Practice Focus on Adult

A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? Select all that apply. 1. Tachycardia 2.Fever 3. Hypotension 4. Oliguria 5. Bradypnea

1. Tachycardia 2. Hypotension 3. Oliguria Rationale: Clients who sustain fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed as well as open fractures. Signs of hypovolemic shock include tachycardia, hypotension, and diminished urine output. Fever and bradypnea are not associated with hypovolemic shock. Test-Taking Strategy: Use the process of elimination. Think about the pathophysiology of hypovolemic shock. Next, think about how the body responds to shock; this will direct you to the correct options. Review the complications of this type of injury and the signs of hypovolemic shock if you had difficulty with this question.

A nurse is monitoring a client who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse, examining the screen, notes no ECG complexes. The nurse would first: 1. Page the health care provider "stat" 2. Call a code 3. Reset the cardiac monitor 4. Assess the client

4. Assess the Client Rationale: A sudden loss of ECG complexes indicates either ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The nurse would assess the client first. If, after assessing the client, the nurse feels that there is an absence of ventricular activity, a code (rapid response team) should be called and emergency response measures initiated. Test-Taking Strategy: Use the steps of the nursing process. The correct option is the only one that addresses assessment. Remember, always assess the client directly before taking any action. Review care of the client attached to a cardiac monitor if you had difficulty with this question.

A nurse is caring for a client who is undergoing lumbar puncture (LP). In which position should the nurse place the client after the procedure? 1. Side-lying semi-Fowler 2. Prone, with the head of the bed slightly elevated 3. Reverse Trendelenburg 4. Dorsal recumbent

4. Dorsal recumbent Rationale: After LP, the client should remain in a supine or dorsal recumbent position for 4 to 12 hours or as prescribed by the health care provider. This position helps prevent headache. Elevating or lowering the head after LP may increase intracranial pressure, resulting in spinal headache. Test-Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the head of the bed should be elevated. Review positioning after LP if you had difficulty with this question.

For which findings, early signs of increased intracranial pressure (ICP), does the nurse caring for a client who sustained a head injury monitor the client? Select all that apply. 1.Decreased level of consciousness 2.Decorticate posturing 3. Shallow, slowed respirations 4.Widened pulse pressure 5. Headache

Decreased level of consciousness Headache Rationale: Early signs of increased ICP include a decreasing level of consciousness (this is the earliest and most sensitive sign), a headache that intensifies with coughing or straining, pupillary changes or visual disturbances, and contralateral motor or sensory losses. Late signs include changes in vital signs (e.g., widened pulse pressure, slowed pulse); shallow, slowed respirations; irregular periods of apnea; hiccups; fever without a source of infection; vomiting; and posturing. Test-Taking Strategy: Note the strategic word "early." Think about the pathophysiology of head injury and recall the pathophysiology of increased ICP. This will direct you to the correct options. Review the early signs of increased ICP and the associated pathophysiology if you had difficulty with this question.

A nurse is assessing a dyspneic client who has been found to have Guillain-Barré syndrome. Which arterial blood gas findings would cause the nurse to conclude that the client is experiencing hypoxemic respiratory failure? 1. PaO2 of 52 mm Hg (6.89 kPa), PaCO2 of 50 mm Hg (6.64 kPa) 2. PaO2 of 50 mm Hg (6.625 kPa), PaCO2 of 40 mm Hg (5.31 kPa) 3. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg (10.6 kPa), partial pressure of arterial carbon dioxide (PaCO2) of 55 mm Hg (7.30 kPa) 4. PaO2 of 70 mm Hg (9.275 kPa), PaCO2 of 45 mm Hg (5.98 kPa)

2. PaO2 of 50 mm Hg (6.625 kPa), PaCO2 of 40 mm Hg (5.31 kPa)

A nurse is preparing to teach a client with newly diagnosed chronic kidney disease (CKD) about the disease and its management. The client's ability to learn is diminished as a result of uremia and anxiety. The nurse makes it a priority to include which when conducting teaching sessions with this client? 1. Family members 2. Charts and diagrams 3. Research articles 4. Printed materials

1. Family Member Rationale: The client with CKD is often faced with such barriers to learning as anxiety and the effects of uremia, including short attention span and memory deficits. The effects of uremia effects usually improve once hemodialysis has begun. The presence of family is helpful, because the family must understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. The presentation of information should be simple, direct, and aimed at the educational level of the client. Charts and diagrams and printed materials may be helpful but are not the priority. Research articles will not be helpful to the client. Test-Taking Strategy: Focus on the information about the client and use your knowledge of teaching and learning principles to answer the question. Eliminate the options that are comparable or alike (i.e., printed material, charts and diagrams, and research articles) in that they will not be helpful to the client with a diminished ability to learn. Review the principles of teaching and learning if you had difficulty with this question.

Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell the client about this type of insulin? Select all that apply. 1.It is usually given once daily, at bedtime. 2.It does not have a peak effect. 3. It may be mixed in a syringe with regular insulin. 4. Its onset of action comes 4 hours after administration.

1. It is usually given once daily, at bedtime. 2. It does not have a peak effect. Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin. Test-Taking Strategy: Knowledge regarding glargine insulin is required to answer this question. Review of the characteristics of glargine insulin if this question was difficult for you.

A client with cancer is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. Which nursing assessment would be given the highest priority while the chemotherapy is being administered? 1.Lung sounds 2. Peripheral pulses 3. Heart rate 4. Level of consciousness

1. Lung sounds Rationale: Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that may progress to pulmonary fibrosis. Pulmonary function studies, along with hematologic, hepatic, and renal function parameters, need to be monitored. The nurse must monitor lung sounds for dyspnea and crackles indicating pulmonary toxicity. The medication should be discontinued immediately if pulmonary toxicity occurs. Although the parameters in the other options may need to be monitored, they are not the priority with this medication. Test-Taking Strategy: Knowledge regarding the toxic effects of bleomycin sulfate is required to answer this question. Eliminate the options that are comparable or alike in that they address circulatory status (i.e., heart rate and peripheral pulses). Also, select lung sounds because it relates to airway. If you had difficulty with this question, review the toxic effects of this medication.

Radiation therapy is prescribed for a client with a brain tumor. Which side effects would the nurse expect the client to experience? Select all that apply. 1.Dizziness 2.Cough 3.Alopecia 4.Hoarseness 5.Dysphagia

1.Dizziness 3.Alopecia

A nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statements by the client indicate an understanding of the medication? Select all that apply. You Answered 1. "I need to take the medication 1 hour before I eat." 2. "I shouldn't drink coffee or tea anymore." 3. "I should put ice on my lips if they swell." 4. "I can use an antihistamine lotion if I get an itchy rash." 5. "I'll start taking a vitamin C supplement each morning." 6. "I need to drink at least 8 glasses of fluid every day."

2. "I shouldn't drink coffee or tea anymore." 6. "I need to drink at least 8 glasses of fluid every day." Rationale: Clients taking allopurinol are encouraged to drink at least 8 glasses of fluid a day. Coffee and tea are avoided because they can increase the level of uric acid in the body. Allopurinol is to be given with milk or immediately after meals to ease gastric distress. If the client experiences a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the health care provider, because these are all signs of hypersensitivity. The client should not take large doses of vitamin C while taking allopurinol, because kidney stones could develop. Test-Taking Strategy: Use the process of elimination. Eliminate the options that indicate hypersensitivity, which is not a normal, expected response. Apply your knowledge of the pathophysiology of gout to address the other options. Remember that the client with gout should drink at least 8 glasses of fluid every day. Review client instructions for allopurinol if you had difficulty with this question.

A client with AIDS is admitted to the hospital with a diagnosis of histoplasmosis, and the nurse monitors the client for signs of progression of the disease. Which finding indicates progression of histoplasmosis? 1. Headache 2. Enlargement of the lymph nodes 3. Nuchal rigidity 4. Blurred vision

2. Enlargement of the lymph nodes Rationale: Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then becomes disseminated, giving rise to enlargement of the lymph nodes, spleen, and liver. The nurse will also note dyspnea, fever, cough, and weight loss. Complaints of nuchal rigidity, headache, and blurred vision are unrelated to the findings noted in histoplasmosis but may be noted in cryptococcosis, a severe debilitating meningitis (and, occasionally, a disseminated disease) in AIDS. Test-Taking Strategy: Use the process of elimination and note the strategic words "progression of the disease." Recalling that lymph nodes may become enlarge with generalized infection will direct you to the correct option. Review the characteristics of histoplasmosis if you had difficulty with this question.

A nurse is caring for a client who has just undergone craniotomy with an infratentorial incision. In which position does the nurse expect that the health care provider will prescribe the client to be placed? 1. High Fowler with the head turned to the left side 2. Flat and on the side 3. Semi-Fowler on the right side 4. Low Fowler with the head and neck midline

2. Flat and on the side Rationale: The client who has undergone infratentorial craniotomy should be kept flat and placed on either side for 24 to 48 hours. This will prevent pressure on the incision site, which is located in the neck. It also prevents the exertion of pressure on the internal tumor excision site by higher cerebral structures. The client who has undergone supratentorial craniotomy would be positioned with the head of the bed elevated 30 degrees to promote venous drainage. Test-Taking Strategy: This question tests your knowledge of the positioning for a client who has a supratentorial versus an infratentorial incision after craniotomy. Remembering that supratentorial indicates that the head should be kept up and infratentorial indicates that the head should be kept down will help you eliminate the incorrect options. Review care of the client after craniotomy if you had difficulty with this question.

