Nursing Alterations test 2 review

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? "My ankles are swollen." "I am tired at the end of the day." "When I eat a large meal, I feel bloated." "I have trouble breathing when I walk rapidly."

"I have trouble breathing when I walk rapidly." Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.

A nurse is monitoring a client's fasting plasma glucose (FPG) level. At which FPG level should the nurse identify that the client has prediabetes? 70 mg/dL (3.9 mmol/L) 100 mg/dL (5.6 mmol/L) 130 mg/dL (7.2 mmol/L) 160 mg/dL (8.9 mmol/L)

100 mg/dL (5.6 mmol/L) The guidelines from the American Diabetes Association have lowered the level of an FPG that indicates whether a client has prediabetes from 110 mg/dL to 100 mg/dL; an FPG of 100 to 125 mg/dL is considered prediabetes (Canada: The guidelines from the Canadian Diabetes Association indicate that an FPG of 6.1 to 6.9 mmol/L is considered prediabetes). A 70 mg/dL (3.9 mmol/L) FPG indicates that the client is hypoglycemic. An FPG of 126 mg/dL (7.0 mmol/L) or higher indicates that the client has diabetes.

While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes? Having diabetes insipidus Eating low-cholesterol foods Being 20 pounds (9 kilograms) overweight Drinking a daily alcoholic beverage

Being 20 pounds (9 kilograms) overweight Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply. Dependent rubor Warm extremities Ulcers on the toes Thick, hardened skin Delayed capillary refill

Dependent rubor Ulcers on the toes Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill longer than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease.

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is related to heart failure? I see spots before my eyes. I am tired at the end of the day. I feel bloated when I eat a large meal. I have trouble breathing when I climb a flight of stairs.

I have trouble breathing when I climb a flight of stairs. Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes, being tired at the end of the day, and feeling bloated are not specific to heart failure.

A nurse adds 20 mEq of potassium chloride to the intravenous solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug? Treat hyperpnea Prevent flaccid paralysis Replace excessive losses Treat cardiac dysrhythmias

Replace excessive losses Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with replacement fluids, is needed. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. Considering the relationship between insulin and potassium, treatment with potassium is prophylactic, preventing the development of dysrhythmias.

The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should instruct the client on which eye problem most associated with diabetes? Cataracts Glaucoma Retinopathy Astigmatism

Retinopathy Diabetic retinopathy is a leading cause of blindness in diabetics. Glaucoma and cataracts also are associated with diabetes, but retinopathy is the most common eye problem. Astigmatism is not associated with diabetes.

A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client? Stop smoking Control blood glucose Start a walking program Eat a low-fat, low-cholesterol diet

Stop smoking Smoking is the single most important risk factor for peripheral arterial diseases, and cessation should be encouraged. Although hyperglycemia is a contributing factor, it is not the primary risk factor for LEAD. Although a sedentary lifestyle is a contributing factor, it is not the primary risk factor for LEAD. Although a high-fat, high-cholesterol diet is a contributing factor, it is not the primary risk factor for LEAD.

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? Lung biopsy Thoracentesis Mediastinoscopy Ventilation-perfusion scan

Thoracentesis A thoracentesis is performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma. A lung biopsy or mediastinoscopy may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? Irritability, polydipsia, and polyuria Polyuria, polydipsia, and polyphagia Nocturia, weight loss, and polydipsia Polyphagia, polyuria, and diaphoresis

Polyuria, polydipsia, and polyphagia Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. Collapsed neck veins Distended abdomen Dependent edema Urinating at night Cool extremities

Distended abdomen Dependent edema Urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.

An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply. Dyspnea Crackles Hacking cough Peripheral edema Jugular distention

Dyspnea Crackles Hacking cough The left ventricle pumps oxygen-rich blood to the rest of the body. Left-sided heart failure occurs when the left ventricle doesn't pump efficiently. This prevents the body from getting enough oxygen-rich blood. The blood backs up into the lungs instead, which causes a buildup of fluid. Common symptoms may include: dyspnea, shallow respirations, crackles, dry, hacking cough, and frothy, pink-tinged sputum. Right-sided heart failure occurs when the right side of the heart can't perform its job effectively. Common symptoms of right-sided heart failure include peripheral edema, weight gain, and jugular distention.

