- consuming to find it and read what LPNs are permitted to do, so another good solution would be for the nurse to check facility policy and follow it.

The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.) a. II b. III c. VI d. XII e. X

ANS: A, B, C The cranial nerves involved with eye function include II, III, IV, V, VI, and VII.

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy

ANS: A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off. e. Give raises based on compliance with reporting.

ANS: A, B, C, D A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE stands for standardize critical information, hardwire within your system, allow opportunities to ask questions, reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manager opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is hardwiring within the system. Encouraging staff to ask questions and think critically about the information is allowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff is resistive and other measures have failed, but this is not part of the SHARE model.

A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines

ANS: A, B, C, D Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present e. Removing hearing aids

ANS: A, B, C, D The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.

ANS: A, B, C, D There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

ANS: A, B, C, E Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

ANS: A, B, C, E People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldnt drive while you are taking this medication.

ANS: A, B, C, E Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included?(Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole

ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

ANS: A, B, D Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood

ANS: A, B, D The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor.

A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the clients plan of care. b. Remind the provider to perform hand hygiene prior to starting the procedure. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day.

ANS: A, B, D The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day. The practitioner who inserts the device should wear sterile gloves, gown and mask, and anyone in the room should wear a mask. A sterile dressing change should be completed per organizational policy, usually every 7 days and as needed.

The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements

ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interdisciplinary team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care

ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused care, using informatics in client care, and using quality improvement in client care.

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

ANS: A, B, D, E There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness

ANS: A, B, E Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the clients shoulder and arm on the operating table d. Preparing to suction the clients airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the clients shoulder and arm on the operating table d. Preparing to suction the clients airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation

ANS: A, C Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive bleeding, and extravasation are not common complications.

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

ANS: A, C, D, E Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. A malnourished client will have fragile skin. b. Malnourished clients always have other problems. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

ANS: A, C, D, E Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.

The student learning about vision should remember which facts related to the eyes? (Select all that apply.) a. Aqueous humor controls intraocular pressure. b. Cones work in low light conditions. c. Glaucoma occurs due to increased pressure in the eye. d. Muscles of the iris control light entering the eye. e. Rods work in low light conditions.

ANS: A, C, D, E The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions.

A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders

ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.

The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology

ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

ANS: A, D, E The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the clients safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

ANS: A, E The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the clients safety.

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a. Notify the health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

ANS: B A PICC that is functioning well without inflammation or infection may remain in place for months or even years. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the physician to have the IV route changed to an oral route.

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

ANS: B A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line.

ANS: B A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

ANS: B All MIS procedures have the potential for becoming open procedures depending on findings and complications. The clients consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.

ANS: B All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. Youre still taking your diabetic medication, right?

ANS: B All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

ANS: B As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

ANS: B At the first sign of phlebitis, the catheter should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1 F (37.8 C) d. Pain rating of 8 on a scale of 0 to 10

ANS: B Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101 F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol)

ANS: B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.

A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional state is known as: a. dementia b. delerium c. amnesia d. depression

ANS: B Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems.

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best? a. Call a time-out to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeons actions to the charge nurse and unit manager.

ANS: B During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then breaks scrub to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

ANS: B During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the clients airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.

The student nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle? a. Actual division (mitosis) b. Doubling of DNA c. Growing extra membrane d. No reproductive activity

ANS: B During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

ANS: B Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the clients questions before the client signs the consent form. The other actions are not appropriate.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the clients family sign the consent.

ANS: B In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the clients ability to provide consent.

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

ANS: B Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.

A defining characteristic of malignant (cancerous) cells is: a. they cannot spread to other tissues or organs. b. they can invade healthy cells, tissues, and organs. c. they are not usually a health risk. d. none of the above.

ANS: B Malignant (cancerous) cells have no comparison to the original cells from which they are derived, and they have the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On the other hand, Benign cells do not have the ability to spread to other tissues or organs.

A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Dont make assumptions about their health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse should never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

ANS: B Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the clients condition.

The inability to pass stool is known as __________. a. constipation b. obstipation c. diarrhea d. incontinence

ANS: B Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition where stool can be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum from constipation, and occurs when stool is watery and without solid form. Elimination is the general term to describe the excretion of waste from the body by the gastrointestinal tract and by the urinary system.

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

ANS: B Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. A: I would like you to order a different pain medication. b. B: This client has allergies to morphine and codeine. c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds. d. S: This client had a vaginal hysterectomy 2 days ago.

ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call physician might order. Situation describes what is happening right now that must be communicated; the clients surgery 2 days ago would be considered background. Assessment would include an analysis of the clients problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired; this information about the surgeons preference might be better placed in background.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

ANS: B SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

ANS: B Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the clients pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort.

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.

ANS: B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best? a. Inform the provider of the issue. b. Obtain a new bottle of eyedrops. c. Rinse the clients right eye thoroughly. d. Wipe the left eye bottle with alcohol.

ANS: B The nurse has contaminated the clean bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best? a. All staff nurses are required to participate in quality improvement here. b. Even being new, you can implement activities designed to improve care. c. Its easy to identify what indicators should be used to measure quality. d. You should ask to be assigned to the research and quality committee.

ANS: B The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

ANS: B The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

ANS: B This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you dont have ulcers, I will have to ask. d. The physician prescribed this medication for you.

ANS: B Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

ANS: B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurses expertise c. Client preferences d. Research findings e. Values of the client

ANS: B, C, D, E EBP consists of utilizing current evidence, the clients values and preferences, and the nurses expertise when planning care. It does not include cost-saving measures.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

ANS: B, C, D, E Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the clients identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths

ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

ANS: B, C, E The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

ANS: B, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

ANS: B, E A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a nose job).

The minimum hourly urinary output in a patient should be at least: a. 5 mL per hour b. 10 mL per hour c. 30 mL per hour d. 60 mL per hour

ANS: C 30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in urinary output i a sign of diminished kidney activity and fluid deficit.

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

ANS: C A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

ANS: C A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.

A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school.

ANS: C Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on safety. Nurse-client ratios differ by unit type and change over time. New technology doesnt necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most important.

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

ANS: C Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the clients gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

ANS: C An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

ANS: C Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.

ANS: C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

The best indicator of fluid volume changes in the body is: a. skin dryness b. weight changes c. blood pressure d. pulse rate

ANS: C Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary indicators.

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? a. You will need to wear a sling on your arm while the device is in place. b. There is no risk of infection because sterile technique will be used during insertion. c. Ask all providers to vigorously clean the connections prior to accessing the device. d. You will not be able to take a bath with this vascular access device.

ANS: C Clients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those are for old people. What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

ANS: C Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. A little sedation will help you get some rest. b. Depression often accompanies fibromyalgia. c. This drug works in the brain to decrease pain. d. You will have more energy after taking this drug.

ANS: C Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.

ANS: C Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

ANS: C Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptom once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adults life d. Usual leisure time activities

ANS: C Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the role that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole wheat bread

ANS: C Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. Cut some sodium out of your diet. b. Dehydration can cause incontinence. c. Have something to drink every 1 to 2 hours. d. Take your diuretic in the morning.

ANS: C Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

ANS: C Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

The most common causes of decreased comfort for a patient are pain and __________. a. light-headedness b. nausea c. emotional stress d. depression

ANS: C Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact the outcome of surgery.

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. Lets ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers.

ANS: C Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

ANS: C Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the clients food preferences as they relate to constipation.

A high-level thinking process that allows an individual to make decisions and judgments is known as: a. amnesia b. personality c. reasoning d. memory

ANS: C Reasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments. Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain and recall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and the clients mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the UAP knew how to take blood pressure b. Double-checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task

ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right away. An experienced UAP should know how to take vital signs and the nurse should not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the UAP.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

ANS: C The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The clients physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)

ANS: C The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that clients baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain

ANS: C The safety pin that prevents the drain from slipping back into the clients body should be pinned to the clients gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

ANS: C The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach Changing only the gloves or only the gown does not restore the sterile sections of the gown. Doing nothing is unacceptable.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I wont wash my incision to keep it dry.

