PrepU: Nursing Process
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Extreme leukocytosis Renal transplantation Sickle cell anemia Essential thrombocythemia
Essential thrombocythemia Explanation: Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect? Deficiency of neutrophils Deficiency of erythrocytes Excess of immature leukocytes Excess of immature erythrocytes
Excess of immature leukocytes Explanation: The bone marrow biopsy of a client with acute myeloid leukemia will reveal an excess of immature leukocytes.
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially, how should the nurse position the client for this test? Prone with the torso elevated Lying on the right side with legs straight Lying on the left side with knees bent Bent over with hands touching the floor
Lying on the left side with knees bent Explanation: For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.
A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. Sterile gauze pads Extension set tubing Alcohol wipes Masks Skin antiseptic
Masks Skin antiseptic Alcohol wipes Sterile gauze pads Explanation: When preparing to perform a dressing change to a central venous access site, sterile technique is essential. The nurse would need to gather masks (for self and the client) to reduce the possibility of airborne contamination, sterile gloves, skin antiseptic, sterile gauze to clean the area, sterile water or saline to clean the area after cleaning with the skin antiseptic, and alcohol wipes to clean the catheter ports. Extension set tubing is not routinely changed with dressing or tubing changes.
The most frequent reason for admission to skilled care facilities includes which of the following? Myocardial infarction Stroke Congestive heart failure Urinary incontinence
Urinary incontinence Explanation: Urinary incontinence is the most common reason for admission to skilled nursing facilities.
A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.) Evaluating temperature and color in the affected extremity Assessing vital signs every 8 hours Assessing the peripheral pulses in the affected extremity Assisting the patient to the bathroom after the procedure Checking the insertion site for hematoma formation
Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity Explanation: The nurse should observe the catheter access site for bleeding or hematoma formation and assess peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours or until discharge. Blood pressure and heart rate should also be assessed during these same time intervals, not every 8 hours. The nurse should evaluate temperature, color, and capillary refill of the affected extremity during these same time intervals. The patient should maintain bed rest for 2 to 6 hours after the procedure.
A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following? The result of urethra abrasion (sexual intercourse) Due to a fistula (direct extension) By ascending infection (transurethral) Through the bloodstream (hematogenous spread)
By ascending infection (transurethral) Explanation: The most common route of infection is transurethral, in which bacteria colonize the periurethral area and enter the bladder by means of the urethra.
A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? Imbalanced nutrition: Less than body requirements Impaired physical mobility Risk for infection Decreased cardiac output
Decreased cardiac output Explanation: An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Urinary retention Acute pain Decreased cardiac output Ineffective airway clearance
Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension? Decreased peripheral vascular resistance Decreased blood pressure with reflex tachycardia Decreased cardiac output and decreased systolic and diastolic blood pressure Increased cardiac output and increased systolic and diastolic blood pressure
Decreased cardiac output and decreased systolic and diastolic blood pressure Explanation: As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.
A client is being seen in the clinic to receive the results of the lab work to determine thyroid levels. The nurse observes the client's eyes appear to be bulging, and there is swelling around the eyes. What does the nurse know that the correct documentation of this finding is? Retinal detachment Exophthalmos Bulging eyes Periorbital swelling
Exophthalmos Explanation: Exophthalmos is an abnormal bulging or protrusion of the eyes and periorbital swelling. These findings are not consistent with retinal detachment.
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? Flail chest Pneumothorax Tension pneumothorax ARDS
Flail chest Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have? Megaloblastic anemia Aplastic anemia Iron deficiency anemia Sickle cell anemia
Iron deficiency anemia Explanation: People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for Hypertension Nausea Nuchal rigidity Mild headache
Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
Which phase of the nursing process encompasses the establishment of expected outcomes? Implementation Assessment Planning Evaluation
Planning Explanation: Planning encompasses specifying expected outcomes. Assessment is directed toward the systematic collection of data about the client's learning needs and readiness to learn. In the implementation phase, the client, the family, and the members of the nursing and health care teams carry out activities outlined in the teaching plan.
