Quiz 6: EVOLVE Practice
79. The nurse is caring for a client just admitted to the critical care unit with a diagnosis of myocardial infarction (MI). In the early period after an MI, why are nutrition interventions and education so important? (SATA) 1. To reduce angina 2. To cut down on cardiac workload 3. To cut down on the cost of a hospital stay 4. To decrease the risk of dysrhythmias 5. To cause weight loss in obese clients 6. To eliminate further deterioration of kidney function
1,2,4
80. The emergency department nurse is caring for a client with a suspected diagnosis of meningitis. The nurse should prepare the client for which test to confirm the diagnosis? 1. Blood culture 2. Lumbar puncture 3. Serum electrolyte panel 4. White blood cell count
2.
1. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow
2. Lying in bed on the unaffected side To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees.
38. The nurse reviews the health care provider's (HCP's) prescriptions for a child with a streptococcal infection. The HCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child? 1. Heart failure (HF) 2. Rheumatic fever (RF) 3. Aortic valve disease (AVD) 4. Pulmonic valve disease (PVD)
2. Rheumatic fever (RF)
5. The nurse working in the outpatient radiology department is giving discharge instructions to a client who has had a bone scan. Which instruction should the nurse include in the client's teaching plan?
3. Drink extra water for a day or so after the procedure. The client should drink large amounts of water for 24 to 48 hours to excrete the radioisotope through the kidneys. No special diet or activity prescriptions or restrictions are required after a bone scan. Nausea or flushing would accompany allergic reaction to a dye, which is not used in this procedure.
13. Following myelography, how should the nurse plan to best position the client? 1. On the left side 2. On the right side 3. Head slightly elevated 4. Head lower than the rest of the body
3. Head slightly elevated The head should be slightly elevated to prevent complications such as leaking of cerebrospinal fluid.
26. The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result? 1. Insignificant and unrelated to pheochromocytoma 2. Lower than normal, ruling out pheochromocytoma 3. Higher than normal, indicating pheochromocytoma 4. Normal results for a client with pheochromocytoma
3. Higher than normal, indicating pheochromocytoma
12. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water
3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
41. The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Sims' position, with the head of the bed flat 2. Prone, with the head turned to the side supported by a pillow 3. Left side-lying position, with the head of the bed elevated 45 degrees 4. Right side-lying position, with the head of the bed elevated 45 degrees
3. Left side-lying position, with the head of the bed elevated 45 degrees
90. The ambulatory care nurse is preparing to assist the health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed? 1. Right lateral side-lying 2. Flat with the head elevated 3. Supine with the right hand under the head 4. Prone with the hands crossed under the head
3. Supine with the right hand under the head
16. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen. 2. Check the client's vital signs. 3. Ventilate the client manually. 4. Start cardiopulmonary resuscitation.
3. Ventilate the client manually.
30. A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention? 1. Allow the client to have bathroom privileges. 2. Keep the client lying flat in bed in the supine position. 3. Withhold oral fluids until the client's gag reflex has returned. 4. Tell the client to report a sore throat immediately because it is a serious complication.
3. Withhold oral fluids until the client's gag reflex has returned.
55. The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period? 1. 1 week 2. 6 hours 3. 8 hours 4. 1 to 2 days
4
84. The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What should the nurse instruct the client to do in preparation for this procedure? 1. Liquids are restricted for 24 hours after the test. 2. A clear liquid diet is required for 4 days before the test. 3. Laxatives should not be taken for at least 1 week before the test. 4. A low-fiber diet needs to be maintained for 1 to 3 days before the test.
4. Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test. Clear liquids or water may be allowed 12 to 24 hours before the test. Laxatives and enemas may be prescribed before the test to cleanse the bowel. The client is encouraged to drink liquids after the procedure to facilitate the passage of barium
63. A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective? 1. "The purpose of the test is to detect lesions in the brain." 2. "The purpose of the test is to inject medication into the bone." 3. "The purpose of the test is to examine the cerebrospinal column." 4. "The purpose of the test is to provide information about the blood vessels."
4. "The purpose of the test is to provide information about the blood vessels."