ANS: C There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best? a. Doing this allows time for absorption. b. I am keeping the drops in the eye. c. This prevents systemic absorption. d. I am stopping you from rubbing your eye.

ANS: C This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. Foods high in vitamin A and vitamin C are important. b. Ill have to cut down on the amount of bacon I eat. c. Im so glad I dont have to give up my juicy steaks. d. Vegetables, fruit, and high-fiber grains are important.

ANS: C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan.

ANS: C With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.

ANS: C, D, E Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the clients skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

ANS: C, D, E The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be directed to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility as the RN is the one who performs that assessment.

A nurse is assessing a client with glioblastoma. What assessment is most important? a. Abdominal palpation b. Abdominal percussion c. Lung auscultation d. Neurologic examination

ANS: D A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.

ANS: D According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

ANS: D After ensuring the clients physiologic status is stable, these manifestations should lead the nurse to assess the clients psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.

ANS: D All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse

ANS: D An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.

A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death

ANS: D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

ANS: D As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the clients chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

ANS: D Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

Specialized cells that circulate in the body to promote clotting are called: a. anticoagulants. b. proteins. c. emboli. d. platelets.

ANS: D Clotting is a complex, multi-step process through which blood forms a protein-based clot to prevent excessive bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when an injury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary, localized, solid plug.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The clients left lower extremity is cool to the touch.

ANS: D Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess this perfusion problem.

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.

ANS: D Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying Lets just give her more time, okay? sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

ANS: D Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

ANS: D For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.

Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in: a. calcium b. magnesium c. sodium d. potassium

ANS: D Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.

A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

The best way for an individual to maintain acid-base balance is to a. avoid or quit smoking. b. exercise regularly. c. eat healthy and well-balanced meals. d. All of the above.

ANS: D Maintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most cases of COPD can be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet can decrease the incidence of type-2 diabetes.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the clients hands. d. Use an abduction pillow.

ANS: D Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the clients white blood cell count. b. Culture any drainage from the wound. c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes.

ANS: D Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

ANS: D Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the clients chart that the cancer classification is TISN0M0. What does the nurse conclude about this clients cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.

ANS: D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

ANS: D The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. Provide a bed bath instead of letting the client take a shower. b. Use sterile technique when changing the dressing. c. Disconnect the intravenous fluid tubing prior to the clients bath. d. Use a plastic bag to cover the extremity with the device.

ANS: D The nurse should ask the UAP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the UAP.

A nurse admits an older client from a home environment where she lives with her adult son and daughter- in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

ANS: D These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

ANS: D To protect the clients skin, the nurse should place a washcloth or the clients gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the clients skin.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids

ANS: D Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV should have one, but this does not take priority over the client whose arm is swollen.

A nurse participates as part of a quality improvement (QI) team to develop a plan to "reduce deep vein thrombosis on a surgical unit." What part of the PICO(T) question does this statement represent?

O (Outcome) P = population/problem I = intervention C = comparison O = outcome T = time

As a result of work completed by a quality improvement (QI) team, a new nursing protocol for preventing catheter-associated urinary tract infections (CAUTIs) is piloted. Which step of the PDSA QI model is associated with this action?

S (Study) P = plan D = do S = study A = act

The nurse prepares to teach a client at risk for increased clotting about interventions to prevent clots. What health teaching would the nurse include? (Select all that apply.) a. "Avoid prolonged periods of sitting." b. "Walk around frequently as much as you can." c. "Avoid crossing your legs when sitting." d. "Drink plenty of fluids, including water." e. "Seek smoking cessation programs if needed." f. "Report any unusual bleeding or bruising."

a. "Avoid prolonged periods of sitting." b. "Walk around frequently as much as you can." c. "Avoid crossing your legs when sitting." d. "Drink plenty of fluids, including water." e. "Seek smoking cessation programs if needed."

The nurse is interviewing a transgender client about sexual orientation, gender identity, and health care. Which questions are appropriate as part of the interview? (Select all that apply.) a. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" b. "Do you have problems being accepted because you are different?" c. "If you have more than one sexual partner, how are you protecting both of you from infections?" d. "Do you have sex with men, women, both, or neither?" e. "Are you in a relationship with someone who lives with you?"

a. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" c. "If you have more than one sexual partner, how are you protecting both of you from infections?" d. "Do you have sex with men, women, both, or neither?" e. "Are you in a relationship with someone who lives with you?"

The nurse prepares a presentation on promoting a healthy gut at a health fair. Which information should the nurse include to prevent constipation? (Select all that apply.) a. "Increase the amount of fresh fruits and vegetables in diet." b. "Do not ignore the urge to defecate." c. "Use over-the-counter laxatives frequently." d. "Decrease the amount of fiber in diet." e. "Maintain fluid intake of at least 2000 mL/day." f. "Establish a regular exercise routine."

a. "Increase the amount of fresh fruits and vegetables in diet." b. "Do not ignore the urge to defecate." e. "Maintain fluid intake of at least 2000 mL/day." f. "Establish a regular exercise routine."

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? a. "The grocery store in my neighborhood went out of business." b. "The landlord of my apartment is putting in an access ramp for wheelchairs." c. "I work with a lot of toxic chemicals in my job." d. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

a. "The grocery store in my neighborhood went out of business."

Which client arterial blood pH value will the nurse interpret as normal? a. 7.37 b. 7.27 c. 7.47 d. 7.5

a. 7.37

Which client arterial blood pH value indicates to the nurse the lowest concentration of free hydrogen ions? a. 7.45 b. 7.42 c. 7.36 d. 7.29

a. 7.45 The concentration of hydrogen ions is inversely (negatively) related to the pH. Thus the lower the pH, the higher the concentration of hydrogen ions and the higher the pH, the lower the concentration of free hydrogen ions. The pH of 7.29 represents the greatest concentration of free hydrogen ions in this list and the pH of 7.45 represents the lowest concentration of free hydrogen ions.

For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis? a. A 35 year old with drug-induced hemolytic anemia b. A 30 year old with poison ivy lesions on 60% of the body c. A 25 year old with penicillin-induced anaphylaxis d. A 40 year old with angioedema and tongue swelling

a. A 35 year old with drug-induced hemolytic anemia Drug-induced hemolytic anemia is a type II hypersensitivity reaction in which the body makes autoantibodies directed against red blood cells that have foreign proteins from the drug attached to them. In this type of reaction, the autoantibody binds to red blood cells, forming immune complexes that destroy red blood cells along with the attached protein. Management starts with discontinuing the offending drug and, performing plasmapheresis (filtration of the plasma to remove specific substances) to remove the formed autoantibodies. Plasmapheresis is not beneficial with other types of hypersensitivity reactions.

Which client is at greatest risk for developing an infection? a. A 65-year-old woman who had heart surgery 4 days ago b. A 54-year-old man with hypertension c. A 21-year-old woman with a fractured tibia in a cast d. A 71-year-old man in a nursing home

a. A 65-year-old woman who had heart surgery 4 days ago

Which nursing action demonstrates use of the principle of justice? a. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. b. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. c. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. d. The parents of a 13 year old are included in discussions about the course of their teen's treatment and care.

a. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer.

Which client will the nurse consider to be at greatest risk for dehydration?? a. A 75-year-old woman with chronic back pain b. A 25-year-old woman taking oral contraceptives c. A 75-year-old man who has a vitamin deficiency d. A 25-year-old man who has frequent esophageal reflux

a. A 75-year-old woman with chronic back pain Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

A client is preparing to give a client an antipyretic drug for a temperature of 101° F (38.3° C). What drug would be the most appropriate for the nurse to administer? a. Acetaminophen b. Aspirin c. Doxycycline d. Ibuprofen

a. Acetaminophen

Which acid-base problem does the nurse expect when the ventilator of a client being mechanically ventilated is set at too high a rate of breaths per minute for 6 hours? a. Acid-deficit alkalosis b. Acid excess acidosis c. Base excess alkalosis d. Base-deficit acidosis

a. Acid-deficit alkalosis A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.