A nurse is monitoring a client with a head injury for signs of diabetes insipidus (DI). Which finding would cause the nurse to suspect that this complication is developing? 1. Serum osmolarity 200 mOsm/kg (200 mmol/kg) 2. Serum sodium level 155 mEq/L (155 mmol/L) 3. Urine output 30 mL/hr for past 4 hours 4. Urine specific gravity 1.020

2. Serum sodium level 155 mEq/L (155 mmol/L) Rationale: One complication of head injury is diabetes insipidus (DI), which may occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. In DI the urine specific gravity ranges from 1.003-1.030 and the serum osmolarity and serum sodium level are high. Large quantities of very dilute urine are excreted, putting the client at risk for severe dehydration. Normal osmolarity ranges from 275 to 295 mOsm/kg (275 to 295 mmol/kg). The normal sodium range is 135 to 145 mEq/L (135-145 mmol/L). The other options are signs of syndrome of inappropriate antidiuretic hormone, which is a complication of intracranial surgery. Test-Taking Strategy: Use the process of elimination, recalling that one complication of head injury is diabetes insipidus. Recalling that diabetes insipidus results in the excretion of large amounts of dilute urine will assist you in eliminating the incorrect options. Review the complications of head injury and the signs of diabetes insipidus if you had difficulty with this question.

A nurse provides dietary instructions to a client with viral hepatitis whose laboratory results indicate liver impairment. The nurse teaches the client: 1. That snacks, particularly those that are salty, are an important part of the diet 2. To increase intake of foods high in protein to promote healing 3. That most calorie intake should consist of foods high in carbohydrates 4. To consume mainly high-fat foods because they are better tolerated

3. That most calorie intake should consist of foods high in carbohydrates Rationale: If liver function is not impaired, a well-balanced diet is adequate. In this case, because liver impairment has been confirmed, protein and sodium intake are limited. Most calories should come from carbohydrates. A low-fat, high-carbohydrate diet may be best tolerated. Test-Taking Strategy: Use general principles of nutrition and the process of elimination. Noting the strategic words "liver impairment" and recalling the function of the liver and the pathophysiology of hepatitis will direct you to the correct option. Review dietary measures for the client with viral hepatitis if you had difficulty with this question.

A client with chronic arterial occlusive disease has a history of intermittent claudication. Which question does the nurse ask to assess the degree to which the client is affected by this condition? 1. "Is your leg pain sharp, and does it occur with exercise?" 2. "Do you have achy leg pain that worsens as the day goes on?" 3. "Do you have sudden chest pain with exertion?" 4. "Does your chest pain feel like heartburn?"

"Is your leg pain sharp, and does it occur with exercise?" Rationale: Blood for measurement of the serum digoxin level is most often drawn immediately before the next dose, although it may also be drawn 6 to 8 hours after a dose. Recall that the purpose of the laboratory test is to measure the serum concentration of the medication to ensure that it is in the therapeutic range. Drawing the blood 8 hours after the last dose was given ensures that the level is not falsely increased. The optimal therapeutic range for digoxin is is 0.5 to 0.8 ng/mL (0.64 to 1.02 nmol/L). Test-Taking Strategy: Use the process of elimination and recall the purpose of this laboratory test. Remember that options that are comparable or alike are not likely to be correct. In this case, each of the incorrect options requires the blood sample to be drawn within a relatively short time after the client has been given the medication. If this question was difficult for you, review the procedure for assessing a client's digoxin level.

A client infected with HIV has a T4 count of 150/mm3 and a low CD4+/CD8+ ratio. On the basis of these values, the nurse concludes that the client is: 1. A risk for opportunistic infection 2.Developing a stronger immune system 3.Clincally improved 4. In sable condition

1. A risk for opportunistic infection Rationale: The percentage and number of CD4+ (T4) and CD8+ (T8) cells are an important part of an immune profile. Individuals with HIV disease usually have a lower-than-normal number of CD4 cells. The normal CD4+ count is between 500 and 1600 cells/mm3. The normal ratio of CD4+ to CD8+ cells is approximately 2:1. In HIV infection, because of the low number of CD4+ cells, this ratio is low. A low CD4+ cell count and a low CD4+/CD8+ ratio are associated with increased incidence of clinical manifestations of the disease, and the client is at risk for opportunistic infection. The nurse uses this information in planning infection-control measures for the client. The remaining options are incorrect interpretations. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate that the client is improving. Review the laboratory tests used to monitor the progress of a client infected with HIV if you had difficulty with this question.