18. The nurse is preparing to care for a client following a gastroscopy procedure. Which priority component should the nurse include in the nursing care plan? 1. Monitor the client's vital signs every hour for 4 hours. 2. Place the client in a supine position to provide comfort. 3. Provide saline gargles immediately on return to the unit to aid in comfort. 4. Check the gag reflex by using a tongue depressor to stroke the back of the client's throat.
4. Check the gag reflex by using a tongue depressor to stroke the back of the client's throat.
25. A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention should the nurse implement? 1. Administering atropine intravenously 2. Administering small doses of a sedative 3. Encouraging additional fluids for the next 24 hours 4. Ensuring the return of the gag reflex before offering food or fluids
4. Ensuring the return of the gag reflex before offering food or fluids
28. A client is scheduled to have a needle liver biopsy. During the procedure, the nurse should instruct the client to take which action? 1. Lie on the right side. 2. Assume a lithotomy position. 3. Breathe deeply as the needle is inserted. 4. Lie supine with the right arm over the head.
4. Lie supine with the right arm over the head. For the health care provider to have optimal access to the liver during a liver biopsy, the client should be instructed to lie in a supine position with the right arm over the head. {After liver biopsy, the pt should be kept on the affected (RIGHT) side}.
56. The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse should expect to delete which prescription on the client's care plan? 1. Monitor hydration status. 2. Assess for nausea and vomiting. 3. Monitor for abdominal discomfort. 4. Maintain a clear liquid diet for 72 hours.
4. Maintain a clear liquid diet for 72 hours.
62. The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1. Monitor the radial pulse every hour. 2. Keep the extremity in a dependent position. 3. Document any changes that occur in the pulse. 4. Place pressure dressings and wraps around the burn sites.
1. In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremities should be elevated, and the health care provider should be notified of any changes in pulses, capillary refill, or pain sensation.
22. The nurse explains to a client why telemonitoring is needed. What response by the client indicates a need for further instruction? 1. "Telemonitoring ignores artifact." 2. "These systems are not fail-proof." 3. "Monitoring helps to diagnose dysrhythmias, ischemia, or infarction." 4. "Electrodes have to be replaced when the conductive gel has dried out."
1. "Telemonitoring ignores artifact."
61. The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1. Monitor vital signs every 4 hours. 2. Monitor mental status every hour. 3. Monitor intake and output every shift. 4. Obtain and record weight every other day.
2
67. The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction? 1. "I should elevate my knee while sitting." 2. "I can apply heat to the site if it becomes uncomfortable." 3. "I should avoid excessive use of the joint for several days." 4. "I should return to the health care provider for suture removal in about 7 days."
2. "I can apply heat to the site if it becomes uncomfortable."
2. While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.
2. Grasp the retention sutures to spread the opening. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts to replace the tube immediately. Calling ancillary services or the health care provider will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.
23. The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen? 1. Limiting fluids 2. Having the client take 3 to 4 deep breaths 3. Asking the client to spit into the collection container 4. Asking the client to obtain the specimen after eating
2. Having the client take 3 to 4 deep breaths
108. The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement should the nurse include when reviewing preparation for the CT with the client? 1. "You will need to stand up straight for the entire procedure." 2. "All scans require the injection of dye before the procedure." 3. "Each set of head scans takes less than 5 minutes to perform." 4. "You will need to remain on bed rest for 12 hours after the scan."
3.
65. The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? 1. "The test will take between 45 minutes and 2 hours." 2. "My hair should be washed the evening before the test." 3. "Cola, tea, and coffee are restricted on the day of the test." 4. "All medications need to be withheld on the day of the test."
4. "All medications need to be withheld on the day of the test."
8. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.
4. Administer oxygen, 8 to 10 L/minute, by face mask.
109. The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP? 1. Cardiac enzymes 2. Serum electrolytes 3. Complete blood count (CBC) 4. Erythrocyte sedimentation rate (ESR)
4. Erythrocyte sedimentation rate (ESR)
1. Wearing sterile gloves 2. Using a sterile container 3. Refrigerating the specimen 4. Sending the specimen directly to the laboratory 5. Positioning the client in a dorsal recumbent position
1,2,4 A stool smear specimen is obtained using sterile gloves and a sterile container. {It is very important to use a wooden applicator to put the stool in the sterile container; it is NOT necessary to obtain the first bowel movement of the day}
63. The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 1. Cut the tube. 2. Reposition the client. 3. Assess the lumens of the tubes. 4. Administer the prescribed analgesics.