The nurse receives the shift report. Which client would the nurse anticipate a need for arterial blood gas assessment? a. Admitted for excessive salicylate ingestion b. Admitted with chronic pancreatitis c. Recent diagnosis of mild chronic obstructive lung disease d. History of controlled type 2 diabetes

a. Admitted for excessive salicylate ingestion

Which problem does the nurse expect resulted in a client's acid-base imbalance during an illness that causes vomiting for 2 days? a. Alkalosis from overelimination of hydrogen ions b. Acidosis from overproduction of of hydrogen ions c. Alkalosis from overproduction of bicarbonate ions d. Acidosis from underelimination of bicarbonate ions

a. Alkalosis from overelimination of hydrogen ions Prolonged or excessive vomiting results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid is lost in the vomit.

Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN? a. An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. b. A client receiving blood products after excessive blood loss during surgery. c. A client admitted for hyperglycemia who has an IV insulin drip and needs frequent glucose checks. d. A client who has a diltiazem IV infusion being titrated to maintain a heart rate between 60 and 80 beats/min.

a. An older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours. The older client admitted for confusion with a heparin lock is the most stable and requires basic monitoring of the IV site for common complications such as phlebitis and local infection, which would be familiar to an LPN/LVN.The client with a diltiazem IV infusion, the client with an IV insulin drip, and the client receiving blood products all are not stable and will require ongoing assessments and adjustments in IV therapy that should be performed by an RN.

The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) a. Apply pneumatic or sequential compression devices. b. Administer anticoagulant therapy. c. Ambulate the client on the day of surgery. d. Elevate the client's legs. e. Keep the legs slightly abducted.

a. Apply pneumatic or sequential compression devices. b. Administer anticoagulant therapy. c. Ambulate the client on the day of surgery.

The nurse is starting a peripheral IV catheter on a client who was recently admitted. What actions does the nurse perform before insertion of the line? (Select all that apply.) a. Apply povidone-iodine to clean skin, dry for 2 minutes. b. Prepare the skin with 70% alcohol or chlorhexidine. c. Clean the skin around the site. d. Wear clean gloves and touch the site only with fingertips after applying antiseptics. e. Shave the hair around the area of insertion.

a. Apply povidone-iodine to clean skin, dry for 2 minutes. b. Prepare the skin with 70% alcohol or chlorhexidine. c. Clean the skin around the site.

A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened 20 hours ago. What action will the nurse take? a. Change the set in about 4 hours. b. Nothing; the set is for long-term use. c. Change the set immediately. d. Change the set in the next 12 to 24 hours.

a. Change the set in about 4 hours.

What is the pathophysiologic basis for Lyme disease progression to stage III? a. Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels b. Failure of the immune system to recognize the causative organism as non-self, allowing it to become a systemic infection c. Triggering of antibodies against infected cells that lead to autoimmune disease d. The special ability of Borrelia burgdorferi to burrow deeply into joint, cardiac, and neurons causing direct damage to these tissues.

a. Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels The causative organisms can switch out parts of its unique surface proteins, which changes the ability of immune sensitized system cells and antibodies to recognize the existing infecting organism allowing it to "hide." Every time a switch occurs, the immune system treats them like a new infection, and develops new antibodies and inflammatory responses to them, resulting in keeping all general and specific immunity actions in continual but ineffective attack mode through all stages of the disease process. This prolonged and continuous process results in persistent and enhanced damage to a variety of tissues and organs.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what will the nurse do to ensure safety? a. Check for blood return. b. Administer 5 mL of a heparinized solution. c. Flush the port with 10 mL of normal saline. d. Palpate the port for stability.

a. Check for blood return. To ensure safety, before a drug is given through an implanted port, the nurse must first check for blood return. If no blood return is observed, the drug should be held until patency is reestablished.If no blood return is observed, the drug should be held until patency is re-established. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety.

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? a. Checking pulse oximetry b. Measuring blood pressure c. Listening to bowel sounds in all four quadrants d. Observing the ECG for flat T-waves

a. Checking pulse oximetry Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) a. Collaboration between members of the interprofessional health care team b. Health policy legislation at the state and national level c. The culture to which the client identifies d. What the individual client believes about health? e. Technology that is available in the local community health center f. The application of systems thinking to care of clients

a. Collaboration between members of the interprofessional health care team b. Health policy legislation at the state and national level c. The culture to which the client identifies d. What the individual client believes about health? e. Technology that is available in the local community health center f. The application of systems thinking to care of clients

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? a. Deflating the blood pressure cuff and giving the client oxygen b. Documenting the finding as the only action Initiating the Rapid Response Team c. Placing the client in the high-Fowler position and increasing the IV flow rate

a. Deflating the blood pressure cuff and giving the client oxygen

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? a. Determining that a new blood pressure reading of 190/100 requires intervention now b. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90 c. Administering amlodipine 5 mg orally once daily d. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake

a. Determining that a new blood pressure reading of 190/100 requires intervention now

The nurse is to administer a unit of whole blood to a postoperative client. What will the nurse do to ensure the safety of the blood transfusion? a. Ensure that another qualified health care professional checks the unit before administering. b. Check the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed. c. Make certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit. d. Ask the client to both say and spell his or her full name before starting the blood transfusion.

a. Ensure that another qualified health care professional checks the unit before administering.

Where do free hydrogen ions normally come from in the human body? (Select all that apply.) a. Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. b. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. c. Ingestion of spicy food increases the concentration of uncontrolled free hydrogen ions. d. The kidney produces hydrogen ions when a urinary tract infection is present. e. Humans breathe in free hydrogen ions in the atmosphere from the buildup of greenhouse gases. f. Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions.

a. Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. b. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. f. Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions. Normal metabolic functions such as metabolism of carbohydrates, proteins, and fats for fuel all result in products that contribute to the free hydrogen ion concentration. Hydrochloric acid in the stomach is broken down into free hydrogen ions and chloride ions. Exercising muscles produce some lactic acid, which also contributes to normal hydrogen ion production. The hydrogen ions present in the urine during a urinary tract infection are produced by the bacteria, not the kidney. Greenhouse gases are not a normal source of free hydrogen ions and neither is the ingestion of spicy foods.

The nurse is teaching a group of senior citizens about recommended immunizations. What immunizations would the nurse include? (Select all that apply.) a. Herpes zoster vaccine b. Pneumococcal vaccine polyvalent vaccine c. Adult Tdap with Td booster every 10 years d. Annual influenza vaccine e. Pneumococcal 13-valent conjugate vaccine

a. Herpes zoster vaccine b. Pneumococcal vaccine polyvalent vaccine c. Adult Tdap with Td booster every 10 years d. Annual influenza vaccine e. Pneumococcal 13-valent conjugate vaccine

The nurse recognizes that handwashing is the best method for preventing infection. Which action(s) by the Centers for Disease Control (CDC) about hand hygiene are recommended? (Select all that apply.) a. If hands are not visibly soiled, use an alcohol-based hand rub. b. Wash hands before and after wearing gloves. c. If hands are visibly soiled, wash them with soap and water. d. Use only soap and water for hand hygiene when planning client contact. e. Wash hands before performing any invasive client procedure.

a. If hands are not visibly soiled, use an alcohol-based hand rub. b. Wash hands before and after wearing gloves. c. If hands are visibly soiled, wash them with soap and water. e. Wash hands before performing any invasive client procedure.

What type of health problem will the nurse expect to see in a client who has very few regulator T cells? a. Increased severity of allergic and other hypersensitivity reactions b. Decreased ability to recognize non-self cells c. Decreased immunoglobulin production d. Increased risk for cancer development

a. Increased severity of allergic and other hypersensitivity reactions Regulator T-cells (Tregs) function to limit the actions of general and specific responses. These cells prevent over-responses to the presence of "foreign proteins" within a person's environment. People who are deficient in these cells have more severe hypersensitivity reactions, allergies, and autoimmune responses.