A client vomits postoperatively. What is the most important nursing intervention? Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. Offer tepid water and juices to replace lost fluids and electrolytes. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. Explanation: When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure? Withhold analgesics for at least 6 hours after the procedure. Inform the client that he or she may experience numbness or pain in the leg. Assess the puncture site frequently for hematoma formation or bleeding. Restrict fluids for 6 hours after the procedure.
Assess the puncture site frequently for hematoma formation or bleeding. Explanation: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system.
A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? Complete blood count (CBC) Western Blot Enzyme-linked immunosorbent assay (ELISA) Schick
Enzyme-linked immunosorbent assay (ELISA) Explanation: The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance? Water of low pressure that can be obtained through all faucets Electricity that loses power, usually for short duration, during storms Little food in the working refrigerator No land line; cell phone available and taken by family member during working hours
No land line; cell phone available and taken by family member during working hours Explanation: A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.
The nurse is caring for a client with an ileal conduit is created after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care? Irrigating the urinary diversion Exercises to promote sphincter control Application of an ostomy pouch Intermittent catheterizations
Application of an ostomy pouch Explanation: An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermittent catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.
The nurse is discussing health care goals with a client. What intervention will a nurse perform when assisting a client to achieve health care goals? Modify unsafe practices performed by the client. Appreciate the client's beliefs about the cause of illness. Disagree with the client's beliefs about the cause of illness. Learn to speak a second language.
Appreciate the client's beliefs about the cause of illness. Explanation: A nurse may disagree with a client's beliefs about their health or illness. However, a nurse must appreciate these beliefs when assisting a client to achieve health care goals. Appraisal and coping are affected by internal characteristics such as health, energy, personal belief systems, commitments, life goals, self-esteem, control, mastery, knowledge, problem-solving skills, and social skills. Learning to speak a second language and modifying unsafe practices performed by the client help to develop a growing expertise in culturally sensitive nursing care.
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse Assesses the client's tracheostomy and lung sounds every 15 minutes Encourages the client to cough every 30 minutes and prn Decreases the amount of humidity set to flow through the tracheostomy tube Sets a schedule to suction the tracheostomy every hour
Assesses the client's tracheostomy and lung sounds every 15 minutes Explanation: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Posting a "No smoking" sign over the client's bed Changing the mask and tubing daily Assessing the client's respiratory status, orientation, and skin color Applying an oil-based lubricant to the client's mouth and nose
Assessing the client's respiratory status, orientation, and skin color Explanation: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism? Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing Imbalanced nutrition: Less than body requirements related to thyroid hormone excess Disturbed body image related to weight gain and edema Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess Explanation: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements related to thyroid hormone excess the most important nursing diagnosis. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing and Disturbed body image related to weight gain and edema may be appropriate for a client with hypothyroidism, which slows the metabolic rate.
The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions? Creatinine and blood urea nitrogen (BUN) levels Potassium levels Magnesium levels Iron levels
Iron levels Explanation: For most patients with MDS, transfusions of RBCs may be required to control the anemia and its symptoms. These patients can develop iron overload from the repeated transfusions; this risk can be diminished with prompt initiation of chelation therapy (see following Nursing Management section).
Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet? Low purine Low oxalate High sodium High protein
Low purine Explanation: A low-purine diet is used for uric acid stones; the benefits, however, are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciuria—approximately half of the clients—need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? Milk the chest tube. Place the head of the patient's bed flat. Disconnect the system and get another. Notify the physician.
Notify the physician. Explanation: Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.
A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? Request the order be discontinued without obtaining the specimen. Obtain the wound culture specimen. Hold the order until purulent drainage is noted. Use an antibiotic cleaning agent before obtaining the specimen.
Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.
The nurse is prioritizing the care of a client who has a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level of Maslow's hierarchy while prioritizing this client's care? Safety and security needs Self-actualization needs Physiologic needs Love and belonging needs
Self-actualization needs Explanation: Self-actualization needs are the fifth and last level of Maslow's hierarchy. Physiologic needs are the first level, safety and security needs are the second level, and love and belonging needs are the third level.
