Practice MC for Exam 1

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A nursing assistant (NA) is assigned to care for a client who had a cemented total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision by the nurse? A. "Ill keep an abduction pillow in place at all times" B. "Ill tell the client not to place a pillow under the surgical knee" C. "Ill apply ice packs to decrease swelling in the knee as ordered" D. "Ill check to make sure the client's leg is not rotated"

A A. "Ill keep an abduction pillow in place at all times"

A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? A. Assess the level of the client's pain. B. Change the subject and talk about the client's hobbies. C. Distract the client with stories about the nurse's family. D. Remind the client that the lower leg was removed.

A A. Assess the level of the client's pain. Rationale: The nurse should recognize that the pain (phantom limb pain) is real to the client and perform a pain assessment in preparation for pain management. The other options are not examples of acknowledging the client's concern or therapeutic responses to the client in this situation.

A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. B. Check the fit of the cast by inserting a tongue blade between the cast and the skin. C. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. D. Keep the cast covered with a soft towel to help it to dry quickly.

A A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. Rationale: The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. The cast dries quickly because it is made of synthetic materials.

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 A. See your ophthalmologist for visual field testing every 6 months Rationale: Hydroxychloroquine has both immunomodulating and anticlotting effects that can be beneficial to clients with SLE. A major complication of this drug is its toxicity to retinal cells causing retinitis that can lead to an irreversible loss of central vision. Clients prescribed hydroxychloroquine are instructed to have frequent eye examinations with visual field testing (before starting the drug and every 6 months thereafter). If retinal toxicity is suspected, the drug is discontinued to preserve the remaining vision.

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 A. The client does not need to have labs drawn for PT or INR Rationale: Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn.

Which assessment is most important for the nurse to perform for the client admitted to the postanesthesia care unit (PACU) after surgery under general anesthesia? A. Determining the client's level of consciousness B. Checking for pain on dorsi and plantar flexion of the foot C. Assessing the response to pin prick stimulation from feet to mid-chest level D. Comparing blood pressure taken in the right arm to blood pressure taken in the left arm.

A A. Determining the client's level of consciousness

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? Select all that apply. A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis

A, B, C, D, E A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis

A 72-year-old female client is admitted to the hospital with pneumonitis as a result of long-term rheumatoid arthritis (RA). She has diabetes mellitus type 2 that has been well controlled on sliding scale regular insulin. The client takes methotrexate (MTX) for her RA and tramadol at night to help relieve pain and promote sleep. The nurse documents the assessment data. Which of the following assessment findings require follow up by the nurse. Select all that apply. A. Admitted to the hospital with pneumonitis as a result of long-term rheumatoid arthritis B. Takes methotrexate (MTX) for RA and tramadol at night to help relieve pain C. History of peripheral vascular disease and diabetic neuropathy D. History of stent placement in her right femoral artery E. Temperature = 99F F. Apical pulse = 86 (regular and strong) G. respirations = 22 and regular H. BP = 148/88 I. O2 saturation = 94% (on 2 L/min my NC) J. States that she sometimes feels a "little short of breath" K. Denies chest pain L. Multiple joint deformities, especially in the hands M. Reports persistent pain in joints, especially in wrists which are swollen and reddened.

A, B, E, G, I, J, L, M A. Admitted to the hospital with pneumonitis as a result of long-term rheumatoid arthritis Rationale: The client has a lung inflammation (pneumonitis) which can be a complication of RA. B. Takes methotrexate (MTX) Rationale: Because she is on MTX, she is at risk for pneumonia and other infections while in the hospital E. Temperature = 99F Rationale: Her slight temperature elevation is likely due to inflammation but needs to be monitored carefully. G. respirations = 22 and regular J. States that she sometimes feels a "little short of breath" Rationale: Her respiratory rate is slightly elevated and could worsen if she experiences more shortness of breath. I. O2 saturation = 94% (on 2 L/min my NC) Rationale: The client's oxygen saturation is slightly low and may improve if the supplemental oxygen flow rate is increased to 3 L. L. Multiple joint deformities, especially in the hands M. Reports persistent pain in joints, especially in wrists which are swollen and reddened. Her slight temperature elevation is likely due to inflammation but needs to be monitored carefully. Rationale: She may need assistance with ADLs because she has joint pain and multiple joint deformities.

Which of the following tests is most sensitive to generalized inflammation in the body A. CRP B. RH factor C. ESR D. WBC E. HgB

A. A. CRP Both ESR and CRP tells us about general inflammation in the body, however, CRP is more sensitive (or better) at detecting inflammation (so it is a better test). Also, ESR can tell us about infection somewhere in the body but CRP does not (it only tells inflammation). CRP IS MORE SPECIFIC IN TELLING US ABOUT INFLAMMATION IN THE BODY.

A patient is found to have a blood glucose of 375 mg/dL, positive ketones in the urine, and blood pH of 7.25. Which condition is this? A. DKA B. HHNS

A. A. DKA

Which is found more commonly in Type 1 Diabetics? A. DKA B. HHNS

A. A. DKA

The _____ ______ secrete insulin which are located in the _______. A. Alpha cells, liver B. Alpha cells, pancreas C. Beta cells, liver D. Beta cells, pancreas

D D. Beta cells, pancreas

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. "Dont worry, treatment will make everything better" D. "You look great. Its what is inside that counts"

B B. "I bet that was hard to say. Thank you for trusting me with your feelings: Rationale: an empathetic response in a hard conversation. It acknowledges the client's bravery for sharing and encourages further therapeutic communication.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? A. "I quit smoking 10 years ago." B. "I had a heart attack 4 months ago." C. "I take a multivitamin daily." D. "I drink a glass of wine a night."

B B. "I had a heart attack 4 months ago." Rationale: Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? A. Lungs for bilateral normal breath sounds B. Urine specimen to assess for the red blood cells C. Pain score and level of alertness D. Skin to evaluate lacerations and abrasions

B B. Urine specimen to assess for the red blood cells Rationale: It is most important for the nurse to determine the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

Which emergency care does the nurse recognize that will be implemented for a client with malignant hyperthermia? Select all that apply. A. Removal of endotracheal tube B. Cessation (stopping) of surgery when possible C. Insertion of Foley catheter to monitor urine output D. Transfer of patient to intensive care unit when stabilized E. Assessment of arterial blood gases (ABGs) for respiratory alkalosis F. Use of active cooling techniques such as cooling blanket and ice packs around the axillae and groin

B, C, D, F B. Cessation (stopping) of surgery when possible C. Insertion of Foley catheter to monitor urine output D. Transfer of patient to intensive care unit when stabilized F. Use of active cooling techniques such as cooling blanket and ice packs around the axillae and groin - Assess arterial blood gases (ABGs) and serum chemistries for metabolic acidosis and hyperkalemia

Which is found more commonly in Type 2 Diabetics? A. DKA B. HHNS

B. B. HHNS

Which of the following symptoms do NOT present in hyperglycemia? A. Extreme thirst B. Hunger C. Blood glucose <60 mg/dL D. Glycosuria

C C. Blood glucose <60 mg/dL

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 tener?"

C C. "Are you able to independently perform ADLs?" Rationale: As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked

Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes? A. "Avoid drinking ice-cold beverages" B. "Be sure to check your BP twice daily" C. "Change your positions slowly when moving from sitting to standing" D. "Check your hands and feet weekly for areas of numbness or sensation change"

C C. "Change your positions slowly when moving from sitting to standing"

Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? A. "Inspect the pins in the traction for signs of infection." B. "Remove the boot every shift to inspect the skin." C. "Do not allow the traction weights to rest on the ground." D. "Remove traction weights when turning the client."

C C. "Do not allow the traction weights to rest on the ground." Rationale; Although Buck's traction is not used commonly today because clients have surgical hip repairs to reduce pain, for some clients such as this client, it is used short term until surgery can be performed. The AP should allow the weights to hang freely and not remove them. There are no pins and the boot can be removed by the nurse for skin inspection.