After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.) a. Keep the device with you at all times. b. After administering the device, hospital monitoring is necessary. c. Use the device before calling 911. d. If the drug becomes discolored, order a replacement device. e. The device CANNOT be given through clothing. f. Inject the device into your arm or your leg.

a. Keep the device with you at all times. b. After administering the device, hospital monitoring is necessary. c. Use the device before calling 911. d. If the drug becomes discolored, order a replacement device.

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) a. Management of hypertension with an angiotensin converting enzyme inhibitor b. Presence of chronic kidney disease c. Vegan diet d. Excessive use of salt substitute e. Daily therapy with a potassium-sparing diuretics f. Past history of hepatitis A

a. Management of hypertension with an angiotensin converting enzyme inhibitor b. Presence of chronic kidney disease d. Excessive use of salt substitute e. Daily therapy with a potassium-sparing diuretics Potential causes of hyperkalemia include excessive use of salt substitutes (which contain high levels of potassium), chronic kidney disease (which prevents adequate excretion of potassium), daily use of a potassium-sparing diuretic (reduces potassium excretion), and the use of an angiotensin converting enzyme inhibitor. Neither a vegan diet nor previous illness with hepatitis A is associated with development of hyperkalemia.

The nurse is providing health teaching at a health fair about preventing influenza. What adult groups are at risk for contracting this disease due to altered immunity? (Select all that apply.) a. Nonimmunized adults b. Adults who do not practice a healthy lifestyle c. Adults with substance use disorder d. Women who are pregnant e. Older adults f. Adults with chronic illness

a. Nonimmunized adults b. Adults who do not practice a healthy lifestyle c. Adults with substance use disorder e. Older adults f. Adults with chronic illness

With which client conditions will the nurse expect an inflammatory response without infection? (Select all that apply.) a. Poison ivy rash b. Otitis media c. Welt formation after a bee sting d. Blister formation from a burn e. Blister from a cold sore f. Acute myocardial infarction

a. Poison ivy rash c. Welt formation after a bee sting d. Blister formation from a burn f. Acute myocardial infarction

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) a. Red meat b. Cereal c. Citrus fruit d. Salt substitutes e. Eggs f. Bread

a. Red meat c. Citrus fruit d. Salt substitutes While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

The nurse is planning care for a client who has decreased mobility. With which interprofessional health care team members would the nurse most likely collaborate? (Select all that apply.) a. Registered dietitian nutritionist (RDN) b. Registered occupational therapist (OTR) c. Primary health care provider (PHCP) d. Respiratory therapist (RT) e. Registered physical therapist (RPT)

a. Registered dietitian nutritionist (RDN) b. Registered occupational therapist (OTR) c. Primary health care provider (PHCP) d. Respiratory therapist (RT) e. Registered physical therapist (RPT)

Which precautions are most important for the nurse to teach as part of health promotion for inflammation and immunity to an 88-year-old client? (Select all that apply.) a. Report any temperature elevation to your primary health care provider immediately. b. Get an influenza vaccination every year. c. Wear gloves when working in your garden. d. Avoid performing any level of aerobic exercise. e. Consider moving into an assisted living facility. f. Be sure to have a tuberculosis skin test every year.

a. Report any temperature elevation to your primary health care provider immediately. b. Get an influenza vaccination every year. c. Wear gloves when working in your garden. Older clients have overall reduced immunity and a higher risk for developing influenza and any other respiratory tract infection. They should receive annual influenza vaccinations. The skin of older adults is thinner, drier, and a greater risk for injury and infection. Wearing gloves when gardening can help prevent injury and reduce the risk for infection. Older clients often do not have greatly elevated temperatures during infection, which contributes to the infection being overlooked until it becomes serious. Thus, older clients should report any increase in temperature above their normal range to identify infections at earlier stages. TB skin tests may be falsely negative in older clients with reduced immunity and annual testing is of no real benefit. Healthy older clients who are cognitively intact and able to care for themselves have no need to change their living arrangements unless they so desire. Older clients can still engage in low-impact aerobic exercise under the supervision of their primary health care provider.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? a. Reports having a bowel movement daily. b. ECG shows an inverted T wave. c. Fasting blood glucose level is 106 mg/dL. d. Two lb weight gain during the past week.

a. Reports having a bowel movement daily. Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

Which acid-base disturbance will the nurse remain alert for when caring for a client who has chest burns with tight eschar banding the chest? a. Respiratory acidosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory alkalosis

a. Respiratory acidosis The tight eschar on the chest can limit chest movement and make breathing less effective with hypoventilation. This problem results in inadequate oxygenation and retention of carbon dioxide, causing respiratory acidosis. Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid-base disturbances are usually caused by nonrespiratory issues.

The nurse is preparing to insert a peripheral venous catheter. What action will the nurse take? a. Select the most distal site. b. Look near the elbow joint first. c. Palpate for hardness of a vein. d. Use the client's dominant arm for insertion.

a. Select the most distal site.

Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? a. Serum calcium b. Serum magnesium c. Serum glucose level d. Serum sodium

a. Serum calcium A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider so actions can be taken to prevent harm.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? a. Shortened QT-interval b. Absent P wave c. Prominent U wave d. Inverted T waves

a. Shortened QT-interval Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow.

The nurse is teaching a health and wellness class at a local senior citizen center. When discussing methods to promote cognition, which options would be included? (Select all that apply.) a. Take music lessons. b. Watch television. c. Read the newspaper. d. Complete crossword puzzles. e. Play card games. f. Learn a new language.

a. Take music lessons. d. Complete crossword puzzles. f. Learn a new language.

A client who was treated last month for a severe respiratory infection reports many of the same symptoms today. Which factor in the client's use of antibiotic therapy most likely caused the client's relapse? a. Taking the antibiotic most days b. Taking the antibiotic as prescribed c. Taking the antibiotic before jogging 2 miles daily d. Taking the antibiotic with a full glass of water

a. Taking the antibiotic most days

The nurse is caring for a client who has delirium. Which statement is correct regarding this health problem? a. The focus of managing delirium is to treat the cause. b. Delirium takes months to years to develop. c. The cause of delirium is not known. d. Validation therapy is the best approach for delirium.

a. The focus of managing delirium is to treat the cause.

Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.) a. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. b. Type IV responses are usually directed against non-self but the response is excessive. c. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema. d. The secondary phase, when prolonged, is primarily responsible for autoimmune disorders. e. Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. f. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.

a. The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. b. Type IV responses are usually directed against non-self but the response is excessive. e. Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. f. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine.

The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? a. Trauma to the joint b. Aging c. Osteoporosis d. Familial history

a. Trauma to the joint

The nurse is preparing to draw blood from a client receiving a course of vancomycin about 30 minutes before the next scheduled dose. For what laboratory test would the blood specimen be most likely tested? a. Trough drug level b. Blood culture and sensitivity c. White blood cell (WBC) count d. Peak drug level

a. Trough drug level When clients receive some intravenous antibiotics, it is essential that the levels of the drug stay consistent within a therapeutic range. To determine if that is the case, peak and trough levels are drawn. A trough level indicates the lowest level of drug available in the blood and is drawn shortly before the next scheduled drug dose. A peak level is assessed 30 to 60 minutes after the drug is given. A culture and sensitivity would not be done while the client is on antibiotics. The WBC count should be decreasing as a result of antibiotic therapy.

Which type of hypersensitivity reaction will the nurse suspect in a client who develops as circular rash on the skin underneath a new necklace worn for 3 days? a. Type IV b. Type I c. Type II d. Type III

a. Type IV A type I reaction occurs rapidly after exposure and is mediated by immunoglobulin E (IgE). Type II reactions occur when the body makes autoantibodies directed against self-cells and attack those cells. Type III reactions occur when an abundance of immune complexes are made and they get stuck in small vessels causing inflammation. A type IV delayed hypersensitivity reaction occurs when sensitized T-cells respond to an antigen by releasing chemical mediators and triggering macrophages. This reaction causes a rash as seen in a metal allergy exposure.