The wife of a client with type 1 diabetes mellitus calls the nurse in the health care provider's office about her husband. She states that her husband is sleepy, that his skin is warm and flushed, and that his breathing is faster than normal. The nurse instructs the wife to: 1. Check his temperature and pulse rate 2. Bring him to the doctor's office 3. Check his blood glucose level 4. Immediately call an ambulance

3. Check his blood glucose level Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the health care provider. Calling an ambulance or bringing him to the health care provideroffice may be done AT A later time if required. The client's temperature and pulse rate are not germane to the client's immediate problem. Test-Taking Strategy: Focus on the data in the question and use the steps of the nursing process. Checking his temperature and pulse rate and blood glucose reflect further assessment of the client; checking the blood glucose level, however, is related specifically to the client's diagnosis, and the blood glucose reading may have an impact on the directions subsequently given to the client's wife.

A nurse is caring for a client who underwent mastectomy 1 day ago. To help restore arm function on the affected side, the nurse encourages the client to use that arm to: 1. Wash her face and upper body and perform perineal care 2. Comb her hair and perform oral hygiene 3. Perform finger and elbow flexion and extension exercises 4. Perform hand wall-climbing exercises

3. Perform finger and elbow flexion and extension exercises Rationale: Immediately after mastectomy the client is encouraged to move the fingers and hands and to flex and extend the elbow. The client may also use the arm for self-care, provided that the client does not raise the arm above shoulder level or abduct the shoulder until the postoperative drains have been removed. The health care provider will prescribe the time frame for additional exercises for the arm on the affected side. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve exercises of the arm on the affected side. Review appropriate exercises for the client who has undergone mastectomy if you had difficulty with this question.

A nurse is caring for a 25-year-old married client who will undergo bilateral orchidectomy for testicular cancer. On which psychosocial concern directly related to the surgery does the nurse place priority in formulating the postoperative plan of care for the client? 1.Ineffective role performance 2.Risk for depression 3.Impaired ability to perform self-care activities 4. Sleep disturbances

Ineffective role performance Rationale: In a client who is to undergo bilateral orchidectomy, the nurse would assign priority to loss of reproductive ability as a psychological concern. The radical effects of this surgery in this area make it likely that the client will have some difficulty adjusting to this consequence of the surgery. The other options are not related directly to the surgery but might be cause for concern if the client experiences difficulty adjusting to the effects of the surgery. Test-Taking Strategy: Use the process of elimination and note the strategic words "priority" and "directly related." Think about what is involved in this surgical procedure to answer correctly. Review the psychosocial concerns following bilateral orchidectomy if you had difficulty with this question

A nurse is monitoring a client with a head injury for signs of diabetes insipidus (DI). Which finding would cause the nurse to suspect that this complication is developing? 1.Urine specific gravity 1.020 2. Serum osmolarity 200 mOsm/kg (200 mmol/kg) 3. Urine output 30 mL/hr for past 4 hours 4. Serum sodium level 155 mEq/L (155 mmol/L)

Serum sodium level 155 mEq/L (155 mmol/L) Rationale: One complication of head injury is diabetes insipidus (DI), which may occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. In DI the urine specific gravity ranges from 1.003-1.030 and the serum osmolarity and serum sodium level are high. Large quantities of very dilute urine are excreted, putting the client at risk for severe dehydration. Normal osmolarity ranges from 275 to 295 mOsm/kg (275 to 295 mmol/kg). The normal sodium range is 135 to 145 mEq/L (135-145 mmol/L). The other options are signs of syndrome of inappropriate antidiuretic hormone, which is a complication of intracranial surgery. Test-Taking Strategy: Use the process of elimination, recalling that one complication of head injury is diabetes insipidus. Recalling that diabetes insipidus results in the excretion of large amounts of dilute urine will assist you in eliminating the incorrect options. Review the complications of head injury and the signs of diabetes insipidus if you had difficulty with this question.

A client with phantom limb pain has decided to use transcutaneous electrical nerve stimulation (TENS) as prescribed by the health care provider, and the nurse provides instructions regarding the use of the TENS unit. Which statements by the client indicate a need for further instruction regarding this pain-relief measure? Select all that apply. 1. "I need to put the electrodes on the areas that you marked." 2. "Now I won't need to take so many pain medications." 3. "I'm so glad this will help relieve the pain." 4. "I'm not sure I'm going to like having those electrodes attached to my skin." 5. "I'm not happy about having to stay in the hospital for this treatment."

1. "I need to put the electrodes on the areas 5. "I'm not happy about having to stay in the hospital for this treatment." Rationale: The TENS unit is a battery-powered stimulator that is worn externally. The purpose of electrical stimulation is to modify the pain stimulus by blocking or changing a painful stimulus with stimulation, causing the client to perceive it as less painful. The client controls the system, thus reducing the need for analgesics. It is attached to the skin with the use of electrodes. The client needs to learn to adjust placement of the surface electrodes and the intensity and timing of the stimuli to maximize pain reduction or relief. It is not necessary that the client remain in the hospital for this treatment. Test-Taking Strategy: Use the process of elimination and note the words "need for further instruction" in the question, which indicate a negative event query and the need to select the incorrect client statements. Eliminate the options that are comparable or alike in that they address the easing of pain. Next recall that hospitalization is not a cost-effective pain-management technique and remember that the client must adjust placement of the surface electrodes. Review the use of the TENS unit if you had difficulty with this question.

A client with acute kidney injury (AKI) has a prescription for oral sodium polystyrene sulfonate. Which serum electrolyte value does the nurse recognize as the cause for this prescription? 1. Calcium 9.8 mg/dL (2.45 mmol/L) 2. Sodium 144 mEq/L (144 mmol/L) 3. Potassium 5.9 mEq/L (5.9 mmol/L) 4. Phosphorus 3.9 mg/dL (1.26 mmol/L)

3. Potassium 5.9 mEq/L (5.9 mmol/L) Rationale: The normal potassium range is 3.5 to 5.0 mEq/L (3.5-5.0 mmol/L), so this client is experiencing hyperkalemia. Of all of the electrolyte imbalances that accompany AKI, hyperkalemia is the most serious, because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to produce excretion of potassium through the gastrointestinal tract. Each of the other values presented in the other options falls within the normal reference range. Test-Taking Strategy: Use the process of elimination. Recall that the potassium level rises in AKI and that it is treated with the medication named in the question. Recalling the normal ranges for the laboratory values set forth in the options will direct you to the correct one. If this question was difficult for you, review these laboratory values and the use of sodium polystyrene sulfonate.

A client has a prescription to have blood drawn from the radial artery for a set of arterial blood gas (ABG) determinations. For which test does the nurse look for a positive result before the blood is drawn? 1. Allen test 2. Trousseau sign 3. Brudzinski sign 4. Babinski reflex

1. Allens test Rationale: The Allen test is performed before blood is drawn for assessment of arterial blood gases. The radial and ulnar arteries are occluded in turn, then released, after which the distal circulation is assessed. If the result is positive, the client has adequate circulation and that site may be used. The Trousseau sign is an indication of the presence of carpopedal spasms, denoting hypocalcemia. The presence of the Brudzinski sign indicates nuchal rigidity. The Babinski reflex is used to assess neurological dysfunction. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with the purposes of various physical assessments. Eliminate the Babinski reflex and Brudzinski sign, because both are indicators of neurological dysfunction. Next, recall that the Trousseau sign is indicative of hypocalcemia. If this question was difficult for you, review the procedure for obtaining blood for ABG determinations.

A nurse educator conducts an informational session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct? Select all that apply. This type of anthrax results from the inhalation of spores. 1. Contact precautions are not always necessary with skin anthrax. 2. Skin anthrax can lead to septicemia if it goes untreated. 3. Early clinical manifestations include mild upper respiratory symptoms. 4. Symptoms may appear as soon as 24 hours after exposure.

1. Contact precautions are not always necessary with skin anthrax. 2. Skin anthrax can lead to septicemia if it goes untreated. 4. Symptoms may appear as soon as 24 hours after exposure.

A nurse caring for a client with a spinal cord injury is watching for signs of autonomic dysreflexia. For which manifestation of this complication does the nurse monitor the client? 1. Nasal stuffiness and headache 2. Tachycardia and blurred vision 3. Hypotension and nausea 4. Pallor and sweating

1. Nasal stuffiness and headache Rationale: The client with a spinal cord injury is at risk for autonomic dysreflexia if the injury is located above the level of T7. The condition is characterized by severe throbbing headache, flushing of the face and neck, bradycardia, nasal stuffiness, and sudden severe hypertension. Other signs include blurred vision, nausea, and sweating. This life-threatening syndrome is triggered by a noxious stimulus below the level of the injury. Test-Taking Strategy: Use the process of elimination. Recalling that a massive sympathetic nervous system response occurs in this complication will assist you in eliminating the incorrect options. Review the signs of autonomic dysreflexia if you had difficulty with this question.

A client hospitalized with an abdominal aortic aneurysm (AAA) suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has increased from 80 to 110 beats/min. The nurse should: 1.Continue to monitor the client's vital signs Correct Answer 2. Immediately contact the health care provider 3. Administer pain medication to the client 4. Evaluate urine output during the previous shift

2. Immediately contact the health care Rationale: The signs and symptoms in the question are indicative of rupture of the AAA. Typical signs and symptoms of rupture include back and flank pain, ecchymosis of the flank and perianal areas, a pulsating abdominal mass, lightheadedness, nausea, and signs of shock. This is an emergency situation, and the client requires simultaneous resuscitation and preparation for immediate surgical repair. The other options are incorrect and would delay necessary treatment. Test-Taking Strategy: Focus on the symptoms identified in the question. Noting the strategic word "suddenly" and recalling the life-threatening complications associated with an AAA will direct you to the correct option. Review the complications of AAA if you had difficulty with this question.

A client with deep vein thrombus (DVT) is undergoing anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 18 seconds, with a control of 11 seconds, and the International Normalized Ratio (INR) is 2.0. The nurse recognizes these results as: 1. Requiring health care provider notification 2.Within the therapeutic range 3. Below the therapeutic range 4. Above the therapeutic range

2. Within the therapeutic range Rationale: The therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control for clients at high risk for thrombus. This client's control value means that the therapeutic range for would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. The client receiving warfarin sodium for DVT should have an INR between 2.0 and 3.0. Test-Taking Strategy: Eliminate the options that are comparable or alike (i.e., requiring health care provider notification and higher than the therapeutic range). To select from the remaining options, note the PT and the control value and recall that the therapeutic range for prothrombin time (PT) is 1.5 to 2 times the control. This will assist you in answering correctly. Review the therapeutic PT level and INR for a client at risk for thrombus formation if you had difficulty with this question.

A client is undergoing anticonvulsant therapy with phenytoin. Which laboratory parameter does the nurse monitor most closely in this client? 1. Serum potassium 2. Serum creatinine 3. Complete blood count (CBC) 4. Blood urea nitrogen (BUN)

3. Complete blood count (CBC) Rationale: Phenytoin is an anticonvulsant. The nurse closely monitors the CBC of a client taking the drug because hematological side effects of this therapy include blood dyscrasias such as agranulocytosis, leukopenia, and thrombocytopenia. Liver function tests, a CBC, and a platelet count should be performed before therapy is begun and periodically during therapy. The potassium level, creatinine, and BUN are not affected by the use of phenytoin. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are assessments of renal function (i.e., creatinine and BUN). To select from the remaining options, recall that phenytoin causes hematological side effects. This will direct you to the correct option. Review the side effects of phenytoin if you had difficulty with this question.

A nurse is preparing to care for a client who just returned from the recovery room after a Billroth II procedure. Which intervention in the plan of care does the nurse question? 1. Maintain NPO status until bowel sounds return. 2.Perform active range-of-motion exercises every 4 hours. 3. Reposition the nasogastric (NG) tube if drainage ceases. 4. Encourage coughing and deep-breathing exercises every hour.

3. Reposition the nasogastric (NG) tube if drainage ceases. Rationale: In a Billroth II resection, an anastomosis is constructed between the proximal remnant of the stomach and the proximal jejunum. Patency of the NG tube is critical in preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically asked to do so by the health care provider, because the tube is placed directly over the suture line. NPO status, active range-of-motion exercises, and coughing and deep-breathing exercises are all appropriate postoperative interventions. Test-Taking Strategy: Use the process of elimination. Eliminate the options that represent general postoperative interventions. Also, consider the anatomical location of the surgical procedure to identify the correct option. Review interventions after a Billroth II procedure if you had difficulty with this question. A nurse is assessing a client admitted to the emergency department with a diagnosis of diabetic ketoacidosis (DKA). The nurse observes the client for respirations that are: Shallow and slow Deep and slow You Answered Shallow and rapid Correct Answer Deep and rapid Rationale: The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are rapid and deep. They occur as the body tries to eliminate carbon dioxide to compensate for the acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the client's respiratory status as part of the assessment of the client's overall status. Test-Taking Strategy: Note the strategic word "ketoacidosis." Use your knowledge of the pathophysiology of acidosis to identify the correct option. Remember that the client in DKA exhibits Kussmaul's respirations. Review the manifestations of diabetic ketoacidosis if you had difficulty with this question.

A nurse is developing a plan of care for a client who has had a stroke and is experiencing homonymous hemianopsia. Which interventions does the nurse include in the care plan to help the client to overcome this deficit? 1. Discouraging the use of eyeglasses until the deficit has resolved 2. Teaching the client to perform active range-of-motion exercises 3. Discouraging the client from using a walker when ambulating 4. Encouraging the client to turn the head from side to side to scan the complete range of vision

4. Encouraging the client to turn the head from side to side to scan the complete range of vision Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and conducts client teaching from within the intact field of vision. The nurse encourages the use of the client's own eyeglasses, if they are available. Discouraging the client from using a walker when ambulating and teaching the client to perform active range-of-motion exercises are unrelated to this deficit. Test-Taking Strategy: Use the process of elimination. Recalling the definition of homonymous hemianopsia and remembering that it is loss of half of the visual field will easily direct you to the correct option. Review the concept of homonymous hemianopsia if you are unfamiliar with it.

The wife of a client with type 1 diabetes mellitus calls the nurse in the health care provider's office about her husband. She states that her husband is sleepy, that his skin is warm and flushed, and that his breathing is faster than normal. The nurse instructs the wife to: 1. Check his blood glucose level 2. Immediately call an ambulance 3. Bring him to the doctor's office 4. Check his temperature and pulse rate

1. Check his blood glucose level Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse would then report to the health care provider. Calling an ambulance or bringing him to the health care provideroffice may be done AT A later time if required. The client's temperature and pulse rate are not germane to the client's immediate problem. Test-Taking Strategy: Focus on the data in the question and use the steps of the nursing process. Checking his temperature and pulse rate and blood glucose reflect further assessment of the client; checking the blood glucose level, however, is related specifically to the client's diagnosis, and the blood glucose reading may have an impact on the directions subsequently given to the client's wife. Review care of the diabetic client experiencing hyperglycemia if you had difficulty with this question.

A nurse is monitoring a client who sustained a blunt chest injury when she hit the steering wheel in a motor vehicle crash. Which findings would cause the nurse to suspect flail chest? Select all that apply. Correct Answer 1. Cyanosis 2. Chest pain 3. Bradycardia 4.Asymmetric chest movements 5. Slow, shallow respirations 6. Increasing dyspnea

1. Cyanosis 2. Chest pain 4.Asymmetric chest movements 6. Increasing dyspnea Rationale: The clinical manifestations of flail chest include severe chest pain; asymmetric (paradoxical) chest movements; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing. Test-Taking Strategy: Use the process of elimination and think about the manifestations that occur in a client with a respiratory problem. Eliminate bradycardia, because the heart rate would be increased, not slowed. Eliminate slow, shallow respirations, because the client's respirations would be rapid, not slow. Review the clinical manifestations of flail chest if you had difficulty with this question.

A nurse performs a fingerstick glucose test on a client who is receiving (Total)parenteral nutrition (TPN) and obtains a reading of 410 mg/dL(22.8 mmol/L). On the basis of this finding, the nurse would most appropriately: 1. Notify the health care provider 2. Administer a dose of NPH insulin 3. Stop the TPN feeding 4. Decrease the flow rate of the TPN feeding

1. Notify the health care provider Rationale: Hyperglycemia is one complication of TPN. Because the glucose reading is increased, the nurse would immediately notify the health care provider and await further instructions. Stopping the TPN feeding, decreasing the flow rate of the TPN feeding, and administering a dose of NPH insulin would not be implemented without a health care provider's prescription. A sliding-scale dose of regular (not NPH) insulin might be prescribed to keep the blood glucose level between 180 and 200 mg/dL (10 to 11.1 mmol/L). Test-Taking Strategy: Use the process of elimination. Eliminate the options that are not within the scope of nursing practice. Your knowledge of the normal glucose range should also help direct you to the correct option. Review care of the client receiving TPN if you had difficulty with this question.

A nurse is studying the results of periodic serum laboratory studies in a client with diabetic ketoacidosis (DKA) who is receiving an intravenous insulin infusion. Which finding should prompt the nurse to contact the health care provider? 1. Potassium 3.1 mEq/L (3.1 mmol/L) 2. Serum pH 7.33 (7.33) 3. Blood glucose 290 mg/dL (16.15 mmol/L) 4. Sodium 137 mEq/L (137 mmol/L)

1. Potassium 3.1 mEq/L (3.1 mmol/L) Rationale: The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Therefore the nurse must carefully monitor the client's serum potassium results and report hypokalemia (i.e., potassium 3.1 mEq/L, 3.1 mmol/L) immediately. A blood glucose reading of 290 mg/dL (16.2 mmol/L)is high and is the reason that the client is receiving the insulin infusion. Normally the blood glucose level is higher than 300 mg/dL (16.7 mmol/L)in DKA, so a value of 290 mg/dL (16.2 mmol/L)indicates improvement in the client's condition. A serum pH of 7.33 is slightly low, reflecting the metabolic acidosis that accompanies DKA. A sodium value of 137 mEq/L (137 mmol/L)is within the normal range; serum sodium values in DKA fluctuate and may be low, normal, or high. Test-Taking Strategy: Use the process of elimination and recall the normal reference ranges for the tests listed in the options. Eliminate the sodium level, because it is a normal value. To select from the remaining options, recall that an increased blood glucose level and low pH are expected in DKA. Review care of the client with DKA if you had difficulty with this question.

A nurse is reviewing the laboratory results of a client with cytomegalovirus retinitis who is receiving foscarnet sodium. Which laboratory test result that will identify a toxic effect of the medication, does the nurse check? 1. Serum creatinine 2. CD4+ T-cell count 3. Liver function studies 4. Sedimentation rate

1. Serum creatinine Rationale: Foscarnet sodium is an antiviral medication. Renal impairment is a major risk with the use of this medication. The serum creatinine level is checked before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. This medication may also cause decreases in the levels of calcium, magnesium, phosphorus, and potassium in the bloodstream. Therefore these parameters are measured with the same frequency. Sedimentation rate, liver function studies, and CD4+ T-cell count are not used to detect toxic effects of this medication. Test-Taking Strategy: Specific knowledge regarding this medication is needed to answer this question. Recalling that this foscarnet sodium is nephrotoxic will direct you to the correct option. Review foscarnet sodium and its toxic effects if you had difficulty with this question.

A client who sustained an extensive full-thickness burn injury is being admitted to the nursing unit. Which prescription by the health care provider would the nurse question? 1. Maintain nasogastric tube with low intermittent suction. 2. Assess vital signs, oxygen saturation, and level of consciousness each hour. 3. Administer morphine sulfate 6 mg intramuscularly every 3 hours as needed. 4. Insert Foley catheter and check urine output each hour.

2. Assess vital signs, oxygen saturation, and level of consciousness each hour. Rationale: The intravenous route is the preferred route of administration of opioids to a burned client because of the potential for problems with absorption from the muscle and stomach. When fluid balance is stabilized, oral opioid agents may be used. The other options are all appropriate interventions for the client with an extensive burn injury. Test-Taking Strategy: Use the process of elimination and focus on the subject, the prescription that needs to be questioned. Read each option carefully and think about the pathophysiology of burns. Recalling that poor absorption occurs with medications administered orally, subcutaneously, or intramuscularly will direct you to the correct option. Review pain management in the burned client if you had difficulty with this question.

A client hospitalized with an abdominal aortic aneurysm (AAA) suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has increased from 80 to 110 beats/min. The nurse should: 1.Evaluate urine output during the previous shift 2. Immediately contact the health care provider 3. Administer pain medication to the client 4. Continue to monitor the client's vital signs

2. Immediately contact the health care provider Rationale: The signs and symptoms in the question are indicative of rupture of the AAA. Typical signs and symptoms of rupture include back and flank pain, ecchymosis of the flank and perianal areas, a pulsating abdominal mass, lightheadedness, nausea, and signs of shock. This is an emergency situation, and the client requires simultaneous resuscitation and preparation for immediate surgical repair. The other options are incorrect and would delay necessary treatment. Test-Taking Strategy: Focus on the symptoms identified in the question. Noting the strategic word "suddenly" and recalling the life-threatening complications associated with an AAA will direct you to the correct option. Review the complications of AAA if you had difficulty with this question.

A nurse is providing dietary instructions to the spouse of a client with newly diagnosed AIDS who is being discharged from the hospital. The nurse instructs the spouse to: 1. Add spices to foods to make them more palatable Correct Answer 2. Serve foods at room temperature 3. Increase the amount of milk and milk products consumed on a daily basis 4. Offer peanut butter and crackers as snacks to increase protein intake

2. Serve foods at room temperature Rationale: The AIDS client may experience problems with nutrition as a result of the side effects of medications, anorexia, nausea and vomiting, altered taste, impaired swallowing and chewing, diarrhea, fatigue, depression, or impaired cognition. Foods are best tolerated either cold or at room temperature. Spicy foods may be irritating and can aggravate nausea. Peanut butter, a sticky food, should be avoided in the client having difficulty swallowing. Milk and milk products can exacerbate diarrhea. Test-Taking Strategy: Use your knowledge of the effects of AIDS on the gastrointestinal system to answer the question. Additionally, knowledge of the general principles of nutrition in a client with an immunosuppressive disorder will help you identify the correct option. Review these nutritional measures if you had difficulty with this question.

A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads: 1. 7.50 2. 7.28 3. 7.40 4. 7.30

3. 7.40 Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40. Test-Taking Strategy: Knowledge that the normal body pH is 7.40 will direct you to the correct option. pH values of 7.28 and 7.30 indicate acidic condition, whereas 7.50 indicates an alkaline condition. Review care of the client who has sustained a chemical splash to the eye if you had difficulty with this question.

A nurse planning care for a client who has undergone transurethral resection of the prostate (TURP) remembers that the most common cause of postoperative pain is: 1. Tension on the Foley catheter 2. Bleeding within the bladder 3. Bladder spasms 4. The location of the incision

3. Bladder Spasm Rationale: Bladder spasms may occur after TURP because of postoperative bladder distention or irritation by the balloon of the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Because the prostate is accessed through the urethra, there is no incision in a TURP. Bleeding within the bladder and tension on the Foley catheter are not common causes of pain. Some surgeons purposely prescribe the application of tension to the catheter for a few hours after surgery to help control bleeding. Test-Taking Strategy: Use the process of elimination. To answer this question accurately, you must be familiar with the concept of pain and how it is managed after this surgical procedure. Knowing that there is no incision with this procedure will assist you in eliminating the option of the lower abdominal incision. To select from the remaining options, recall that bladder spasms are a problem after this surgery. Review the causes of pain after TURP if you had difficulty with this question.