1.
95. The nurse is teaching a client about an upcoming colonoscopy procedure. The nurse would include in the instructions the fact that the client will be placed in which position for the procedure? 1. Left Sims' 2. Right Sims' 3. Knee-chest 4. Lithotomy
1. Left Sims
31. The nurse is assisting the health care provider during a colonoscopy procedure. The nurse helps the client to assume which position for the procedure? 1. Left Sims' 2. Lithotomy 3. Knee chest 4. Right Sims'
1. Left Sims'
15. A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome
1. Right pneumothorax
54. A client is scheduled for a test to detect kidney tumors or cysts. What test is considered safest for the client? 1. Ultrasonography 2. Nephrotomography 3. Excretory urography 4. Computed tomography
1. Ultrasonography
13. A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (SATA) 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.
2,3
100. The nurse is caring for a client who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? (SATA) 1. Clients with an allergy to sulfa 2. Clients with infection near the LP site 3. Clients with increased intracranial pressure 4. Clients receiving anticoagulation medications 5. Clients with a history of migraine headaches 6. Clients who have severe degenerative vertebral joint disease
2,3,4,6
14. The nurse provides discharge instructions to a client following myelography. Which instructions should the nurse provide? Select all that apply. 1. Restrict fluid intake. 2. Avoid bending over. 3. Avoid strenuous exercise. 4. Rest with the head elevated. 5. Expect some clear drainage from the dressing site.
2,3,5
68. The nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions? 1. "The procedure will take all day." 2. "I need to have an injection 2 to 3 hours before the procedure." 3. "I will need to avoid food and fluids and remain on bed rest for 2 days after the procedure." 4. "I need to get a good night's rest because I will have to stand for several hours for this test."
2. A gallium scan is similar to a bone scan but with injection of gallium isotope instead of radioisotope. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client needs to lie still during the procedure.
104. A health care provider is about to perform a paracentesis for a client with abdominal ascites. The nurse assisting with the procedure should help the client into which position? 1. Supine 2. Upright 3. Right side-lying 4. Left side-lying
2. An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally sits upright in a chair, with the feet flat on the floor and with the bladder emptied before the procedure
60. The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1. Elevate the head of the bed. 2. Monitor oxygen saturation levels every 4 hours. 3. Encourage coughing and deep breathing every 4 hours. 4. Assess respiratory rate and breath sounds every 4 hours.
4
106. The nurse is giving postprocedure instructions to a client returning home after arthroscopy of the shoulder. What is the priority instruction for this client? 1. "Do not eat or drink anything until tomorrow morning." 2. "Keep the shoulder completely immobilized for the rest of the day." 3. "You need to refrain from strenuous activity for the next few weeks." 4. "Report any fever or redness and heat at the site to your health care provider."
4.
62. A client requires a myelogram, and the ambulatory care nurse is providing instructions to the client regarding preparation for the procedure. Which statement by the client indicates a need for further instruction? 1. "My jewelry will need to be removed." 2. "An informed consent form will need to be signed." 3. "My procedure will take approximately 45 minutes." 4. "I need to be sure to eat a full meal before the procedure."
4.
94. A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction should the nurse provide to the client in preparation for the test? 1. Eat a normal breakfast on the day of the test. 2. Take insulin as scheduled on the day of the test. 3. Eat a low-carbohydrate diet for at least 3 days before the test. 4. Avoid alcohol, coffee, and tea for 36 hours before and during the test.
4. Avoid alcohol, coffee, and tea for 36 hours before and during the test.
7. A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside? 1. Intubation tray 2. Morphine sulfate injection 3. Portable chest x-ray machine 4. Chest tube and drainage system
4. Chest tube and drainage system Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse should have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops.
4. The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? (SATA) 1. It is a painless test. 2. It emits slightly more radiation than a chest x-ray does. 3. Upper body clothing will need to be removed for testing. 4. Increased fluid intake is necessary following the procedure. 5.Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed
1,5 The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.
74. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's health care provider? 1. Schilling test 2. Clotting time 3. Bone marrow biopsy 4. White blood cell differential
1. The Schilling test is used to determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. This test involves the use of a small oral dose of radioactive B12, followed by a large nonradioactive intramuscular (IM) dose. The IM dose helps flush the oral dose into the urine if it was absorbed. A 24-hour urine collection is performed to measure the amount of radioactivity in the urine
71. A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse should tell the client that which will be necessary before the procedure is performed? 1. Insertion of a Foley catheter 2. A signed informed consent form 3. Clear liquids only on the day of the procedure 4. Administration of antihypertensive medication
2. Extracorporeal shock wave lithotripsy is done with the client under epidural or general anesthesia. The client must sign a consent form for the procedure and must have no oral intake beginning the night before the procedure. The client needs an intravenous line for the procedure as well.
72. The nurse is providing instructions to a client who has had a bone scan. The nurse should instruct the client to take which measure? 1. Avoid eating or drinking for 24 hours. 2. Take a liquid laxative daily for the next 3 days. 3. Increase fluid intake for the next 24 to 48 hours. 4. Ambulate vigorously several times for the next 2 days.
2. The client should be encouraged to drink large amounts of water for 24 to 48 hours to facilitate urinary excretion of the radioisotope.
49. The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium? 1. Hypothermia 2. Decreased blood pressure 3. Hematoma in the left groin 4. Discomfort in the left groin
2. Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure.
111. The health care provider (HCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? 1. "It is an antigen found on the surface of the red blood cell." 2. "It is an antibody found on the surface of the red blood cell." 3. "An acute transfusion reaction can happen if I get blood incompatible with mine." 4. "If I have group AB blood, I'm a universal recipient because I have no antibodies to react to the transfused blood."
2. "It is an antibody found on the surface of the red blood cell."
96. An ultrasound examination of the gallbladder is scheduled for a client with a suspected diagnosis of cholecystitis. Correct instructions about the procedure should include which statement made by the nurse? 1. "This procedure may cause discomfort." 2. "This test requires that you lie still for short intervals." 3. "This procedure is preceded by the administration of oral tablets." 4. "This procedure requires that you not eat or drink anything for 24 hours before the test."
2. "This test requires that you lie still for short intervals."
102. The nurse is told to draw an arterial blood gas sample with the client on ambient air. The nurse documents in the record that the client was receiving how much oxygen for this procedure? 1. 16% 2. 21% 3. 30% 4. 40%
2. 21% Ambient air is the same thing as room air, which contains 21% oxygen. It is not possible to give a client 16% oxygen because it is less than room air. The remaining options of 30% and 40% contain oxygen amounts that are commonly used to supplement oxygen for clients having respiratory difficulty.
57. The nurse is scheduling diagnostic tests for a client. Which of the diagnostic tests prescribed should be performed last? 1. Barium enema 2. Barium swallow 3. Gallbladder series 4. Oral cholecystogram
2. Barium swallow
32. A client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse should provide a list of foods from which diet type? 1. Liquid 2. Fat-free 3. Low-protein 4. High-carbohydrate
2. Fat-free
11. A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1. Place the child in a supine position. 2. Notify the health care provider (HCP). 3. Place the child in Trendelenburg's position. 4. Increase the flow rate of the intravenous fluids.
2. Notify the health care provider (HCP). In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP.
1. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system immediately. 4. Place a sterile dressing over the disconnection site.
2. Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.
44. The nurse is caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which client problem should be the priority? 1. Risk for dehydration caused by bleeding in the gastrointestinal tract 2. Risk for choking and aspiration related to a poor gag reflex postprocedure 3. Lack of knowledge of postprocedure care related to not having had an EGD before 4. Sore throat related to passage of the endoscope through the pharyngeal region during EGD
2. Risk for choking and aspiration related to a poor gag reflex postprocedure
65. The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1. "Constricted blood vessels have caused a loss of protein in the blood." 2. "Leaking blood vessels have led to increased protein amounts in the blood." 3. "Leaking blood vessels have led to decreased protein amounts in the blood." 4. "Constricted blood vessels have led to increased protein amounts in the blood."
3.
98. The nurse is teaching a client about what to expect during a gallium scan. The nurse should include which item as part of the instructions? 1. The procedure is noninvasive. 2. The client must stand erect during the filming. 3. The procedure takes about 30 to 60 minutes to perform. 4. The client should remain on bed rest for the remainder of the day after the scan.
3.
64. The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1. Heart failure 2. Pulmonary edema 3. Cardiogenic shock 4. Aortic insufficiency
3. 1. Heart failure 2. Pulmonary edema 3. Cardiogenic shock 4. Aortic insufficiency
105. The nurse is planning care for a client returning to the nursing unit after a bone biopsy. Which nursing action would be contraindicated in the postprocedure care for this client? 1. Monitor vital signs. 2. Administer oral analgesics as needed. 3. Place the limb in a dependent position for 24 hours. 4. Monitor biopsy site for swelling, bleeding, or hematoma.
3. The biopsied limb would be elevated for 24 hours to reduce edema, not placed in a dependent position
82. A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? 1. Encourage intake of fluids. 2. Shave the anticipated entry site. 3. Ask the client about allergies and previous reactions. 4. Contact the operating room regarding the need for the procedure.
3. usage of contrast dye
46. The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? 1. Serum electrolytes 2. Urine specific gravity 3. 24-hour fluid intake and output without restricting food or fluid intake 4. Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland
3. 24-hour fluid intake and output without restricting food or fluid intake
2. The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees
4. After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.
76. A nursing student is assigned to an adult client who is scheduled for bone marrow aspiration. The coassigned nurse asks the nursing student about the possible sites that could be used for obtaining the bone marrow. The student demonstrates understanding of the procedure by identifying what as the correct aspiration site? 1. Ribs 2. Femur 3. Scapula 4. Iliac crest
4. The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing.
24. A female client is scheduled to have a chest radiograph. Which question is most important for the nurse to ask when assessing this client? 1. "Can you hold your breath easily?" 2. "Are you wearing any metal chains or jewelry?" 3. "Are you able to hold your arms above your head?" 4. "Is there any possibility that you could be pregnant?"
4. The most important item for the nurse to ask about is the client's pregnancy status, because pregnant women should not be exposed to radiation.
93. The nurse is developing a plan of care for a client who will be returning to the nursing unit after a percutaneous transhepatic cholangiogram. The nurse should include which intervention in the postprocedure plan of care? 1. Encourage fluid and food intake. 2. Allow the client bathroom privileges only. 3. Allow the client to sit in a chair for meals. 4. Place a sandbag or other approved device over the insertion site.
4. Place a sandbag or other approved device over the insertion site. A percutaneous transhepatic cholangiogram is an x-ray of the biliary duct system that is taken with the use of an iodinated dye instilled via a percutaneous needle inserted through the liver into the intrahepatic ducts. This procedure may be done when a client has jaundice or persistent upper abdominal pain, although ultrasound scans and endoscopic retrograde cholangiopancreatography are usually the preferred tests. After this procedure, the nurse monitors the client's vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag or other pressure device is placed over the insertion site to prevent bleeding
40. The nurse is assisting the health care provider with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which position? 1. Left side-lying, with the right arm elevated above the head 2. Right side-lying, with the left arm elevated above the head 3. Left side-lying, with a small pillow or towel under the puncture site 4. Right side-lying, with a small pillow or towel under the puncture site
4. Right side-lying, with a small pillow or towel under the puncture site Following a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours. This helps to immobilize the area and provides pressure to minimize bleeding in this vascular organ
9. How should the nurse position the client for pericardiocentesis to treat cardiac tamponade? 1. Supine with slight Trendelenburg's position 2. Lying on the right side with a pillow under the head 3. Lying on the left side with a pillow under the chest wall 4. Supine with the head of the bed elevated at a 45- to 60-degree angle
4. Supine with the head of the bed elevated at a 45- to 60-degree angle The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac.
39. A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? 1. Knee chest, with the foot of the bed elevated 2. Supine, with the head of the bed elevated 45 to 90 degrees 3. Semi Fowler's, with the knees placed on top of 1 pillow 4. Supine, with the head of the bed elevated about 15 degrees
4. Supine, with the head of the bed elevated about 15 degrees