Which types of problems will the nurse expect to find more frequently in a client who does not make adequate amounts of immunoglobulin A (IgA)? (Select all that apply.) a. Upper respiratory infections b. Cystitis c. Excessive bleeding d. Contact dermatitis e. Anaphylaxis f. Diarrhea

a. Upper respiratory infections b. Cystitis f. Diarrhea IgA is the secretory immunoglobulin that is present in highest concentrations in the secretions of the mouth, gastrointestinal tract, and genitourinary tract. IgA helps prevent infections in these body areas and does not circulate in significant amounts. It is not associated with any types of allergic reactions such as anaphylaxis or contact dermatitis. It plays no role in the blood clotting cascade.

The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? (Select all that apply.) a. Using nasal mupirocin for at least a week before surgery b. Avoiding sleeping with pets in the client's bed c. Showering the night before and the morning of surgery with chlorhexidine d. Giving antibiotics before and after surgery for at least 3 days e. Sleeping on clean linen wearing clean nightwear

a. Using nasal mupirocin for at least a week before surgery b. Avoiding sleeping with pets in the client's bed c. Showering the night before and the morning of surgery with chlorhexidine e. Sleeping on clean linen wearing clean nightwear

Which conditions could cause a client to develop acidosis? (Select all that apply.) a. Ventilator at too low a tidal volume b. Sepsis c. Severe diarrhea d. Hypovolemic shock e. Prolonged nasogastric suctioning f. Hyperventilation

a. Ventilator at too low a tidal volume b. Sepsis c. Severe diarrhea d. Hypovolemic shock Sepsis and hypovolemic shock result in anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. When a ventilator is set at too low of a tidal volume for the client's size, hypoventilation occurs with poor gas exchange and retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis. Hyperventilation can result in respiratory alkalosis, not acidosis. Prolonged nasogastric suctioning results in a loss of hydrochloric acid and leads to an acid-deficit metabolic alkalosis.

While in the hospital, a client developed a methicillin-resistant infection in an open foot ulcer. Which nursing action would be appropriate for this client? a. Wear a gown and gloves to prevent contact with the client or client-contaminated items. b. Have the client wear a surgical mask when being transported out of the room. c. Wear a mask when working within 3 feet (91 cm) of the client. d. Assign the client to a private room with a negative airflow.

a. Wear a gown and gloves to prevent contact with the client or client-contaminated items.

What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, "My face has changed so much. I feel really ugly"? a. "I know what you mean, I feel that way sometimes too." b. "I bet that was hard to say. Thank you for trusting me with your feelings." c. "Don't worry, treatment will make everything better." d. "You look great. It's what is inside that counts."

b. "I bet that was hard to say. Thank you for trusting me with your feelings."

The nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection and is starting oral delafloxacin therapy. What health teaching would the nurse include about this drug? a. "Take the drug every day until you feel you better or until your fever does away." b. "Take the drug at least 2 hours before or 6 hours after any antacids or minerals." c. "Take the drug every other day as prescribed unless you feel nauseated." d. "If you forget a dose of the drug, wait until the next day to take the next dose."

b. "Take the drug at least 2 hours before or 6 hours after any antacids or minerals."

What is the nurse's best response to a 38-year-old client with a large wound who does not want to receive a tetanus toxoid vaccination because he had a tetanus shot just 1 year ago? a. "Tetanus is a more serious disease and a "booster" is required every year to ensure adequate immunity and protection against it." b. "You may not need this vaccination now, I will check with your health care provider." c. "You need this vaccination because the strain of tetanus changes every year." d. "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago."

b. "You may not need this vaccination now, I will check with your health care provider." When people have been "boosting" their tetanus antibodies on a regularly scheduled basis, they should have sufficient circulating antibodies to mount a defense against exposure to tetanus. If this client's medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, he does not need another one now.

What is the most important precaution for the nurse to teach a client who has few natural killer cells and the natural killer cells are not very active? a. "You will need to avoid people with viral infections because it is harder now for you to develop antibodies." b. "You will need to have yearly checkups because your risk for cancer development is greater now." c. "You will be at an increased risk for developing allergies, so it will be necessary for you to avoid common allergens." d. "You will no longer develop a fever when you have an infection, so you must learn to identify other symptoms of infection."

b. "You will need to have yearly checkups because your risk for cancer development is greater now."

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? a. 3000 b. 6300 c. 9300 d. 7000

b. 6300 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL).

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? a. A 26 year old with hyperparathyroidism b. A 70 year old who has alcoholism and malnutrition c. A 40 year old taking tetracycline for an infection d. A 35 year old athlete taking NSAIDs for joint pain

b. A 70 year old who has alcoholism and malnutrition

Which client situation reflects the health care system of managed care? a. A client obtains vaccinations at a local community health center that is close to home. b. A client receives an annual physical where the cost has been predetermined as $80. c. A client sees a designed family physician who coordinates all aspects of the client's care. d. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

b. A client receives an annual physical where the cost has been predetermined as $80.

A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? a. Ibuprofen b. Acetaminophen c. Tramadol d. Gabapentin

b. Acetaminophen

For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.) a. Hyperactive deep tendon reflexes b. Acute confusion c. Lethargy d. Hypotension e. pH 7.49 f. Tall T-waves

b. Acute confusion c. Lethargy d. Hypotension f. Tall T-waves When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). The pH will be below 7.35, which is a characteristic of acidosis. Acute confusion occurs because of reduced gas exchange and reduced cognition.

Which client health problems will the nurse identify as an infectious process along with inflammation rather than inflammation alone? (Select all that apply.) a. Tendonitis b. Appendicitis c. Asthma d. Cystitis e. Anaphylaxis f. Sepsis

b. Appendicitis d. Cystitis f. Sepsis Appendicitis is most commonly the result of an infectious process (usually bacterial), as is sepsis, although a widespread inflammatory response can accompany sepsis. Cystitis is a bladder infection most often with a bacterial infection cause. s are commonly caused by bacterial and viral infections. Tendonitis usually is a result of a closed or overuse injury and is characterized by inflammation without infection. Anaphylaxis is an allergic response, not an infection. Asthma is an irritant/allergic reaction, not an infection although a respiratory infection makes asthma worse.

Which action is the priority for the nurse to take to prevent harm for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min? a. Asking about exposure to possible allergens b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100% c. Reassuring the client that appropriate interventions are being instituted d. Starting an IV infusion of normal saline

b. Applying oxygen via a high-flow nonrebreather mask at 90% to 100% The immediate priority is to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

Which type of immunity will the nurse initiate by administering an infusion of IV immunoglobulin to a client? a. Natural active immunity b. Artificial passive immunity c. Artificial active immunity d. Natural passive immunity

b. Artificial passive immunity The client will be receiving antibodies made in the body of another person and thus, is not actively involved in the production of these antibodies. That makes the immunity passive rather than active. Because the client is making the antibodies in response to an injection (vaccination) rather than in response to actually being sick with influenza, the immunity is artificial.

What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare? a. Check all your stools for the presence of blood or a black, tarry appearance. b. Do not suddenly stop taking the drug when your flare is over. c. Be sure to take this drug with food. d. Take 30 mg in the morning and 15 mg at night.

b. Do not suddenly stop taking the drug when your flare is over.

A male client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work where he received 12 hours of IV fluids. On assessment, the nurse notes the presence of a palpable cord 1 inch (2.5 cm) in length and streak formation. How will the nurse document the assessment? a. Grade 2 phlebitis b. Grade 3 phlebitis c. Grade 1 phlebitis d. Grade 4 phlebitis

b. Grade 3 phlebitis Grade 1 = only erythema with or without pain; the client has additional symptoms. Grade 2 = only pain at the access site with erythema and/or edema; the client has additional symptoms. Grade 3 = pain at the access site with erythema and/or edema and streak formation with a 1' palpable cord. Grade 4 = pain at the access site with erythema and/or edema, streak formation, a palpable venous cord longer than 1 inch (2.5 cm), and purulent drainage. No purulent drainage is present in this client, and the palpable cord is 1 inch (2.5 cm) in length.

Which assessment finding on a client with no other health problems does the nurse consider the greatest potential threat to the client's immune system? a. Has old scar formation related to an appendectomy. b. Has poor oral hygiene and numerous dental caries. c. Displays orthostatic hypotension and is mildly dehydrated. d. Displays occasional skipped heartbeats during auscultation.

b. Has poor oral hygiene and numerous dental caries.