The nurse is conducting a health history when a middle-aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations. Which question should the nurse ask next? "When was your first menstrual period?" "Do you feel like hurting yourself?" "Are you finished having children?" "Are you taking any hormone replacement therapy?"
"Are you taking any hormone replacement therapy?" Explanation: To ensure a thorough health history, a client who exhibits symptoms of perimenopause should be assessed for the use of hormone replacement therapy to alleviate the symptoms. This information adds to the data reported by the client. Asking if the client feels like hurting herself may be extreme with the report of mood fluctuations. Asking if the client is finished having children produces little additional data. Asking the first menstrual period is part of the health history but not the best question to ask after the client's statement.
The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following? "It is a test for balance." "It is a test for muscle strength." "It is a test for motor ability." "It is a test for coordination."
"It is a test for balance." Explanation: The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? 275-300 mOsm/kg 350-544 mOsm/kg >408 mOsm/kg <136 mOsm/kg
275-300 mOsm/kg Explanation: In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).
The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? 4 to 5 mm Hg 1 to 3 mm Hg 8 to 12 mm Hg 6 to 7 mm Hg
8 to 12 mm Hg Explanation: The goal in colloidal fluid replacement is to achieve a central venous pressure of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? A disease process is present. The ET tube must be pulled back. The X-ray is inconclusive. The ET tube must be advanced.
A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? Administering large doses of oral antibiotics as ordered Instructing the client to ambulate twice daily Administering large doses of I.V. antibiotics as ordered Withholding all oral intake
Administering large doses of I.V. antibiotics as ordered Explanation: Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.
The nurse is providing care to a client following a knee arthroscopy. What would the nurse expect to include in the client's plan of care? Keeping the affected knee flexed. Maintaining the client's NPO status. Applying warm packs to the insertion site. Administering the prescribed analgesic.
Administering the prescribed analgesic. Explanation: After an arthroscopy, the client's entire leg is elevated without flexing the knee. A cold pack is placed over the bulky dressing covering the site where the arthroscope was inserted. A prescribed analgesic is administered as necessary. The client is allowed to resume his or her usual diet as tolerated.
The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care? Mouthwash and water Dextrose and water Full-strength peroxide Baking soda and water
Baking soda and water Explanation: When a client is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.
Which nursing assessment finding indicates the client with renal dysfunction has not met expected outcomes? Urine output is 100 ml/hr. Client reports increasing fatigue. Client rates pain at a 3 on a scale of 0 to 10. Client denies frequency and urgency.
Client reports increasing fatigue. Explanation: Fatigue, shortness of breath, and exercise intolerance are consistent with unexplained anemia, which can be secondary to gradual renal dysfunction.
The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate? Sensorineural Conductive Mixed Central
Conductive Explanation: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear.
The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan? Establishment of priorities during the planning phase Identification of problems and risks that require nursing management during the nursing diagnosis phase Providing referrals and delegating and managing client care during the implementation phase Data gathering, identification of client strengths, and assurance of client safety during the assessment phase
Data gathering, identification of client strengths, and assurance of client safety during the assessment phase Explanation: Establishment of priorities, identification of problems and risks, and delegation and management of client care are all roles of the registered nurse during the nursing process. Data gathering, identification of client strengths, performance of assessments and assurance of client safety are role of the LPN when using the nursing process to develop the client plan of care.
The nurse is evaluating a client's social support network. The nurse knows that the network will assist the client in coping with stress when which action is noted? Son does not acknowledge his mother's diagnosis. Client avoids situations that expose her to new people. Client finds new recipes online that were posted by other users. Daughter helps mother with laundry.
Daughter helps mother with laundry. Explanation: Social networks assist in the management of stress when they provide material aid and tangible services, such as a daughter helping her mother with the laundry. In addition, networks should provide a positive social identity and emotional support as well as access to information and new social contacts/social roles.