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 C. "Have eye examinations every 6 months while on the drug." Rationale: Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes.

Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? A. Talking with a psychiatrist about the amputation B. Engaging in diversional activities to avoid focusing on the amputation C. Talking with an amputee close to the client's age who has a similar amputation D. Drawing a picture of how the client sees him- or herself

C C. Talking with an amputee close to the client's age who has a similar amputation Rationale: Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation.Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

An 83-year-old female client with dementia has undergone hip replacement surgery after a fall. Under normal circumstances before the fall, the client regularly ambulated. The nurse is preparing to discharge the client from the hospital back to the memory care until of an extended-care facility. Due to the type of surgery the client has undergone, she is currently most at risk for ____. A. Brain attack B. Pressure Injury C. Venus thromboembolism D. Falling E. Constipation F. Aspiration G. Hemorrhage H. Undernutrition

C C. Venus thromboembolism One of the most significant risks associated with hip replacement surgery (or any major orthopedic surgery) is venous thromboembolism, especially in the early postoperative period.

Which patient population is most at risk for DKA? A. Middle-aged adults who are obese B. Older-adults with Type 2 diabetes C. Newly diagnosed diabetes D. None of the options

C. C. Newly diagnosed diabetes

The PACU nurse caring for a client with a nasogastric (NG) tube notes that 300 mL of bright red blood has collected. What is the appropriate nursing action? A. Document as a normal finding B. Immediately remove the NG tube C. Place the client in Trendelenburg position D. Call the client's surgeon to report the drainage.

D D. Call the client's surgeon to report the drainage.

The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? A. Affected foot slightly cooler than the other foot. B. Reports pain level is 4 on a 0-10 pain intensity scale. C. Pedal pulse on affected foot is 1+ and regular. D. Reports tingling and numbness in affected foot.

D D. Reports tingling and numbness in affected foot. Rationale: This client is at risk for neurovascular compromise or compartment syndrome from the external dressing. Pain and a slightly cooler foot is to be expected. However, the client should not have tingling and numbness suggesting that arterial blood flow is diminished.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment? A. Pain at the surgical site B. Verbal stimuli needed to awaken C. Sore throat upon swallowing D. Snoring sounds when inhaling

D D. Snoring sounds when inhaling Rationale: Snoring sounds when inhaling may indicate respiratory depression. The rest of the options are normal findings

True or False: Osmotic diuresis is present in HHNS and DKA due to the kidney's inability to reabsorb the excessive glucose which causes glucose to leak into the urine which in turn causes extra water and electrolytes to be excreted.

True

True or False: Treatment of Hyperglycemic Hyperosmolar Nonketotic Syndrome is similar to the treatment of Diabetic Ketoacidosis.

True

True or False: When priming the tubing for an Insulin infusion it is best practice to waste 50cc to 100cc of insulin prior to starting the infusion because insulin absorbs into the plastic lining of the tubing.

True

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 3. Report any infection to your rheumatology HCP immediately

3. Report any infection to your rheumatology HCP immediately Indicated Rationale: Clients are at high risk for infection development and progression to more serious infection rapidly as a result of the immunosuppressive aspects of drug therapy. Influenza vaccination and beginning treatment for any infection early are critical to prevent harm.

A 50-year-old male client newly diagnosed with type 2 diabetes mellitus attended a diabetes education session with a diabetes educator 1 month ago. His management regimen includes dietary modification, increasing his weight-bearing exercise to at least 150 minutes weekly, and taking the antidiabetic drug, regular-release exenatide, twice daily by injection. He is returning to the clinic for follow-up on his health and evaluation of the effectiveness of the management plan. The nurse is assessing him, answering his questions, and reinforcing the diabetes education presented a month ago. For each of the assessment findings, determine if they are effective, ineffective, or unrelated. 4. A1c = 5.9%

4. A1c = 5.9% Effective The A1c of 5.9% is very good. The goal of management for diabetes is to keep the A1c under 6% to prevent macrovascular and microvascular complications. This finding indicates the client is implementing the prescribed management plan.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 4. Bathe or shower no more frequently than once weekly

4. Bathe or shower no more frequently than once weekly Contraindicated Rationale: Hygiene is important and bathing no more than once weekly not only is not recommended, but it also can increase the risk for some infections. Clients are taught to clean the skin with mild soap and to avoid harsh, perfumed substances that may irritate the skin further.

Which nurse statement needs further teaching in regards to giving blood. A. I will complete the RBC transfusion within 6 hours B. I will check the pt verification with another registered nurse C. I will use the normal saline solution to begin the blood transfusion D. I will remain with the pt for the first 15 to 30 minutes of the infusion

A A. I will complete the RBC transfusion within 6 hours

This condition happens gradually and is more likely to affect older adults? A. HHNS B. DKA

A. A. HHNS

What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry B. Check the surgical dressing to ensure that it is intact C. Assess neurovascular assessment in the affected arm D. Monitor intake and output

A. A. Monitor vital signs, including pulse oximetry

The nurse is performing an assessment on a client who has arrived in the preoperative holding area. Which client statement requires immediate nursing intervention? A. "I'm a little bit anxious about my surgery" B. "When I eat shrimp, my tongue swells, and I have difficulty breathing" C. "This left knee replacement will help me walk much more comfortably again" D. "Before I get discharged home, I want to have my eyeglasses and hearing aids returned'

B B. "When I eat shrimp, my tongue swells, and I have difficulty breathing"

Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites. A. 75 y/o client whose blood glucose levels show little variation B. 55 y/o client who has hypoglycemic unawareness C. 80 y/o client with type 2 DM D. 45 y/o client with type 1 DM

B B. 55 y/o client who has hypoglycemic unawareness

Which of the following patients is at most risk for Type 2 diabetes? A. A 6 year old girl recovering from a viral infection with a family history of diabetes. B. A 28 year old male with a BMI of 49. C. A 76 year old female with a history of cardiac disease. D. None of the options provided.

B B. A 28 year old male with a BMI of 49. Type 2 diabetes risk factors are related to lifestyle....being obese is a risk factor (BMI >30 in males is considered obese). So, the 28 year old male with a BMI of 49 is most at risk for Type 2.

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 dark, 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 B. Do not suddenly stop taking the drug when your flare is over rationale: All of the precautions are correct and important. However, the most critical precaution is to not suddenly stop taking the drug, which could lead to acute adrenal insufficiency and even death. This dose of the drug (45 mg daily) would need to be tapered down over a period of weeks to prevent adrenal insufficiency.

A client has a synthetic cast placed for a right wrist fracture in the emergency department. Which priority health teaching is important for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling" C. "Move the fingers of the right hand frequently to promote blood flow" D. "Report coolness or discoloration of your right hand to your doctor" E. "Don't place any device under the cast to scratch the skin if it itches"

B, C, D, E B. "Use an ice pack for the first 24 hours to decrease tissue swelling" C. "Move the fingers of the right hand frequently to promote blood flow" D. "Report coolness or discoloration of your right hand to your doctor" E. "Don't place any device under the cast to scratch the skin if it itches"

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

Which of the following patients is MOST LIKELY experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms? A. A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. B. A 66 year old with type I diabetes that has ketones present in their urine. C. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. D. A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting.