The nurse is caring for a client diagnosed with bowel and bladder incontinence. Which is a priority collaborative problem for this client? a. Indequate nutrition b. Impaired skin integrity c. Altered level of consciousness d. Decreased fluid volume

b. Impaired skin integrity

The nurse is caring for a client at end of life. What is the nurse's priority for the client's care? a. Promote coping. b. Increase comfort. c. Ensure adequate nutrition. d. Maintain breathing.

b. Increase comfort.

The nurse requests a conference with members of the interprofessional health care team regarding care for a complex client. Which Interprofessional Education Collaborative Competency does this request represent? a. Role-Responsibilities b. Interprofessional Communication c. Values/Ethics for Interprofessional Practice d. Teams and Teamwork

b. Interprofessional Communication

A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the charge nurse teach the new nurse to use for this client? a. Short peripheral catheter b. Midline catheter c. Peripherally inserted central catheter d. Tunneled percutaneous central catheter

b. Midline catheter For a client with fragile veins (which occur with long-term corticosteroid use) and the need for a catheter for 5 days, the midline catheter is the best choice.Tunneled central catheters usually are used for clients who require IV access for longer periods. Peripherally inserted central catheters usually are used for clients who require IV access for longer periods. A short peripheral catheter is likely to infiltrate before 5 days in a client with fragile veins, requiring reinsertion.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? a. Nose and ears have a slightly yellow-tinged appearance. b. Neck veins are now distended in the sitting position. c. Breath sounds can be heard in the right lower lung lobe. d. Weight is unchanged from that obtained yesterday.

b. Neck veins are now distended in the sitting position. Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status.

The nurse is teaching a health and wellness class. What would the nurse include in the discussion of common risk factor for impaired cellular regulation? (Select all that apply.) a. Drinking alcohol b. Smoking c. Over the age of 70 d. Poor nutrition e. Physical inactivity

b. Smoking c. Over the age of 70 d. Poor nutrition e. Physical inactivity

What is the nurse's interpretation of a laboratory result that indicates a client has a high blood concentration of IgG directed against the human papilloma virus? a. The client is at risk for major hypersensitivity reactions to attenuated vaccines. b. The client is mounting an appropriate response to a recurrent exposure to the virus. c. The client is in the midst of his or her first response to human papilloma infection. d. The client is at increased risk for becoming ill from opportunistic infectious organisms.

b. The client is mounting an appropriate response to a recurrent exposure to the virus.

How will the nurse interpret a client's white blood cell count that has a total count of 9000 cells/mm3(9 x 109/L) with a lymphocyte count of 4200 cells/mm3 (4.2 × 109/L)? a. The count indicates the client has an increased risk for infection. b. The client most likely has a viral infection. c. The count is completely normal. d. The client most likely has a bacterial infection.

b. The client most likely has a viral infection. Although the total white blood cell count is within the normal range, the lymphocyte count is elevated. The most common cause of lymphocyte count elevation is an actual viral infection. Bacterial infections are associated with higher total counts and higher neutrophil counts.

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) a. Systems thinking is not affected by health policy at the national level. b. The complexity of client care can affect systems thinking. c. Systems thinking shifts the focus from safety to quality in care. d. It is important for the nurse to place all focus on individualized client care. e. Systems thinking allows the nurse to assess the root of problems. f. Interprofessional, collaborative care is fostered when using systems thinking.

b. The complexity of client care can affect systems thinking. e. Systems thinking allows the nurse to assess the root of problems. f. Interprofessional, collaborative care is fostered when using systems thinking.

The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? a. "Be aware that the drug may cause secondary types of cancer." b. "Expect nausea and vomiting for the first week after starting the drug." c. "Have eye examinations every 6 months while on the drug." d. "Keep this medication in the refrigerator at all times."

c. "Have eye examinations every 6 months while on the drug."

The nurse is teaching a client who is being discharged about care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? a. "The PICC line can stay in for months." b. "I have less chance of getting an infection because the line is not in my hand." c. "I can continue my 20-mile (32-km) running schedule as I have in the past." d. "I can still go about my normal activities of daily living."

c. "I can continue my 20-mile (32-km) running schedule as I have in the past."

The nurse has provided health teaching for a female client starting on methotrexate (MTX) for early rheumatoid arthritis. What statement by the client indicates a need for further teaching? a. "I will try to avoid crowds because I could easily get an infection." b. "I will start folic acid supplements whichh can help decrease side effects." c. "I can drink alcohol in small amounts at night to help me relax." d. "I will use strict birth control while I am taking this drug."

c. "I can drink alcohol in small amounts at night to help me relax." All of these statements are correct about MTX except that the client needs to avoid all alcoholic beverages to prevent liver toxicity.

What is the nurse's best response to a client who had a severe allergic reaction to shrimp states, "I have had shrimp once before and did not have a reaction. Why is this happening now?" a. "Allergies are tricky, and many reasons for responses are not known." b. "It is most likely that you didn't eat enough shrimp the first time to cause a reaction." c. "The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." d. "This means you may be allergic to something else and not to shrimp."

c. "The first time your body recognized the shrimp as an allergen, and the second time it reacted to it."

Which number will the nurse calculate as the absolute neutrophil count (ANC) for a client whose differential includes: total WBCs 5300/mm3 (5.3 × 109/L ); segs 2800/mm3 (2.8 × 109/L); bands 200/mm3 (0.20 × 109/L); monos 250/mm3 (0.25 × 109/L); lymphs 2000/mm3 (2.0 × 109/L); eosins 25/mm3 (0.025 × 109/L); basos 25 (0.025 × 109/L)? a. 2800/mm3 (2.8 × 109/L) b. 3200/mm3 (3.2 × 109/L) c. 3000/mm3 (3.0 × 109/L) d. 2300/mm3 (2.3 × 109/L)

c. 3000/mm3 (3.0 × 109/L) The absolute neutrophil count is calculated by adding the mature neutrophil count (segs) with the slightly less mature band neutrophil count (which will mature within a matter of hours into segs). Monos, lymphs, eosins, and basos are not neutrophils.

Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis? a. A 33-year-old African-American man whose father died from a myocardial infarction. b. A 33-year-old white woman whose sister has Grave disease. c. A 33-year-old African-American woman whose mother has psoriasis. d. A 33-year-old man whose identical twin brother has acute myelogenous leukemia.

c. A 33-year-old African-American woman whose mother has psoriasis. SLE is an autoimmune disorder that is much more common in women than in men and has a genetic predisposition related to tissue type. A client with SLE is very likely to have another close relative who also has an autoimmune disorder, such as psoriasis (myocardial infarction, type 2 diabetes mellitus, and thrombotic stroke are not autoimmune disorders). In addition, the incidence of SLE is about eight times greater for African-American women than for white women.

Which client will the nurse observe frequently for indications of hyperkalemia? a. A 72 year old receiving total parenteral nutrition b. A 65 year old taking furosemide for chronic heart failure c. A 38 year old being managed for diabetic ketoacidosis d. A 30 year old who has anxiety-induced hyperventilation

c. A 38 year old being managed for diabetic ketoacidosis Hyperkalemia occurs as compensation for any type of acidosis, including diabetic ketoacidosis, by having cells take up excess hydrogen ions (from the acidosis) in exchange for releasing intracellular potassium to maintain electroneutrality in both fluid compartments. The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Hyperventilation leads to respiratory alkalosis, which causes hypokalemia. Furosemide increases potassium loss, leading to hypokalemia.

After receiving the change-of-shift report, which client does the nurse assess first? a. A 67 year old with nausea and vomiting who reports abdominal cramps. b. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. c. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. d. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

c. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) a. Testing skin turgor b. Asking about any abdominal pain c. Assessing cognition d. Checking deep tendon reflexes e. Monitoring urine output f. Checking for the presence of fever

c. Assessing cognition e. Monitoring urine output The serum sodium is extremely low, which makes depolarization slower and cell membranes less excitable. It also can cause cerebral edema to form, leading to confusion and seizure activity. When sodium levels become very low, coma and death may occur. Assessing cognition and checking deep tendon reflexes are the most important assessment data to obtain. Monitoring urine output needs to be done but is not the priority action in this situation. Assessing skin turgor, presence of abdominal pain, and fever are not an urgent assessment to prevent immediate harm.