A nurse has been using the nursing process as a framework for planning and providing client care. What action would the nurse do during the evaluation phase of the nursing process? Provide information on a follow-up appointment for a postoperative client. Have a client provide input on the quality of care received. Document a client's improved air entry with incentive spirometry use. Remove a client's surgical staples on the scheduled postoperative day.
Document a client's improved air entry with incentive spirometry use. Explanation: During the evaluation phase of the nursing process, the nurse determines the client's response to nursing interventions. An example of this is when the nurse documents whether the client's spirometry use has improved the condition. A client does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.
The nurse is preparing a patient for a gynecologic examination when the patient says, "I hope the exam doesn't hurt as much as intercourse with my husband does." What should the nurse document this finding as? Dysmenorrhea Dysuria Dyspareunia Dysthymia
Dyspareunia Explanation: Dyspareunia (difficult or painful intercourse) can be superficial, deep, primary, or secondary and may occur at the beginning of, during, or after intercourse.
The nurse is caring for a client with breast cancer and removal of axillary lymph nodes. Which assessment finding is documented and brought to the physician's attention as potential lymphedema? Drainage from the areola Fluid accumulation under in the axilla Enlargement of the arm or hand A reddened area around the breast
Enlargement of the arm or hand Explanation: Lymphedema, soft-tissue swelling from accumulated lymphatic fluid, occurs in some women after they have undergone breast cancer surgery and the removal or irradiating of axillary lymph nodes. Lymphedema does not impact the breast area or axilla.
The rehabilitation nurse is caring for a 25-year-old client who suffered extensive injuries in a motorcycle accident. During each interaction with the client, what action should the nurse perform most frequently? Evaluate the client's positioning. Complete a physical assessment. Assist the client to ambulate. Plan nursing interventions.
Evaluate the client's positioning. Explanation: During each client contact, the nurse evaluates the client's position and assists the client to achieve and maintain proper positioning and alignment. The nurse does not complete a physical assessment during each client contact. Similarly, the nurse does not plan nursing interventions or assist the client to ambulate each time the nurse has contact with the client.
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? Deficient fluid volume Excess fluid volume Risk for imbalanced nutrition, more than body requirements Impaired urinary elimination
Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? Malnutrition Risk Decreased Fluid Volume Risk Impaired Swallowing Aspiration Risk
Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
As a circulating nurse, what task are you solely responsible for? Handing instruments to the surgeon. Keeping records. Counting sponges and needles. Estimating the client's blood loss.
Keeping records. Explanation: The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.
A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for? Left hip arthroscopy Closed reduction of the left hip. Left hip arthroplasty Open reduction and internal fixation of the left hip.
Left hip arthroplasty Explanation: Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.
Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? Cervical Thoracic Lower lumbar Upper lumbar
Lower lumbar Explanation: The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.
The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? Neutrophils Basophils Eosinophils Monocytes
Neutrophils Explanation: Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Oxygen saturation (SaO2) of 85% Blood-tinged stools Heart rate of 84 beats/minute Decreased cough and gag reflexes
Oxygen saturation (SaO2) of 85% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following? Partial laryngectomy Hemilaryngectomy Supraglottic laryngectomy Total laryngectomy
Partial laryngectomy Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
During a physical examination, the nurse finds that a client has thin, dry hair with flaky skin, recessed gums, and ridged, brittle nails. The nurse can conclude what from these data? Poor hygienic practices Poor nutritional status Inability to perform activities of daily living Lower income status
Poor nutritional status Explanation: The state of nutrition is often reflected in a person's appearance. Hair, teeth, nails, and skin can serve as indicators of general nutritional status and intake of specific nutrients. Indicators of good nutrition in the hair include that it is shiny and firm, not dry and thin. Flaky skin can be a sign of poor nutrition. Nails indicating good nutrition are firm and pink, not brittle and ridged. Recessed gums are seen with poor nutrition.
The nurse recognizes that goal of treatment for metastatic bone cancer is to: Reconstruct the bone with a prosthesis Diagnose the extent of bone damage Cure the diseased bone and cartilage Promote pain relief and quality of life
Promote pain relief and quality of life Explanation: Treatment of metastatic bone cancer is palliative.
While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? Risk for Ineffective Peripheral Tissue Perfusion Disturbed Kinesthetic Sensory Perception Unilateral Neglect Related to Hematoma Risk for Infection
Risk for Ineffective Peripheral Tissue Perfusion Explanation: The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion.
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: Risk for ineffective therapeutic regimen management Risk for avascular necrosis of the joint Situational low self-esteem Disturbed body image
Risk for ineffective therapeutic regimen management Explanation: The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.
The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for? Bone marrow biopsy Schilling test Magnetic resonance imaging (MRI) study Bone marrow aspiration
Schilling test Explanation: The classic method of determining the cause of vitamin B12 deficiency is the Schilling test, in which the patient receives a small oral dose of radioactive vitamin B12, followed in a few hours by a large, nonradioactive parenteral dose of vitamin B12 (this aids in renal excretion of the radioactive dose).
The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? Myoglobin and CK-MB Sodium and glucose levels T3 and T4 BUN and creatinine
Sodium and glucose levels Explanation: In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.
You are evaluating the expected outcomes on a client who is recovering from a cardiac catheterization. What is an expected outcome that you would evaluate? The client and family understands the client's CV diagnosis. The client and family understands the discharge instructions. The client and family understands the need for medication. The client and family understands the need to restrict activity for 72 hours.
The client and family understands the discharge instructions. Explanation: The client is relaxed and feels secure. The test is performed uneventfully or the client is stabilized when complications are managed successfully. The client and family have an accurate understanding of the diagnostic testing process and discharge instructions. The scenario does not indicate that the client has a CV diagnosis, a need for medication, or a need to restrict their activity for 72 hours.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The client has a pneumothorax. The chest tube is obstructed. The system is functioning normally. The system has an air leak.
The system has an air leak. Explanation: Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? Arthrodesis Total arthroplasty Hemiarthroplasty Osteotomy
Total arthroplasty Explanation: A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? Wash the area around the tube with soap and water daily. Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. Administer antibiotics via the tube as prescribed. Irrigate the skin surrounding the insertion site with normal saline before each use.
Wash the area around the tube with soap and water daily. Explanation: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not given to prevent site infection.
A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client? twice per shift as often as needed once upon arrival and 1hour later once upon arrival and every 2 hours afterward
as often as needed Explanation: Assessment is an important, recurring nursing activity that continues as long as a need for healthcare exists. During assessment, the nurse methodically obtains data about the client's health, illness, and change in condition.
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: atelectasis. pleural effusion. pulmonary edema. oxygen toxicity.
atelectasis. Explanation: In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition? catheter-related bloodstream infections hemorrhage air embolism pneumothorax
catheter-related bloodstream infections Explanation: Catheter-related bloodstream infections (CRBSIs) are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.
A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to: sexually transmitted disease. cryptorchidism. testosterone therapy during childhood. early onset of puberty.
cryptorchidism. Explanation: Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? elevation of upper body on pillows metoclopramide pantoprazole a low-fat diet
metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.
A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing? anaphylactic neurogenic hypovolemic cardiogenic
neurogenic Explanation: Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other nervous system damage; client symptoms include dry skin and bradycardia with hypotension. Cardiogenic shock is seen in clients with impaired heart function. Hypovolemic shock is caused by decreased intravascular volume. Anaphylactic shock is caused by a severe allergic reaction; clients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction; specifically, an immunoglobulin E-mediated response.
A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about: chronic, excessive acetaminophen use. recent streptococcal infection. family history of pernicious anemia. childhood asthma.
recent streptococcal infection. Explanation: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client requiring mechanical ventilation following surgery. returning to the nursing unit with two chest tubes. returning from surgery with no drainage tubes. requiring sedation until the chest tube(s) are removed.
returning to the nursing unit with two chest tubes. Explanation: The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. elevated blood urea nitrogen and creatinine levels and hyperglycemia. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count.
subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.