C C. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL Hallmark of HHNS is an EXTREME high blood glucose (>600 mg/dL), is precipitated by infection, and is more common in type 2 diabetics. The 69 year old is a type 2 diabetic due to the clue that the option states the patient has missed doses of Metformin (which is an oral type 2 diabetic medication). DKA presents with elevated blood glucose >300 mg/dL and ketones which HHNS does not.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A. Surgical repair of the rotator cuff B. Patient-controlled analgesia with morphine C. Activity limitations for the affected arm D. Prescribed exercises of the affected arm

C C. Activity limitations for the affected arm Rationale: The immediate conservative treatment for this client is to limit activity in the injured arm.Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched? A. Rheumatoid arthritis - leflunomide B. Osteoarthritis - acetaminophen C. Acute gout - allopurinol D. Systemic lupus erythematosus - prednisone

C C. Acute gout - allopurinol

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 C. Gouty arthritis Rationale: 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.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs? A. Absence of erythema and tenderness at the surgical site B. Ability to flex and extend the right knee C. Large amount of serosanguineous or bloody drainage D. Mild to moderate pain controlled with prescribed analgesics

C C. Large amount of serosanguineous or bloody drainage Rationale: A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? A. Positive Ketones in the urine B. Polydipsia C. Oliguria D. Abdominal Pain

C C. Oliguria Oliguria means low urinary output...in DKA there is POLYURIA (high urinary output)

Which of the following statements is INCORRECT about Hyperglycemic Hyperosmolar Nonketotic Syndrome? A. HHNS occurs mainly in type 2 diabetics. B. This condition presents without ketones in the urine. C. Metabolic alkalosis presents in severe HHNS. D. Intravenous Regular insulin is used to treat hyperglycemia.

C. Metabolic alkalosis presents in severe HHNS.

A 53-year-old client underwent surgery to repair a left ankle fracture that was sustained during a skiing accident. The client has been transported back to the medical-surgical unit following discharge. After completing an initial assessment, the nurse provides interventions to facilitate the client's recovery. For each nursing action determine if it is indicated, contraindicated, or nonessential. 1. Place pillows under the knees to gently elevate the legs

Contraindicated Pillows should not be placed under the legs, as this action can restrict circulation and increase the risk for venous thromboembolism.

What type of insulin do you expect the doctor to order for treatment of DKA? A. IV Novolog B. IV Levemir C. IV NPH D. IV Regular Insulin

D D. IV Regular Insulin

Indicated Adequate hydration is necessary to promote the return of peristalsis. Hydration may be accomplished through administration of IV fluids, if prescribed, or oral intake. This can be assessed by inspecting the color and moisture of mucous membranes; the turgor, texture, and "tenting" of the skin (test over the sternum or forehead of an older patient); the amount of drainage on dressings; and the presence (or absence) of axillary sweat.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 1. Protect yourself from sun exposure with hats, long sleeves, and sunscreen

1. Protect yourself from sun exposure with hats, long sleeves, and sunscreen Indicated Rationale: Exposure to ultraviolet light, especially sunlight, exacerbates all aspects of the disorder, not just skin manifestations, and must be avoided at all times to prevent harm.

2. Reports using sunscreen of SPF 40 or wearing a hat when outdoors Unrelated The use of sunscreen and sun avoidance is not specific to the management of diabetes.

The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at highest risk for surgical complication? A. 52 y/o who takes aspirin daily B. 58 y/o who has well-controlled type II diabetes C. 64 y/o who has just received pre-surgical prophylactic antibiotics D. 69 y/o who will be discharged after surgery to an extended-care facility

A A. 52 y/o who takes aspirin daily

A patient who has diabetes is nothing by mouth as prep for surgery. The patient states they feel like their blood sugar is low. You check the glucose and find it to be 52. The next nursing intervention would be to: A. Administer Dextrose 50% IV per protocol B. Continue to monitor the glucose C. Give the patient 4 oz of fruit juice D. None, this is a normal blood glucose reading

A A. Administer Dextrose 50% IV per protocol This question requires critical thinking because the patient is NPO for surgery and can NOT eat but is experiencing hypoglycemia. Normally, you could give the patient 15 grams of a simple carbohydrate like 4 oz of fruit juice or soda, glucose tablets, gel etc. per hypoglycemia protocol However, the patient can NOT eat due to surgery prep. Therefore the nurse would need to administer Dextrose 50% IV per protocol to help increase the blood glucose and recheck the glucose level.

What health teaching by the nurse is important to clients diagnosed with SLE? A. Avoid sun exposure to prevent disease flareups Exacerbate flare up B. Try not to nap because it will affect your sleep C. If you have a fever for more than 5 days, notify your provider Should be reported immediately D. Avoid leafy green vegetables to prevent bleeding

A A. Avoid sun exposure to prevent disease flareups Exacerbate flare up

Which of the following is NOT a typical finding in HHNS? A. Blood pH <7.35 B. Dehydration C. Mental status changes D. Osmotic diuresis

A A. Blood pH <7.35

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Administer the prescribed analgesic. C. Place a dressing on the affected area. D. Immobilize the left leg with a splint.

A A. Check the dorsalis pedis pulses. Rationale: The essential nursing action is to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

A 36-year-old male is newly diagnosed with Type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? A. Diet and exercise regime B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough

A A. Diet and exercise regime

A patient has an infection and reports not checking their blood glucose or regularly taking Metformin. What condition is this patient MOST at risk for? A. HHNS B. DKA C. Metabolic alkalosis D. Metabolic acidosis

A A. HHNS

The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? A. Inspect the pins to monitor for infection and do not remove crusts. B. Make sure that the wound is managed using a moist wound healing method. C. Keep the leg covered to keep the extremity warm to promote circulation. D. Keep the extremity elevated to three pillows while in bed or in a chair.

A A. Inspect the pins to monitor for infection and do not remove crusts. Rationale: An external fixator is a series of pins attached to a metal frame to hold the bone ends in place while the wound can be managed. The nurse would frequently monitor the pin insertion sites for signs and symptoms of infection. Crusting that occurs at the sites should not be removed because it helps seal the open pin site areas to prevent infection. Leg elevation is important but the client would not necessarily need three pillows.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Avoid the use of antiembolism stockings. D. Administer pain medication before deep-breathing exercises.

A A. Keep the client's heels off the bed at all times. Rationale: Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area.Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

Type 1 diabetics typically have the following clinical characteristics: A. Thin, young with ketones present in the urine B. Overweight, young with no ketones present in the urine C. Thin, older adult with glycosuria D. Overweight, adult-aged with ketones present in the urine

A A. Thin, young with ketones present in the urine

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 A. Trauma to the joint Rationale: The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity.

A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? (Select all that apply.) A. Elevate the left leg above the level of the heart. B. Tell the client to keep his left leg still. C. Apply an elastic wrap or ankle or compression brace. D. Administer morphine via IV push. E. Apply heat to promote blood flow and healing.

A, B, C A. Elevate the left leg above the level of the heart. B. Tell the client to keep his left leg still. C. Apply an elastic wrap or ankle or compression brace. Rationale: The nurse follows the RICE approach to emergency care of clients who experience a sports-related injury, which includes rest, ice, compression, and elevation of the affected part. Heat may be used after 24 hours, but ice is needed now to reduce swelling. The client does not need a strong opioid for this injury.

A pt with RA is in the hospital for an unrelated issue. The pt reports that sleep, which is always difficult, is even harder now. What non pharmacological actions by the nurse are most appropriate? SATA A. Assess the pts usual bedtime routine B. Allow the pt uninterrupted rest time C. Limit environmental noise as much as possible D. Offer a warm massage or warm shower at night E. Call the doctor for an order for a strong sleeping pill like temazepam F. Call the doctor for an order for a mild sleeping pill like diphenhydramine (Benadryl)

A, B, C, D A. Assess the pts usual bedtime routine B. Allow the pt uninterrupted rest time C. Limit environmental noise as much as possible D. Offer a warm massage or warm shower at night

Whos at risk for developing OA? Select all that apply. A. Obese older woman living alone B. Slender, nonsmoking, middle aged man C. Middle aged man who worked construction 25 years Repetitive knee action D. Young woman with family history of RA E. Middle aged adult with multiple knee injuries from playing soccer in high school

A, C, E A. Obese older woman living alone C. Middle aged man who worked construction 25 years Repetitive knee action E. Middle aged adult with multiple knee injuries from playing soccer in high school

The nurse would expect which findings when assessing a patient with early RA? A. Fatigue B. Bony nodes in finger joints C. Subcutaneous nodules D. Inflammation of joints E. Low grade fever F. Weight loss

A, D, E A. Fatigue D. Inflammation of joints E. Low grade fever WRONG B. Bony nodes in finger joints -OA C. Subcutaneous nodules - LATE RA D. Weight loss - LATE RA (Anorexia is early) ((i guess))

Which are characteristics of compartment syndrome? Select all that apply. A. Pallor of the extremity B. Warmth of the extremity C. Petechiae over the extremity D. Numbness and tingling of the extremity. E. Pain on passive stretch of the muscle traveling through the compartment

A, D, E A. Pallor of the extremity D. Numbness and tingling of the extremity. E. Pain on passive stretch of the muscle traveling through the compartment D is because of the swelling

Which of the following statements are INCORRECT about Diabetic Ketoacidoisis? A. Extreme Hyperglycemia that presents with blood glucose >600 mg/dL B. Ketones are present in the urine C. Metabolic acidosis is present with Kussmaul breathing D. Potassium levels should be at least 3.3 or higher during treatment of DKA with insulin therapy

A. A. Extreme Hyperglycemia that presents with blood glucose >600 mg/dL Extreme Hyperglycemia that presents with blood glucose >600 mg/dL is present only in Hyperglycemic Hyperosmolar Nonketotic Syndrome.

A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? A. "I need to make sure I have an ergonomically sound computer station." B. "I need to exercise repetitively to strengthen my wrists." C. "I should stretch my fingers and wrists frequently during the day." D. "I may need to wear a wrist splint when my wrist gets inflamed."

B B. "I need to exercise repetitively to strengthen my wrists." Rationale; All of these statements are correct except that CTS is caused by repetitive motion such as that caused by working every day on computers. Repetitive exercises would therefore not be appropriate.

The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? A. Ensure that each crutch fits firmly into the client's armpit. B. Be sure that the top of each crutch is well padded. C. Use the crutch on the affected side only. D. Check to see how many steps the client can take with the crutches.

B B. Be sure that the top of each crutch is well padded. Rationale: The crutches are used a set and require that the nurse ensure that the client does not develop axillary nerve damage. The tops of the crutches should be well padded and should be at least 2 to 3 finger-breadths below the armpit.

A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? A. Chronic osteomyelitis B. Complex regional pain syndrome C. Severe osteoporosis D. Compartment syndrome

B B. Complex regional pain syndrome Rationale: When pain is not managed appropriately or interventions are not implemented to prevent complex regional pain syndrome (CRPS), the client is at risk for developing CRPS, a chronic debilitating complication of traumatic injury.

A patient with diabetes has a morning glucose of 50. The patient is sweaty, cold, and clammy. Which of the following nursing interventions is the MOST important? A. Recheck the glucose level B. Give the patient ½ cup (4 oz) of fruit juice C. Call the doctor D. Keep the patient nothing by mouth

B B. Give the patient ½ cup (4 oz) of fruit juice

A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient's labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next? A. Start the IV fluids and administer the insulin bolus and drip as ordered B. Hold the insulin and notify the doctor of the potassium level of 2.5 C. Hold IV fluids and administer insulin as ordered D. Recheck the glucose level

B B. Hold the insulin and notify the doctor of the potassium level of 2.5 Remember when insulin is given it helps take potassium back into the cell which will cause potassium blood levels to fall. Insulin therapy is to be started only if the patient's potassium level is 3.3 or greater.

Which of the following statements are true regarding Type 2 diabetes treatment? A. Insulin and oral diabetic medications are administered routinely in the treatment of Type 2 diabetes. B. Insulin may be needed during times of surgery or illness. C. Insulin is never taken by the Type 2 diabetic. D. Oral medications are the first line of treatment for newly diagnosed Type 2 diabetics.

B B. Insulin may be needed during times of surgery or illness

A Type 2 diabetic may have all the following signs or symptoms EXCEPT: A. Blurry vision B. Ketones present in the urine C. Glycosuria D. Poor wound healing

B B. Ketones present in the urine

You are providing care to a patient experiencing diabetic ketoacidosis. The patient is on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern? A. Patient complains of thirst. B. Patient has a potassium level of 2.3 C. Patient's skin and mucous membranes are dry. D. Patient is nauseous.

B B. Patient has a potassium level of 2.3 Insulin causes potassium to enter back into the cell; therefore removing it from the blood. If the potassium is already 2.3, the patient can bottom out their potassium level. Therefore, the patient needs potassium supplements which requires a doctor's order.

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure B. Perform a neurovascular assessment C. Report the client's concern to the primary health care provider. D. Inspect the skin under the elastic bandage.

B B. Perform a neurovascular assessment

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure B. Preform a neurovascular assessment C. Report the client's concern to the primary health care provider D. Inspect the skin under the elastic bandage

B B. Preform a neurovascular assessment

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? (Select all that apply.) A. Urinary tract infection (UTI) B. Acute compartment syndrome (ACS) C. Fat embolism syndrome (FES) D. Osteomyelitis E. Heart failure

B, C, D, B. Acute compartment syndrome (ACS) C. Fat embolism syndrome (FES) D. Osteomyelitis Rationale: ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

A patient undergoing treatment for Hyperglycemic Hyperosmolar Nonketotic Syndrome has a blood glucose of 799. The doctor has ordered intravenous fluids and intravenous Regular insulin therapy. Which of the following findings causes concern before starting insulin therapy? A. Regular insulin cannot be given intravenously; therefore, the nurse needs to clarify the doctor's order. B. The patient's potassium level is 3.1. C. The patient is complaining of severe thirst and has dry mucous membranes. D. The patient is confused and drowsy.

B. B. The patient's potassium level is 3.1. Prior to insulin administration for HHNS the potassium level should be >3.3 because insulin causes potassium to enter back to the cell....which will cause further hypokalemia.

Which client statement regarding appropriate pain control requires nursing intervention? A. "I'll listen to music when I feel pain" B. "Before exercise or PT, I'll be sure I've taken my medication" C. "If the prescribed dose of medication doesn't help my pain, I'll take an extra dose" D. "I plan to keep a pain diary so I can see trends about when my pain worsens"

C C. "If the prescribed dose of medication doesn't help my pain, I'll take an extra dose"

A patient is being discharged home after recovering from HHNS. Which statement by the patient requires patient re-education about this condition? A. "I will monitor my blood glucose levels regularly." B. "If I become sick I will monitor my blood glucose more frequently and drink lots of fluids." C. "This condition happens suddenly without any warning signs." D. "It is important I take my medication as prescribed."

C C. "This condition happens suddenly without any warning signs." HHNS presents GRADUALLY and the patient will experience early signs such as polyuria, polydipsia, and EXTREME hyperglycemia. DKA happens suddenly.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? A. "Avoid rigorous exercise." B. "Avoid contact sports." C. "Wear helmets when riding a motorcycle." D. "Avoid driving in inclement weather."

C C. "Wear helmets when riding a motorcycle." Rationale: Those who ride motorcycles or bicycles should wear helmets to prevent head injury.Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, but it is also opposed to what many health care professionals recommend to maintain health.

Which patient is MOST likely to develop Diabetic Ketoacidosis? A. A 25 year old female newly diagnosed with Cushing's Disease taking glucocorticoids. B. A 35 year old female newly diagnosed with Type 2 diabetes. C. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin. D. None of the options are correct.

C C. A 36 year old male with diabetes mellitus who has been unable to eat the past 2 days due to a gastrointestinal illness and has been unable to take insulin.

Which of the following is NOT a medical treatment for DKA and HHNS? A. IV regular insulin B. Isotonic fluids C. Bicarbonate D. IV potassium Solution

C C. Bicarbonate

As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action? A. Have the client sign the form. B. Contact the anesthesiologist. C. Contact the surgeon. D. Explain the procedure.