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? a. Monitoring 24-hour urine output b. Monitoring the serum calcium levels c. Assessing the blood pressure hourly d. Asking the client whether a headache is present

c. Assessing the blood pressure hourly Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis? a. Gastrointestinal system b. Respiratory system c. Cardiovascular system d. Autonomic nervous system

c. Cardiovascular system During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death.

The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? a. Monitor vital signs frequently to detect early complications. b. Perform focused cardiovascular and respiratory assessments. c. Check that the client can dorsiflex and plantar flex the foot on the operative leg. d. Monitor for excessive blooding and bruising during the infusion.

c. Check that the client can dorsiflex and plantar flex the foot on the operative leg.

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? a. Clinical judgment is a fixed process. b. Clinical judgment is not required to make an informed decision. c. Clinical judgment is an outcome of critical thinking. d. Clinical judgment happens outside the context of the scenario.

c. Clinical judgment is an outcome of critical thinking.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? a. Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) b. Assessing for furrows on the tongue to determine dryness of oral mucous membranes c. Comparing blood pressure measurements in the lying, sitting, and standing positions d. Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

c. Comparing blood pressure measurements in the lying, sitting, and standing positions

The nurse notes that a client has a pale cool left leg without palpable pulses. What would be the nurse's best action at this time? a. Continue to monitor the client's left leg. b. Document the assessment findings. c. Contact the Rapid Response Team (RRT). e. Elevate the client's left leg.

c. Contact the Rapid Response Team (RRT).

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? a. Decreased blood volume; increased blood osmolarity b. Increased blood volume; decreased blood osmolarity c. Decreased blood volume; decreased blood osmolarity d. Increased blood volume; increased blood osmolarity

c. Decreased blood volume; decreased blood osmolarity The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity.

The nurse is caring for an older hospitalized client. Which physiologic age-related change(s) increase(s) the client's risk for infection? (Select all that apply.) a. Increased cough and gag reflexes b. Urinary incontinence c. Decreased intestinal motility d. Decreased immune response e. Thinning skin

c. Decreased intestinal motility d. Decreased immune response e. Thinning skin

Which nursing element reflects systems thinking at the global level of practice? a. Facility health policy b. Quality improvement initiative c. Determinants of health d. Interprofessional practice

c. Determinants of health

Bedside (point-of-care) computers are an example of informatics used in health care primarily for which purpose? a. Enhancing collaboration and coordination of care b. Offering clients access to email and the Internet c. Documenting interprofessional care d. Retrieving data for evidence-based practice

c. Documenting interprofessional care

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? a. Decreased osmotic pressure; decreased hydrostatic pressure b. Decreased osmotic pressure; increased hydrostatic pressure c. Increased osmotic pressure; increased hydrostatic pressure d. Increased osmotic pressure; decreased hydrostatic pressure

c. Increased osmotic pressure; increased hydrostatic pressure The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? a. Medical home b. Community health care c. Inpatient care d. Rehabilitation care

c. Inpatient care

What is the most important action to prevent harm for the nurse to perform after a client's oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved? a. Teaching the client about symptoms to report immediately to the primary health care provider b. Instructing the client to discard the offending drug after being discharged c. Monitoring the client for return of symptoms for at least the next 2 to 4 hours d. Assessing the vein above the IV infusion site for a firm, cordlike texture

c. Monitoring the client for return of symptoms for at least the next 2 to 4 hours All actions are important, although phlebitis is not likely to occur from IV therapy for angioedema. The ACEI class of drugs have a longer half-life and remain in the body longer than does the corticosteroid infusion used to treat the angioedema. As a result, symptoms can recur after first resolving when corticosteroid therapy is stopped. The client remains at risk and must be monitored for at least 2 to 4 hours for return of angioedema.

How do immune system cells differentiate between normal, healthy body cells and non-self cells within the body? a. All normal, healthy body cells are considered a part of the immune system. b. Immune system cells recognize normal healthy body cells by the presence of the nucleus, a structure that is lacking in non-self cells. c. Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells. d. Non-self cells are easily identified by the immune system cells because non-self cells are much larger than normal, healthy body cells.

c. Non-self cells express surface proteins that are different from normal, healthy body cells and are recognized as "foreign" by immune system cells.

Which principal nursing actions best support a focus on client safety? (Select all that apply.) a. Respect for others b. Client restraints c. Preoperative checklists d. Handwashing e. Five rights of drug administration

c. Preoperative checklists d. Handwashing e. Five rights of drug administration

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? a. Chvostek sign is negative. b. Respiratory rate is 22 breaths/min. c. Pulse rate is 76 beats/min and regular. d. Hematocrit is 42%.

c. Pulse rate is 76 beats/min and regular.

The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? a. Legality b. Beneficence c. Self-determination d. Justice

c. Self-determination

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) a. Tops of the forearms b. Skin of the shins c. Skin of the forehead d. Skin over the abdomen e. Skin over the sternum f. Back of the hand

c. Skin of the forehead e. Skin over the sternum Assess skin turgor in an older client by pinching the skin over the sternum or on the forehead, rather than on the back of the hand. With aging the skin loses elasticity and tents on hands and arms even when the client is well hydrated and thus, changes in these areas are not reliable indicators of hydration status. Many older clients have dry flaky skin on the shins regardless of hydration status. The skin of the abdomen is looser in older clients and also is not a reliable skin area to check hydration status.

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? a. Sodium 132 mEq/L (mmol/L) b. Potassium 3.5 mEq/L (mmol/L) c. Sodium 148 mEq/L (mmol/L) d. Potassium 5.3 mEq/L (mmol/L)

c. Sodium 148 mEq/L (mmol/L)

What does the nurse recognize is the fastest growing technology being used for informatics? a. Drug information b. Medication bar code administration c. Telehealth and telenursing d. Electronic health record

c. Telehealth and telenursing

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) a. Keeping the client NPO during drug treatment b. Pushing the drug as a bolus slowly over 5 minutes c. Using an IV controller to deliver the drug d. Checking IV access for blood return after the infusion e. Initiating the IV in a hand vein for rapid access f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

c. Using an IV controller to deliver the drug f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution Best practice technique for administering parenteral potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution at a rate never to exceed 20 mEq/hr. A pump or controller device must be used to deliver the drug to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest. IV potassium must be infused via a large vein with a high volume of flow, avoiding the hand. Potassium is not to be infused or pushed as a bolus to prevent cardiac. Assessing the IV access for placement and an adequate blood return is performed before administering potassium-containing solutions. It is not necessary or good practice to keep the client NPO during parenteral potassium administration.

The nurse is revising an agency's recommended central line-associated bloodstream infection (CLABSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) a. During insertion, draping just the area around the site with a sterile barrier b. Making certain that observers of the insertion are instructed to look away during the procedure c. Using chlorhexidine for skin disinfection d. Thorough hand hygiene before insertion e. Removing the client's venous access device (VAD) when it is no longer needed

c. Using chlorhexidine for skin disinfection d. Thorough hand hygiene before insertion e. Removing the client's venous access device (VAD) when it is no longer needed

Which precaution is appropriate for the nurse to take to prevent the transmission of Clostridium difficile infection? a. Carefully wash hands that are visibly soiled. b. Wear a mask with eye protection and perform proper handwashing. c. Wear gloves when in contact with the client's body secretions or fluids. d. Wear a mask and gloves when in contact with the client.

c. Wear gloves when in contact with the client's body secretions or fluids.

The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? a. Take up knitting to slow down joint degeneration. b. Eat at least 2 yogurts every day. c. Wear supportive shoes at all times. d. Begin a jogging or running program.

c. Wear supportive shoes at all times.