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes? Ketones in the blood but not in the urine Glucose in the urine but not hyperglycemia Hyperglycemia and urine negative for ketones Blood and urine positive for both glucose and ketones

Hyperglycemia and urine negative for ketones In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia. Ketones in the blood but not in the urine does not occur with either type. In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia and diabetes mellitus. Glucose in the urine but not hyperglycemia is impossible; if glycosuria is present, the level of glucose in blood first must exceed the renal threshold of 160 to 180 mg/dL (8.9 to 10 mmol/L). Blood and urine positive for both glucose and ketones is expected in uncontrolled type 1 diabetes.

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? Prevent dyspnea Prevent cyanosis Increase oxygen concentration to heart cells Increase oxygen tension in the circulating blood

Increase oxygen concentration to heart cells Administration of oxygen increases the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although administering oxygen will increase oxygen tension in the circulating blood, it is not specific to heart cells, which are hypoxic when there is a myocardial infarction from a coronary occlusion.

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? Diazepam Meperidine Flurazepam Morphine sulfate

Morphine sulfate For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO 2 89 mm Hg, PCO 2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? Respiratory alkalosis Poor oxygen perfusion Normal acid-base balance Compensated metabolic acidosis

Normal acid-base balance All data are within expected limits; PO 2 is 80 to 100 mm Hg, PCO 2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within the expected limits of 80 to 100 mm Hg. With metabolic acidosis, the pH is less than 7.35.

A nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. What information is most important for the nurse to include in the teaching plan? Maintenance of a low-potassium diet Avoidance of foods high in cholesterol Signs and symptoms of digoxin toxicity Importance of an adequate intake and output

Signs and symptoms of digoxin toxicity The risk of digoxin toxicity increases when the client is receiving digoxin and furosemide, a loop diuretic; loop diuretics can cause hypokalemia, which potentiates the effects of digoxin, leading to toxicity. Digoxin toxicity can result in dysrhythmias and death. When a client is receiving a loop diuretic, the diet should be high in potassium. Although teaching the need to avoid foods high in cholesterol may be included in the teaching plan, it is not the priority. Although it is important to maintain adequate intake and output because potassium chloride should not be taken when there is a decreased urinary output, the priority is monitoring for signs of digoxin toxicity.

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? Whole milk with oatmeal Garden salad with olive oil Tuna fish with a small apple Soluble fiber cereal with yogurt

Whole milk with oatmeal An overall heart healthy diet includes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts, legumes and non-tropical vegetable oils. Whole milk is high in saturated fat and should be avoided.

The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply. The client should obtain a finger stick blood glucose reading before each meal. The client does not need to follow a specific diet until insulin is required. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan does not need to include signs and symptoms of hypoglycemia, as the client is not on insulin. The teaching plan should include sick day rules.

The client should obtain a finger stick blood glucose reading before each meal. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include sick day rules. All diabetic clients, regardless of type, should check finger stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore, the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day rules. All diabetic clients should follow the American Diabetes Association diet.

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK)

Troponin Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.

The nurse is teaching a client with asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of how to use a peak flow meter? Select all that apply . "Readings in the green zone mean that my asthma is under control." "If I get a reading in the yellow zone, I need to stop what I'm doing and rest, then recheck in an hour." "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day." "I don't need to check my peak flow readings if I take a reliever drug."

"Readings in the green zone mean that my asthma is under control." "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day." Peak flow meters are used to measure how well the client's asthma is controlled. Readings in the green zone mean the asthma is under control; however, readings in the red zone indicate a serious respiratory problem that needs to be addressed immediately. The client will need to take a reliever drug and seek emergency help immediately. Peak flow readings need to be measured twice a day. If a reading in the yellow zone occurs, the client should use the reliever drug and then measure the peak expiratory flow (PEF) again in a few minutes to determine whether the drug is working. Improvement in PEF should be seen. Clients need to check the PEF any time a reliever drug is used to determine the drug's effectiveness.

A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." What is the nurse's best response? "This is related to your illness rather than to your medication." "Take the medication because this is not a serious side effect." "This side effect is only temporary. You should continue the medication." "The medication may need to be discontinued. Come to the clinic this afternoon."

"The medication may need to be discontinued. Come to the clinic this afternoon." Yellow vision indicates digoxin toxicity; the medication should be withheld until the healthcare provider can assess the client and check the digoxin blood level. Yellow vision is related to digoxin therapy, not the client's underlying medical condition. Yellow vision is a sign of digoxin toxicity; taking more digoxin will escalate the digoxin toxicity.

A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiologic changes associated with a long history of diabetes? Blurry, spotty, or hazy vision Arthritic changes in the hands Hyperactive knee and ankle jerk reflexes Dependent pallor of the feet and lower legs

Blurry, spotty, or hazy vision Blurry, spotty, or hazy vision; floaters or cobwebs in the visual field; and cataracts or complete blindness can occur as a result of diabetes. Diabetic retinopathy is characterized by abnormal growth of new blood vessels in the retina (neovascularization). More than 60% of clients with type 2 diabetes have some degree of retinopathy after 20 years. Arthritic changes of the hands are not a usual complication associated with diabetes mellitus. Clients who are diabetic have peripheral neuropathy, which is characterized by hypoactive, not hyperactive, reflexes. Peripheral vascular disease is indicated by dependent rubor with pallor on elevation, not dependent pallor.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. Olive oil Chicken broth Enriched whole milk Red meats, such as beef Vegetables and whole grains Liver and other glandular organ meats

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. Confusion Hyperactivity Excessive thirst Fruity-scented breath Decreased urinary output

Confusion Excessive thirst Fruity-scented breath Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.

The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? Causes mild perspiration Occurs after moderate exercise Continues after rest and nitroglycerin Precipitates discomfort in the arms and jaw

Continues after rest and nitroglycerin When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. Edema Vertigo Polyuria Ascites Palpitations

Edema Ascites Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system. Clinical manifestations include edema, ascites, hepatomegaly, tachycardia, and fatigue. Dyspnea occurs in left-sided heart failure because of pulmonary congestion and inadequate delivery of oxygen to all body cells. Vertigo generally is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output (polyuria). Palpitations may indicate dysrhythmias or anxiety.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include to decrease the risk of complications? Select all that apply. Examine the feet daily Wear well-fitting shoes Perform regular exercise Powder the feet after showering Visit the primary healthcare provider weekly Test bathwater with the toes before bathing

Examine the feet daily Wear well-fitting shoes Perform regular exercise Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary healthcare provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? Spinal stenosis Buerger disease Rheumatoid arthritis Intermittent claudication

Intermittent claudication Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.

The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? Intravenous administration of regular insulin Administer insulin glargine subcutaneously at hour of sleep Maintain nothing prescribed orally (NPO) status Intravenous administration of 10% dextrose

Intravenous administration of regular insulin A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client's blood glucose.

A 15-year-old adolescent is found to have type 1 diabetes. What should the nurse include when teaching the adolescent about type 1 diabetes? It does not always require insulin. It involves early vascular changes. It occurs more often in obese adolescents. It has a more rapid onset than does type 2 diabetes.

It has a more rapid onset than does type 2 diabetes. A characteristic difference between type 1 and type 2 diabetes is the rapid onset of type 1 diabetes. Type 1 diabetes often is first diagnosed during an episode of acute ketoacidosis. Children, adolescents, and adults with type 1 diabetes are insulin dependent. Vascular changes are complications associated with long-standing diabetes. Maturity-onset diabetes of the young (MODY), similar to type 2 diabetes, is more often seen in obese teenagers. Adolescents with type 1 diabetes tend to be at or below the expected weight for their height and bone structure.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? Cataracts Esophagitis Kidney failure Diabetes mellitus

Kidney failure Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What common complications of diabetes might the nurse expect to identify when assessing this client? Select all that Leg ulcers Loss of visual acuity Thick, yellow toenails Increased growth of body hair Decreased sensation in the feet

Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet Leg ulcers are a common response to the microvascular and macrovascular changes associated with diabetes. Retinopathy, damage to the microvascular system of the retina (e.g., edema, exudate, and local hemorrhage), occurs as a result of the occlusion of the small vessels in the eyes, causing microaneurysms in the capillary walls. Thick, yellow toenails result from prolonged inadequate arterial circulation to the feet. Pedal pulses diminish, which can result in gangrene, necessitating amputation. Diabetic neuropathies affect 60% to 70% of people with diabetes. It is theorized that consistent hyperglycemia causes a buildup of sorbitol and fructose in the nerves that results in impairment via an unknown process. Inadequate arterial circulation to hair follicles results in a lack of hair on the feet and ankles. The skin becomes dry and cracks, predisposing it to leg ulcers and infection.

Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease? Incisional pain Popliteal pulse rate Degree of hair growth Lower extremity color

Lower extremity color Checking color and temperature, part of the neurovascular assessment, provides data about current perfusion of the extremity and the possibility of graft occlusion/blockage. Although pain assessment is essential, incisional pain does not provide data about the neurovascular status of the extremity; a dramatic increase in pain or severe continuous, aching pain is indicative of graft occlusion. Although the presence and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the popliteal rate. Clients with peripheral arterial disease experience loss of extremity hair, which will not change suddenly because of surgery.

Which nursing interventions are important when caring for clients receiving IV digoxin? Select all that apply. Monitor the heart rate closely Check the blood levels of digoxin Administer the dose over 1 minute Monitor the serum potassium level Give the drug with other infusing medications

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level Bradycardia or other dysrhythmias may occur; therefore, the heart rate and rhythm should be monitored. ECG monitoring should be continuous. The digoxin level is checked before administration to avoid toxicity. A low serum potassium level when digoxin is administered can contribute to toxicity. Digoxin should be given over a 5-minute period through a Y-tube or three-way stopcock. There are many syringe, Y-site, and additive incompatibilities; the manufacturer recommends that digoxin not be administered with other drugs.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? Elevate the foot of the bed. Perform urinary catheter care every 12 hours. Place in the high-Fowler position. Perform a neurovascular assessment every 2 hours.

Perform a neurovascular assessment every 2 hours. Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of or lower than the heart. A general anesthetic is not used; therefore voiding is not a concern. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop? Metabolic alkalosis caused by excessive production of acid metabolites Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation

Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.

A client who is negative for human immunodeficiency virus (HIV) but who has a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding? The erythema does not meet the criterion for a diagnosis of tuberculosis; the results are negative. The clinical manifestations indicate that the client has tuberculosis; the results are positive. The results are indeterminate because of the client's history of COPD. The client has been exposed to the pathogen that causes tuberculosis.

The client has been exposed to the pathogen that causes tuberculosis. The size of the induration determines the clinical significance of the reaction; an induration of 5 mm or more is considered positive in a client with HIV, indicating exposure to the tuberculosis bacillus or vaccination with bacillus Calmette-Guérin (BCG) vaccine, not the presence of active disease. The finding of an induration of 10 mm is a positive response. The size of the induration, not the amount of erythema, is used to determine the test result. Having COPD does not alter the reading; however, HIV does.

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? The client may need up to 60% oxygen flow via Venturi mask. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. The client should receive humidified oxygen delivered by a face mask. The client's respiratory treatment plan should have oxygen eliminated from it.

The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. Exogenous oxygen is necessary, but it must be delivered in low concentrations. It is not the method of oxygen delivery that is a concern, but rather the concentration of the oxygen. High oxygen concentrations will increase serum oxygen levels and interfere with the stimulus to breathe, which is a lowered oxygen level. The client will develop carbon dioxide narcosis when high levels of exogenous oxygen are administered. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen concentrations higher than 2 L/min. More research is needed before this theory is applied clinically. Usually, the body's stimulus to breathe is an elevated carbon dioxide level. In a client with COPD, breathing instead responds to lowered oxygen levels because of the body's exposure to continuously elevated levels of carbon dioxide.

The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis? Select all that apply. Verify breath sounds. Encourage deep breaths. Observe for signs of pneumonia. Ensure a chest x-ray is performed after the procedure. Instruct the client to cough during the procedure.

Verify breath sounds. Encourage deep breaths. Ensure a chest x-ray is performed after the procedure. Breath sounds should be verified in all lung fields after thoracentesis to rule out lung collapse. The client is encouraged to perform deep breaths to help expand the lungs. A chest x-ray should be obtained after the procedure to check for pneumothorax. Observing for signs of hypoxia and a pneumothorax is essential, but the signs of pneumonia may not be useful after thoracentesis. The client should be instructed not to talk or cough during the procedure because it may cause injury to the lungs.

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? Put on a gown when entering the room Place the client with another client who has TB Wear a particulate respirator when caring for the client Don a surgical mask with a face shield when entering the room

Wear a particulate respirator when caring for the client A high-particulate filtration mask that meets Centers for Disease Control (CDC) performance criteria (Canada: Public Health Agency of Canada [2013] Canadian Tuberculosis Standards, 7th edition) for a tuberculosis respirator must be worn to protect healthcare providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply. Fever Stridor Wheezing Tachycardia Hypotension

Wheezing Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase. An increased temperature is characteristic of sepsis, not asthma. Stridor is due to foreign body obstruction, not asthma. Hypertension, not hypotension, may occur with asthma.