C C. Contact the surgeon. Rationale: The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed. It is not appropriate to have the client sign the form until the surgeon has clarified the procedure with the client.

An 81-year-old female client with a long history of osteoporosis is admitted to the emergency department with report of right groin and low back pain as a result of falling in the grocery store. She tells the nurse that she went shopping with her daughter as usual on Saturdays but her daughter was in another part of the store when she slipped on something on the floor. The client begins to cry because she is in pain and afraid that she will not be able to continue living independently in her apartment. She reports her pain as an 8 on a 0-10 pain scale. The nurse recognizes that an osteoporotic client is at high risk for _____. A. Arthritis B. Bone cancer C. Fracture D. Paget disease E. Spinal stenosis

C C. Fracture Clients who have osteoporosis are at high risk for fragility fractures, especially those involving spongy bone such as hips, wrists, and vertebral column.

A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? A. Check the client's blood pressure frequently. B. Monitor the client's pain level. C. Monitor the client's respiratory rate. D. Perform circulation checks before and after the procedure.

C C. Monitor the client's respiratory rate. Rationale; The drugs used for moderate sedation can suppress respiratory rate which requires constant monitoring during the procedure. The client should not feel any pain.

A patient diagnosed with diabetes mellitus is being discharged home and you are teaching them about preventing DKA. What statement by the patient demonstrates they understood your teaching about this condition? A. "I should not be alarmed if ketones are present in my urine because this is expected during illness." B. "It is normal for my blood sugar to be 250-350 mg/dL while I'm sick." C. "I will hold off taking my insulin while I'm sick." D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

D D. "It is important I check my blood glucose every 3-4 hours when I'm sick and consume liquids."

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "I can't believe that this has happened to me. I can't stand to look at it." B. "I do not want any visitors while I'm in the hospital." C. "My spouse will be the only person to change my dressing." D. "It will take me some time to get used to this."

D D. "It will take me some time to get used to this." Rationale: Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping.Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? A. Prone for the first 1 to 2 hours B. High-Fowler for the first hour C. Side-lying for the first 2 hours D. Flat supine for the first 1 to 2 hours

D D. Flat supine for the first 1 to 2 hours Rationale: The flat supine position provides support for the percutaneous or minimally invasive surgical procedure.

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. Lisinopril C. Aspirin D. Hydralazine

D D. Hydralazine Rationale: 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.

A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? A. Ensure that weights are placed on the floor. B. Remove the traction weights only for bathing. C. Ensure that pins are not loose and tighten as needed. D. Inspect the skin at least every 8 hours.

D D. Inspect the skin at least every 8 hours. Rationale: The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown.Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

Hyperglycemic Hyperosmolar Nonketotic Syndrome would have all of the following signs and symptoms EXCEPT? A. Dry mucous membranes B. Polyuria C. Blood glucose >600 mg/dL D. Kussmaul breathing

D D. Kussmaul breathing Kussmaul breathing is found in DKA due to the compensatory mechanism of the respiratory system. Remember that in DKA there are excessive ketones (none are present in HHNS) which are acids and this causes metabolic acidosis. Therefore, the respiratory system tries to "blow off" extra acid (carbon dioxide) to try to make the blood more alkalotic.

A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery? A. Diagnostic B. Cosmetic C. Curative D. Palliative

D D. Palliative Rationale: Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon? A. Sanguineous drainage at the suture site B. Crusting along the incision line C. Serosanguineous drainage on the dressing D. Redness and swelling around the incision

D D. Redness and swelling around the incision Rationale: The nurse's concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.

The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL (mmol/L) and a hemoglobin A1C of 5.9%. What is the nurse's interpretation of these findings? A. The client's glucose control for the past 24 ours has been good, but the overall control is poor B. The client's glucose control for the past 24 hours has been poor, but the overall control is good C. The values indicate that the client has poorly managed his or her disease D. The values indicate that the client has managed his or her disease well.

D D. The values indicate that the client has managed his or her disease well.

An 81-year-old female client with a long history of osteoporosis is admitted to the emergency department with report of right groin and low back pain as a result of falling in the grocery store. She tells the nurse that she went shopping with her daughter as usual on Saturdays but her daughter was in another part of the store when she slipped on something on the floor. The client begins to cry because she is in pain and afraid that she will not be able to continue living independently in her apartment. She reports her pain as an 8 on a 0-10 pain scale. To effectively. manage her pain, the client will probably have ____. A. Pelvic sling B. External fixation C. IV opioids D. Buck traction E. Open reduction/Internal fixation

E E. Open reduction/Internal fixation Pain will be managed by surgical hip repair (open reduction/internal fixation).

What statement or statements are INCORRECT regarding Diabetic Ketoacidosis? A. DKA occurs mainly in Type 1 diabetics. B. Ketones are present in the urine in DKA. C. Cheyne-stokes breathing will always present in DKA. D. Severe hypoglycemia is a hallmark sign in DKA. E. Options C & D

E E. Options C & D

True or False: DKA and HHNS mainly occur in type 2 diabetics.

False False: DKA is most common in Type 1 diabetics, whereas HHNS is most common in Type 2 diabetics.

True or False: Hypertonic fluids, such as 3% saline, are the first line of treatment to correct dehydration in HHNS.

False False: Isotonic (0.9% NS) solutions are usually the first-line treatment or the physician may order a hypotonic solution such 0.45% NS to replenish the dehydrated cell. ....this depends on the severity of dehydration. A 5% Dextrose 0.45% NS may be added when the glucose has reached 300 mg/dL, but is not first-line treatment. However, 3% Saline is never used.

A 53-year-old client underwent surgery to repair a left ankle fracture that was sustained during a skiing accident. The client has been transported back to the medical-surgical unit following discharge. After completing an initial assessment, the nurse provides interventions to facilitate the client's recovery. For each nursing action determine if it is indicated, contraindicated, or nonessential. 6. Check nasogastric (NG) tube placement every 4-8 hours

Indicated If a nasogastric (NG) tube is present, it should be assessed every 4 to 8 hours to prevent aspiration. Further assessment should be accomplished also before instilling any liquid (including drugs) into the tube. The nurse will also assess for fluid and electrolyte imbalances, as well as nares discomfort.

A 53-year-old client underwent surgery to repair a left ankle fracture that was sustained during a skiing accident. The client has been transported back to the medical-surgical unit following discharge. After completing an initial assessment, the nurse provides interventions to facilitate the client's recovery. For each nursing action determine if it is indicated, contraindicated, or nonessential. 5. Contact partner to stay with the client until bedtime

Nonessential Asking the partner to stay with the client until bedtime is a nonessential activity that will not improve nor complicate the client's status, unless there is a specific request articulated by the client.

1. Weighs 10 lb (4.5kg) less than 1 month ago Effective The client's weight loss demonstrates effectiveness of the education intervention, even if he is not yet at an ideal weight. The weight loss achieved in 1 month is significant.

The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective? A. "The wound will completely heal in about 2 months." B. "I should remove the dressing if the wound is draining." C. "I may need to restrict my activities for several months." D. "Some bleeding from the incision is normal for several weeks."

C C. "I may need to restrict my activities for several months." Rationale: To protect the integrity of the wound, activities may need to be restricted.The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage are not normal after 5 days. The length of time it takes for a wound to heal varies, which can be up to 2 years.

10. Rest more when fever is present Indicated Rationale: Fatigue is a major symptom of the disorder and clients are encouraged to get sufficient rest. This is more important when fever or flare is present.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 2. Keep skin lesions covered with sterile dressings

2. Keep skin lesions covered with sterile dressings Contraindicated Rationale: Skin lesions do not need to be covered with sterile dressings. Covering lesions with dressings may make the client more aware of appearance changes and cause psychological harm.

3. Fasting blood glucose 132 mg/dL (7.5 mmol/L) Ineffective The client's fasting blood glucose level is not yet within the expected range and therefore, the expected outcome of the educational intervention may not have been met. However, with the client's A1c being below 6% and the FBG representing only 1 day, the client is most likely following the management regimen quite well most of the time.

5. Avoid NSAIDs when taking acetaminophen Contraindicated Rationale: Taking NSAIDs and acetaminophen together is not a problem. Because the client may be relying on acetaminophen for pain control, avoiding this drug when taking NSAIDs as part of the daily drug therapy regimen could result in harm from increased pain.

5. Reports going barefoot in his home to allow feet to "air out" Ineffective Going barefoot in the home is not consistent with the expected outcomes of the diabetes educational intervention. Clients are instructed to always wear firm-soled shoes and slippers and never to go barefoot. The nurse will need to follow up with more instruction about foot care to help reduce the risk for injury.

6. Eats within 30 minutes of injecting exenatide Effective Exenatide can cause hypoglycemia and clients are educated to be certain to eat a full meal within 60 minutes of injecting the drug. The fact that the client is eating his meals within 30 minutes of injecting the drug is consistent with the management plan and indicates effectiveness of the diabetes education intervention.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 6. Perform at least 15 min of lower-impact activities and strength-building exercises daily

6. Perform at least 15 min of lower-impact activities and strength-building exercises daily Indicated Rationale: Regular lower-impact and strength-building exercises help promote mobility and prevent harm from deconditioning.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 7. Do not abruptly stop taking your prescribed corticosteroid

7. Do not abruptly stop taking your prescribed corticosteroid Indicated Rationale: Chronic corticosteroid use suppresses adrenal function. Abruptly stopping these medications can cause harm by triggering the life-threatening complication of acute adrenal insufficiency.

7. Walks at a moderate pace two miles 5 days a week Effective Walking 2 miles at a moderate pace 5 days/week constitutes weight-bearing activity for a minimum of 150 minutes, and indicates effectiveness of the diabetes education intervention.

8. Get an influenza vaccination every year Indicated Rationale: Clients are at high risk for infection development and progression to more serious infection rapidly as a result of the immunosuppressive aspects of drug therapy. Influenza vaccination and beginning treatment for any infection early are critical to prevent harm.

A 48-year-old female client has noticed chronic fatigue, persistent joint and muscle pain, and recurrent fevers without an obvious cause for the past 3 months. The nurse also observes a butterfly-shaped rash over the client's nose and cheeks. After a complete physical examination and many diagnostic tests, the client is found to have systemic lupus erythematosus (SLE). Drug therapy with immunosuppressive and anti-inflammatory agents are prescribed by the rheumatologist. The nurse is planning an education session for the client about the disorder and its management. For each nursing action determine if it is indicated, contraindicated, or nonessential. 9. Eat a low-calorie diet with less animal and protein fat

9. Eat a low-calorie diet with less animal and protein fat Nonessential Rationale: A balanced diet is important for maintaining general health. No particular dietary change is needed specifically for SLE management.

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"

A A. "Nicotine reduces blood flow to your organs and increases the risk for permanent damage" Rationale: Nicotine in any form constricts blood vessels and reduces perfusion. Perfusion is already reduced by the vasculitis that is part of the disease. Thus, use of nicotine greatly increases the risk for necrosis of many tissues and organs. Although smoking or vaping do increase the risk for lung cancer, their effects on blood vessels are a greater issue for the client with SLE. Nicotine neither reduces the effectiveness of drug therapy nor promotes muscle cell loss.

Which client does the nurse identify at greatest risk for slow wound healing? A. A 47-year-old man with obesity and diabetes B. A 58-year-old woman who smokes 2 packs of cigarettes daily C. A 78-year-old man with controlled hypertension D. A 21-year-old woman with an STI

A A. A 47-year-old man with obesity and diabetes Rationale: Obesity and diabetes significantly place a client at greatest risk for slow wound healing.The other clients may encounter slower wound healing, yet they are not at the highest risk like the client with obesity and diabetes.

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, B, C A. Apply pneumatic or sequential compression devices. B. Administer anticoagulant therapy. C. Ambulate the client on the day of surgery. Rationale: Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression.

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, B, C, D, E 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.

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, B, C, E 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 Rationale: All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection. Because infections are a very serious matter, we are we recommend all patients use Bactroban (mupirocin) ointment prior to surgery to help prevent infection. You will start using this ointment five days prior to surgery. Your surgeon has ordered this medication to decrease the risk of infection in your new hip or knee

An 87-year-old male client had an open reduction/internal fixation for a right fractured hip this morning. Before surgery, his wife of 50 years states that the client has been in excellent health and is mentally intact. He still works 2 days a week as an accountant and is completely independent in ADLs. The nurse plans care for the client to ensure his safety and quality postoperative care. Which nursing actions would the nurse include in his plan of care for today? (Select all that apply.) A. Complete a cognitive/mental status assessment B. Maintain pneumatic or sequential compression devices C. Perform and document a skin assessment D. Assist the client to ambulate with a cane in his room E. Assess the client's swallowing ability F. Remind assistive personnel (AP) to perform frequent mouth care G. Use a multimodal pain management approach to promote comfort H. Avoid the use of an indwelling urinary catheter

A, B, C, E, F, G, H A. Complete a cognitive/mental status assessment B. Maintain pneumatic or sequential compression devices C. Perform and document a skin assessment E. Assess the client's swallowing ability F. Remind assistive personnel (AP) to perform frequent mouth care G. Use a multimodal pain management approach to promote comfort H. Avoid the use of an indwelling urinary catheter Rationale: The staff would assist him to get out of bed to a chair on the day of surgery, not ambulate.

The nurse is reviewing the plan of care for a 70-year-old female client who has had osteoarthritis for over 10 years. Her husband asks the nurse if there are guidelines for daily activity and the needs for exercising. What statements will the nurse include for the client's self-management related to exercise? (Select all that apply.) A. "Perform only the specific exercises that the physical therapist recommended for you." B. "Do your exercises on both "good" and "bad" days to be consistent. C. "Ask your husband to help you with passive- or active-assist exercises." D. "Respect pain and reduce the number of repetitions if joints are inflamed." E. "Avoid resistive exercises when your joints are inflamed." F. "Do not substitute usual daily activities for specific prescribed exercises."

A, B, D, E, F A. "Perform only the specific exercises that the physical therapist recommended for you." B. "Do your exercises on both "good" and "bad" days to be consistent. D. "Respect pain and reduce the number of repetitions if joints are inflamed." E. "Avoid resistive exercises when your joints are inflamed." F. "Do not substitute usual daily activities for specific prescribed exercises." All of these statements should be part of the nurse's health teaching about self-management related to exercise for osteoarthritis except that exercises should be active rather than passive- or active-assist for better strengthening benefits.

Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.) A. White blood cell count 14,000 mm3 B. Potassium, 3.9 mEq/L (3.9 mmol/L) C. Creatinine, 1.9 mg/dL (168 mcmol/L) D. Fasting glucose, 80 mg/dL (4.4 mmol/L) E. Sodium, 140 mEq/L (140 mmol/L)

A, C A. White blood cell count 14,000 mm3 C. Creatinine, 1.9 mg/dL (168 mcmol/L) Rationale: These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count). A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.

Which health teaching by the nurse is important for clients diagnosed with systemic lupus erythematosus? Select all that apply. A. "Take frequent rest periods to prevent fatigue" B. "Avoid green leafy vegetables to prevent bleeding" C. "Avoid sun exposure to prevent disease flare-ups" D. "Report fever to your HCP immediately" E. "Use a mild soap for bathing to prevent skin irritation"

A, C, D, E A. "Take frequent rest periods to prevent fatigue" C. "Avoid sun exposure to prevent disease flare-ups" D. "Report fever to your HCP immediately" E. "Use a mild soap for bathing to prevent skin irritation"

The primary health care provider prescribes acetaminophen for a client with osteoarthritis. Which health teaching will the nurse provide for the client regarding this drug? Select all that apply. A. "Don't take more than 3000-4000 mg of this drug each day" B. "Stop taking the drug if unusual bleeding occurs and call your primary health care provider" C. "Tell your primary health care provider if you notice any yellowing of your skin or eyes" D. "Expect fluid accumulation in your legs and feet that usually gets worse during the day" E. "Check over-the-counter drugs to see if they contain acetaminophen"

A, C, E A. "Don't take more than 3000-4000 mg of this drug each day" C. "Tell your primary health care provider if you notice any yellowing of your skin or eyes" E. "Check over-the-counter drugs to see if they contain acetaminophen"

Which physiologic actions result from normal insulin secretion? Select all that apply A. Increased liver storage of glucose as glycogen B. Increased gluconeogenesis C. Increased cellular uptake of blood glucose D. Increased breakdown of lipids (fats) for fuel E. Increased production and release of epinephrine F. Decreased storage of free fatty acids in fat cells G. Decreased blood glucose levels H. Decreased blood cholesterol levels

A, C, G, H A. Increased liver storage of glucose as glycogen C. Increased cellular uptake of blood glucose G. Decreased blood glucose levels H. Decreased blood cholesterol levels

A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Avoid extending your left hip behind you when you sit" B. "Do not flex your hips more than 90 degrees when toileting" C. "You may cross your legs to be more comfortable in a chair" D. "Avoid twisting your body when moving or performing ADLs" E. "Stand on your right leg and pivot into the chair when getting out of bed"

A, D, E A. "Avoid extending your left hip behind you when you sit" D. "Avoid twisting your body when moving or performing ADLs" E. "Stand on your right leg and pivot into the chair when getting out of bed"

A 27-year-old female client who has had type 1 diabetes since the age of 5 years and who is now 6 months pregnant is admitted to the emergency department with diabetic ketoacidosis (DKA). She is alert and oriented. She is having difficulty talking because her respiratory rate is 36 very deep breaths/min. She says she is thirsty and tired. The nurse has started IV fluids with continuous infusion of half-normal saline and insulin. Due to the client's DKA and thirst, she is currently most likely at risk for ___A___ and ___B___. During her hospital stay, she is most likely at risk for complications associated of her therapy, especially ____C____ and ___D___.

A. Dehydration B. Hypotension C. Hypoglycemia D. Fluid Overload Due to the client's DKA and thirst, she is currently most likely at risk for DEHYDRATION and HYPOTENSION. During her hospital stay, she is most likely at risk for complications associated of her therapy, especially HYPOGLYCEMIA and FLUID OVERLOAD.

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 B. Acetaminophen Rationale: Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice.

Which action does the nurse implement for a client with wound evisceration? A. Irrigate the wound with warm, sterile saline. B. Cover the wound with a sterile, warm, moist dressing. C. Replace tissue protruding into the opening. D. Apply direct pressure to the wound.

B B. Cover the wound with a sterile, warm, moist dressing. Rationale: Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Replacing protruding tissue could induce infection.

A 30-year-old female client comes to the emergency department after developing symptoms of anaphylaxis after eating supper at a restaurant. She has a diagnosed allergy to peanuts but did not knowingly eat anything containing peanuts. She says she feels dizzy and has a lump in her throat. Her vital signs are:Heart rate = 104 beats/min and threadyBlood pressure = 86/40Oxygen saturation = 80% The nurse prepares to first administer _____ by the ____ route. A. Epinephrine 1 mg/mL concentration, subcutaneous B. Epinephrine 1 mg/mL concentration, Intramuscular C. Corticosteroids, Intramuscular D. Diphenhydramine, Intramuscular

B B. Epinephrine 1 mg/mL concentration, Intramuscular First-line therapy for anaphylaxis is epinephrine 1 mg/mL concentration at 0.3 to 0.5 mL, depending on the client's size. The preferred route is intramuscular. This drug constricts blood vessels, improves cardiac contraction, and dilates the bronchioles. The same dose may be repeated every 5 to 15 minutes if needed

An 81-year-old female client with a long history of osteoporosis is admitted to the emergency department with report of right groin and low back pain as a result of falling in the grocery store. She tells the nurse that she went shopping with her daughter as usual on Saturdays but her daughter was in another part of the store when she slipped on something on the floor. The client begins to cry because she is in pain and afraid that she will not be able to continue living independently in her apartment. She reports her pain as an 8 on a 0-10 pain scale. The pain in her right groin and lower back is most likely due to ___. A. Hip dislocation B. Fractured hip C. Osteoarthritis D. Femoral artery obstruction E. Muscle sprain

B B. Fractured hip The client's report of severe pain in her groin is a classic indicator that she likely has a fractured hip.

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 B. Hot compresses or moist heating pad Rationale: Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client.

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority? A. Ensure that the correct procedure is noted in the client's health record. B. Witness marking of the left knee site with the client awake and the surgeon present. C. Communicate with the surgeon confirming the client will have a left knee arthroscopy. D. Verify with the client that a left knee arthroscopy will be performed.

B B. Witness marking of the left knee site with the client awake and the surgeon present. Rationale: The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.The nurse will also ensure that the correct procedure is in the clients health record; verify with the client that the left knee arthroscopy will be performed, and communicate with the surgeon that the client is having a left knee arthroscopy. However, these are all done after the priority of witnessing the client awake and surgeon present to mark the left knee site.

The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) A. "I will take off my stockings one to three times a day for 30 minutes." B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." D. "These stockings help promote blood flow." E. "I feel like these stockings are compressing my legs just a bit."

B, C B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." Rationale: Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result.

A 48-year-old female client who is 30 lb (13.6 kg) overweight is being examined for possible type 2 diabetes. Her random blood glucose level is 285 mg/dL (15.9 mmol/L) and her most recent meal was 3 hours ago. Select the personal history and other assessment findings that indicate factors that increase this client's risk for type 2 DM. SATA A. Is 5 foot 6 inches tall B. Mother has T2DM C. First baby weight 11lb D. A1c is 11.3% E. Has a sedentary lifestyle and performs no regular exercise F. Reports increased thirst G. Smokes 1 pack of cigarettes per day H. Has one glass of wine with dinner nightly I. Had her first baby at ge 39 yr J. Has an open area on her right leg from a scratch injury 5 weeks ago that has not healed.

B, C, D, E, F, J B. Mother has T2DM Rationale: Type 2 diabetes mellitus is caused by a gene-environment interaction. The predisposition is inherited in an autosomal dominant pattern, making the fact that the client's mother has type diabetes a strong risk fact. C. First baby weight 11lb Rationale: Many women who are genetically susceptible for development of type 2 diabetes have gestational diabetes during pregnancy. Even if the client was not tested for gestational diabetes while pregnant, having a first baby that weighed more than 9 lb (4 kg) is strongly suggestive of gestational diabetes. D. A1c is 11.3% Rationale: Normal is below 5.7%, 5.7-6.4% is pre-diabetes, more than 6.5% indicates diabetes. E. Has a sedentary lifestyle and performs no regular exercise Rationale: The two lifestyle factors that promote the development of type 2 diabetes in a genetically susceptible client are obesity and being sedentary. F. Reports increased thirst Rationale: Higher than normal blood glucose levels cause increased blood osmolarity, which increases the sensation of thirst. J. Has an open area on her right leg from a scratch injury 5 weeks ago that has not healed. Rationale: Adults without diabetes would be expected to have wounds that are not complicated by infection heal within 1 to 2 weeks and not still be open after 5 weeks, even on the lower leg. Height, smoking, age at first pregnancy, and ingesting one glass of wine daily do not promote development of type 2 diabetes in a susceptible client, although smoking and drinking can increase the risk for complications of the disease.

Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. A. The oxygen saturation is 97% B. The serum potassium level is 3.9 mEq/L (3.0 mmol/L) C. The client requests to talk with a registered dietitian about weight loss E. The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago F. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker

B, C, F B. The serum potassium level is 3.9 mEq/L (3.0 mmol/L) C. The client requests to talk with a registered dietitian about weight loss F. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker

The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) A. Ten pounds (4.5 kg) over ideal body weight B. Takes saw palmetto for benign prostatic hyperplasia (BPH) C. Anesthesia complications experienced by partner D. Currently prescribed methylprednisolone therapy E. Age 59 years F. History of diabetes mellitus

B, D, F B. Takes saw palmetto for benign prostatic hyperplasia (BPH) D. Currently prescribed methylprednisolone therapy F. History of diabetes mellitus Rationale: B)Any type of herbal preparation has the potential to interfere with anesthesia or recovery. D)Methylprednisolone use can decrease the body's ability to fight infection. F)Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but not anesthesia complications experienced by a partner. Obesity increases the risk for poor wound healing, but being 10 lb (4.5 kg) overweight does not categorize this client as obese.

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 C. A 33-year-old African-American woman whose mother has psoriasis. Rationale: 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.

A client was originally scheduled for surgery at noon. The surgeon is delayed, and the surgery has been rescheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? A. Give at noon as originally prescribed B. Cancel orders; preoperative prophylactic antibiotics are given optionally C. Adjust the administration time to be given within 1 hour before surgery D. Hold the preoperative antibiotic so it can be administered immediately following surgery

C C. Adjust the administration time to be given within 1 hour before surgery

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 bleeding and bruising during the infusion

C C. Check that the client can dorsiflex and plantar flex the foot on the operative leg Rationale: To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain

What client teaching will the nurse provide regarding postoperative leg exercises to minimize the risk for development of deep vein thrombosis after surgery? A. Only perform each exercise one time to prevent overuse B. Begin exercises by sitting at a 90 degree angle on the side of the bed C. Point toes of one foot toward the bottom of bed; then point toes of same leg toward his or her face D. Bend knee, and push heel of foot into bed until the calf and thigh muscles contract. Repeat several times; then switch legs

C C. Point toes of one foot toward the bottom of bed; then point toes of same leg toward his or her face

A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed? A. Restraints due to naloxone causing agitation B. Activation of the Rapid Response Team C. Supplemental pain medication D. External pacing to regular heartbeat

C C. Supplemental pain medication Rationale: Supplemental pain medication will be anticipated, as reversal of the opioid via naloxone reduces the analgesic effect also.The vital signs do not warrant activation of the Rapid Response Team, external pacing, nor restraints.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Call the legal department to draft the paperwork. B. Thank the adult child for sharing the parent's desires. C. Talk to the client to be sure of their wishes. D. Document the conversation in the electronic health record.

C C. Talk to the client to be sure of their wishes. Rationale: The nurse would first talk to the client in order to determine the client's wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such.

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 C. Wear supportive shoes at all times Rationale: Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.

The nurse is caring for an older-adult client who reports being "afraid to get hooked" on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked" B. "Don't worry, I won't give you any opioid medications" C. "Tell me what makes you most fearful about taking opioid medication" D. "There are ways we can keep you from becoming dependent on these drugs" E. "Older adults are much less likely to rely on pain medications than younger people"

C, D C. "Tell me what makes you most fearful about taking opioid medication" D. "There are ways we can keep you from becoming dependent on these drugs"

A 53-year-old client underwent surgery to repair a left ankle fracture that was sustained during a skiing accident. The client has been transported back to the medical-surgical unit following discharge. After completing an initial assessment, the nurse provides interventions to facilitate the client's recovery. For each nursing action determine if it is indicated, contraindicated, or nonessential. 3. Assess for return of clear or straw-colored urine of at least 20 mL/hr per 8 hour shift

Contraindicated Output should be close to total intake for a 24-hour period. A urine output of less than 30 mL/hr (240 mL/8 hr) should be reported to the surgeon. This can indicate possible hypovolemia or renal complications.

A 53-year-old client underwent surgery to repair a left ankle fracture that was sustained during a skiing accident. The client has been transported back to the medical-surgical unit following discharge. After completing an initial assessment, the nurse provides interventions to facilitate the client's recovery. For each nursing action determine if it is indicated, contraindicated, or nonessential. 4. Administer pain medicaiton only when client reports discomfort of 7 or greater on a scale of 0-10

Contraindicated Pain medication should be administered as prescribed; not just when the client reports a certain level of pain. In the early postoperative period, it is important to manage pain adequately to allow the body to begin the healing process.

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"

D D. "At the first sign of a flare, I will begin taking my medication again" Rationale: The client's statement suggests that he or she believes that daily medication is not needed and would be required only during a flare. However, daily drug therapy is essential to slow the progression of the disease and organ damage.Low-impact exercise such as walking is highly recommended to maintain mobility and promote cardiovascular health. Fevers are often associated with a flare. There is no contraindication to taking both NSAIDs and acetaminophen.

A scrub person is discussing artificial nail use with the nurse. The scrub person states, "I do not use artificial nails; I'm wearing gel polish to strengthen my nails." What is the appropriate nursing response? A. "I understand. That is my nail treatment of choice also" B. "Hand hygiene is enhanced by covering natural nails" C. "Wear double gloves to prevent puncture or contamination" D. "Gel polish is a type of artificial nail that alters skin flora and impedes hand hygiene"

D D. "Gel polish is a type of artificial nail that alters skin flora and impedes hand hygiene"

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases" B. "That's phantom limb pain, and every amputee has that" C. "Your foot has been amputated, so it's in your head" D. "On a scale of 0 to 10, how would you rate your pain?"

D D. "On a scale of 0 to 10, how would you rate your pain?"

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse? A. "I will have a bandage on my chest." B. "My family will not be able to see me right away." C. "I will wake up with a tube in my throat." D. "Pain medication will take away all of my pain."

D D. "Pain medication will take away all of my pain." Rationale: Pain medication will reduce pain, but will not take it away completely.The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.

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 D. "The bus is coming to pick me up from the senior center three times a week so I can play cards" Rationale: Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.

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

A 30-year-old female client comes to the emergency department after developing symptoms of anaphylaxis after eating supper at a restaurant. She has a diagnosed allergy to peanuts but did not knowingly eat anything containing peanuts. She says she feels dizzy and has a lump in her throat. Her vital signs are:Heart rate = 104 beats/min and threadyBlood pressure = 86/40Oxygen saturation = 80% After administering Epinephrine 1 mg/mL concentration by the Intramuscular route, the next drug the nurse prepares to administer is _____ by the ____ route. A. Corticosteroids, subcutaneous B. Acetaminophen, intramuscular C. Diphenhydramine, intramuscular D. Diphenhydramine, intravenous

D D. Diphenhydramine, intravenous The second drug usually given to manage anaphylaxis is diphenhydramine (25 to 50 mg) delivered intravenously to interfere with binding of histamine to its receptors in blood vessels.

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

An 83-year-old female client with dementia has undergone hip replacement surgery after a fall. Under normal circumstances before the fall, the client regularly ambulated. The nurse is preparing to discharge the client from the hospital back to the memory care until of an extended-care facility. When she returns to the extended-care facility, she is also most likely at risk for complications associated with impaired mobility, especially ___. A. Brain attack B. Pressure Injury C. Venus thromboembolism D. Falling E. Constipation F. Aspiration G. Hemorrhage H. Undernutrition

D D. Falling Because the client with dementia was ambulatory before the fall, she is likely to attempt to walk again when she is in the familiar environment of her extended-care facility. With dementia, she may not be able to retain directions to call for a nurse if she wishes to ambulate. This places her at a high risk for falling if she attempts to get herself up

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