What is the relationship between free hydrogen ions and carbon dioxide? a. An increase in free hydrogen ions always lowers carbon dioxide levels. b. Carbon dioxide can bind free hydrogen ions to increase the pH. c. Carbon dioxide can bind free hydrogen ions to decrease the pH. d. An increase in free hydrogen ions always increases carbon dioxide levels.

d. An increase in free hydrogen ions always increases carbon dioxide levels. In human physiology and homeostasis, free hydrogen ions and carbon dioxide levels are directly related. Any condition that changes the concentration of one always causes a corresponding change in the concentration of the other in the same direction. Carbon dioxide is not a buffer and does not directly bind free hydrogen ions.

Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease? a. Convalescent serum b. Corticosteroids c. Biological response modifiers d. Antibiotics

d. Antibiotics

Which action does the nurse expect is most likely to help restore acid-base balance in a client whose arterial blood pH is 7.17 immediately after a grand mal seizure? a. Administering bicarbonate orally or intravenously b. Providing hydration with IV normal saline c. Administering insulin d. Applying oxygen

d. Applying oxygen The severe acidosis seen immediately following a grand mal seizure is both respiratory and metabolic in origin (a combined acidosis). The client does not breathe during the actual seizure, which causes a huge retention of carbon dioxide (respiratory acidosis). The carbon dioxide level is very high because the seizing muscles are working hard under anaerobic conditions creating lots of lactic acid and hydrogen ions (metabolic acidosis), which are then converted to carbon dioxide through the carbonic anhydrase reaction. If the client stops having seizure activity, he or she will return to acid-base balance without intervention. This return occurs earlier when oxygen is applied. Bicarbonate is not lost during a seizure and most definitely should not be replaced. Hydration and insulin do nothing to restore acid-base balance in this situation.

The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? a. Penicillin b. Clindamycin c. Vancomycin d. Cefazolin

d. Cefazolin Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty.

For which client does the nurse remain alert for the possibility of respiratory acidosis? a. Client with increased urinary output b. Client who is anxious and breathing rapidly c. Client receiving IV normal saline bolus d. Client with multiple rib fractures

d. Client with multiple rib fractures A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid-base imbalance.

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? a. Medical home b. Inpatient care c. Long-term care d. Community Health Center

d. Community Health Center

The nurse is checking an IV fluid order and questions accuracy. What nursing action is appropriate? a. Ask the charge nurse about the order. b. Start the fluid as ordered. c. Contact the pharmacy for clarification. d. Contact the prescribing health care provider.

d. Contact the prescribing health care provider.

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? a. Urge the client to drink more water. b. Notify the primary health care provider. c. Assess the client's deep tendon reflexes. d. Document the finding as the only action.

d. Document the finding as the only action.

The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? a. Excessive production of saliva in the mouth b. Intermittent episodes of diarrhea c. Abdominal bloating after eating d. Dry eyes

d. Dry eyes Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina.

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? a. Checking for presence of dependent edema b. Assessing blood pressure c. Measuring intake and output d. Elevating the head of the bed

d. Elevating the head of the bed Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? a. Serum chloride level is 100 mEq/L (mmol/L) b. Blood urea nitrogen (BUN) is elevated c. Arterial blood pH is 7.37 d. Hematocrit is 29% (0.29 volume fraction)

d. Hematocrit is 29% (0.29 volume fraction) When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia. The chloride level is normal. Elevated levels are associated with dehydration and reduced kidney function. The arterial pH is normal.

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? a. Pulse pressure has decreased. b. Client reports feeling hungry. c. Hematocrit is 58% (0.58 volume fraction). d. Hourly urine output is greater than 15 mL.

d. Hourly urine output is greater than 15 mL. The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status.

Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem? a. Vitamin D b. Lisonopril c. Aspirin d. Hydralazine

d. Hydralazine Hydralazine is a blood pressure medication that has been found to cause drug-induced SLE. None of the other drugs are associated with drug-induced SLE, although lisinopril, an angiotensin-converting enzyme inhibitor, is associated with development of angioedema.

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? a. Teaching the client which foods to avoid b. Administering sodium polystyrene sulfonate orally c. Collaborating with the registered dietitian nutritionist to provide a potassium-restricted diet d. Initiating continuous cardiac monitoring

d. Initiating continuous cardiac monitoring

Which differential count will the nurse report to the primary health care provider for a client whose white blood count indicates a total count of 10,000 cells/mm3 (10 × 109/L)? a. Eosinophils 200/mm3 (0.2 × 109/L) b. Lymphocytes 2100/mm3 (2.1 × 109/L) c. Segmented neutrophils 6000/mm3 (6 × 109/L) d. Monocytes 2000/mm3 (2 × 109/L)

d. Monocytes 2000/mm3 (2 × 109/L) The normal monocyte population in peripheral blood should be not greater than 5%. A monocyte count of 2000 in 10,000 white blood cells represents 20% of the total and indicates a significant increase.

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? a. Assistive personnel b. Physical therapist c. Licensed social worker d. Occupational therapist

d. Occupational therapist

Which cell types provide protective responses during inflammation? a. Natural killer cell b. Basophils c. Eosinophils d. Platelets e. Macrophages f. Neutrophils

d. Platelets Macrophages and neutrophils initiate and complete phagocytosis against invading microorganism, providing the body with protection against infection. Natural killer cells are not particularly active during inflammation. Eosinophils and basophils are responsible for vascular changes, not protection. Platelets have no direct role in the protection provided by inflammation.

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? a. Generate solutions b. Take actions c. Recognize cues d. Prioritize hypothesis

d. Prioritize hypothesis

The nurse is caring for a client who is immobile. The client is most at risk to develop which complication? a. Hypertension b. Muscle hypertrophy c. Diarrhea d. Renal calculi

d. Renal calculi

The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include? a. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter improves success with venipuncture. b. Placement of the catheter on the back of the client's dominant hand is preferred. c. When the catheter is inserted into the forearm, excess hair should be shaved before insertion. d. Skin integrity can be compromised easily by the application of tape or dressings.

d. Skin integrity can be compromised easily by the application of tape or dressings.

When flushing a client's central line with normal saline, the nurse feels resistance. Which action will the nurse take first? a. Decrease the pressure being used to flush the line. b. Use "push-pull" pressure applied to the syringe while flushing the line. c. Obtain a 10-mL syringe and reattempt flushing the line. d. Stop flushing and try to aspirate blood from the line.

d. Stop flushing and try to aspirate blood from the line. The nurse's first step is to stop flushing and try to aspirate blood from the line. If resistance is felt when flushing any IV line, the nurse should stop and further assess the line. Aspiration of blood would indicate that the central line is intact and is not obstructed by thrombus.Decreasing the pressure to flush the line is not appropriate. Continuing or reattempting to flush the line, or using a push-pull action on the syringe, might result in thrombus or injection of particulate matter into the client's circulation.

Which nursing assessment data indicate the need for immediate nursing intervention? a. Client states, "It really hurt when the nurse put the IV in." b. Transparent dressing was changed 5 days ago. c. Tubing for the IV was last changed 72 hours ago. d. The vein feels hard and cordlike above the insertion site.

d. The vein feels hard and cordlike above the insertion site.

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) a. Administers IV furosemide 40 mg as prescribed. b. Sets a goal for client to resume normal activities within 4 weeks following surgery. c. Compares temperature at 0600 with temperature taken at 1200. d. Contacts health care provider after obtaining blood pressure of 200/100. e. Collects information about how client sustained an injury. f. Notes pressure injury of 2 inches by 1 inch on sacrum.

e. Collects information about how client sustained an injury. f. Notes pressure injury of 2 inches by 1 inch on sacrum.

Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia? a. Underelimination of bicarbonate ions b. Underproduction of hydrogen ions c. Overelimination of bicarbonate ions d. Overelimination of hydrogen ions e. Overproduction of hydrogen ions f. Underelimination of hydrogen ions g. Underproduction of bicarbonate ions h. Overproduction of bicarbonate ions

e. Overproduction of hydrogen ions Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions.