Renal lippincot comp tests
168. The nurse teaches a client scheduled for an I.V. pyelogram what to expect when the dye is injected. The nurse knows that the client has cor- rectly understood what was taught when he states that he may experience which of the following sen- sations when the dye is injected? I 1. A metallic taste. I 2. Flushing of the face. I 3. Cold chills. I 4. Chest pain.
168. 2. As the dye is injected, the client may experi- ence a feeling of warmth, flushing of the face, and a salty taste in the mouth. The client should not experi- ence chest pain or cold chills; these would be adverse reactions warranting close monitoring of the client.
140. The nurse assesses a client who is receiving a tube feeding. Which of the following situations would require prompt intervention from the nurse? 1. The client is sitting upright in bed while the feeding is infusing. 2. The feeding that is infusing has been hanging for 8 hours. 3. The client has a gastric residual of 25 mL. 4. The feeding solution is at room temperature.
( 140. 2. Feeding solutions that have not been infused after hanging for 8 hours should be dis- carded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.)
155. A client is scheduled for a creatinine clear- ance test. Which one of the following preparations is appropriate for the nurse to make? I 1. Instruct the client about the need to collect urine for 24 hours. I 2. Prepare to insert an indwelling urethral cath- eter. I 3. Provide the client with a sterile urine collec- tion container. I 4. Instruct the client to force fluids to 3,000 mL/ day.
1 (155. 1. A creatinine clearance test is a 24-hour urine test that measures the degree of protein break- down in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to force fluids.)
108. Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recom- binant (Activase)? 1. Potassium level. 2. Lee-White clotting time. 3. Hemoglobin level, hematocrit, and platelet count. 4. Blood glucose level.
108. 3. The baseline laboratory data that are estab- lished before a client is started on tissue plasmi- nogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.
116. The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which of the following statements by the client indicates that the client understands the teaching? I 1. "I should take antihistamines to decrease the I 2. I 3. I 4. itching I am experiencing." "It is safe to apply a nonperfumed lotion to my skin." "A heating pad, set on the lowest setting, will help decrease my discomfort." "I can apply an over-the-counter cortisone ointment to relieve the dryness."
116. 2. Irradiated skin can become dry and irri- tated, resulting in itching and discomfort. The client should be instructed to clean the skin gently and apply nonperfumed, nonirritating lotions to help relieve dryness. Taking an antihistamine does not relieve the skin dryness that is causing the itching. Heat should not be applied to the area because it can cause further irritation. Medicated ointments, especially corticosteroids, which is controversial, should not be applied to the skin without the order of the radiation therapist.
118. The nurse is preparing a client for a thoracen- tesis. How should the nurse position the client for the procedure? I 1. Supine with the arms over the head. 2. Sims' position. 3. Prone position without a pillow. 4 Sitting forward with the arms supported on the bedside table.
118. 4. In preparation for a thoracentesis, the client should be asked to sit forward and place his arms on the bedside table for support. This posi- tion provides access to the chest wall and intercos- tal spaces for insertion of the needle. The supine, Sims', or prone position would not provide ade- quate access to the chest wall or separate the inter- costal spaces sufficiently for needle insertion.
121. Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed? I 1. Provide the client with oral hygiene. I 2. Offer the client liquids to drink. I 3. Encourage the client to cough and deep breathe. I 4. Auscultate the client's bowel sounds.
121. 1. The nurse's first action after the removal of a NG tube is to provide the client with oral hygiene. Then it is appropriate to give the client liquids to drink if the client is no longer on nothing-by-mouth status. There is no association between removal of an NG tube and having the client cough and deep- breathe. Auscultating the client's bowel sounds should be done before removal of the NG tube.
124. The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine speci- men. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. Monday and end at 7 a.m. Tuesday? I 1. Collect and save the urine voided at 7 a.m. on Monday. I 2. Send the first voided urine specimen on Mon- day to the laboratory for culture. I 3. Collect and save the urine voided at 7 a.m. on Tuesday. I 4. Keep each day's urin
124. 3. When finishing a 24-hour urine collection, the final voided urine is saved and added to the col- lection container. The first urine specimen, voided at 7 a.m. Monday, is discarded. The urine is not sent for a urine culture. It is not necessary to separate each day's collection of urine.
130. A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three- way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP? I 1. To control bleeding in the bladder. I 2. To instill antibiotics into the bladder. I 3. To keep the catheter free from clot obstruction. I 4. To prevent bladder distention.
130. 3. Continuous irrigation, usually consist- ing of sterile normal saline, is used after TURP to keep blood clots from obstructing the catheter and impeding urine flow. Antibiotics may be instilled in the bladder with the use of an irrigating solution, but this is not the primary reason for using continu- ous irrigation in TURP. The irrigating solution may secondarily help prevent bladder distention because it keeps the catheter from becoming obstructed.
131. Which of the following sounds should the nurse expect to hear when percussing a distended bladder? I 1. Hyperresonance. I 2. Tympany. I 3. Dullness. I 4. Flatness.
131. 3. A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.
137. A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care? I 1. Take apical heart rate after each dose of morphine. I 2. Assess urinary output every 8 hours. I 3. Assess mental status every shift. I 4. Check for pedal edema every 4 hours.
137. 2. Morphine can cause urinary retention. The nurse should assess the client for urinary hesitancy or retention, and note the urinary output. It is not necessary to take the apical heart rate after each dose of morphine. Mental status should be assessed after each dose because morphine can cause such effects as sedation, delirium, and disorientation. Assessing for pedal edema is not necessary.
138. When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications? I 1. Essential amino acid deficiency. I 2. Essential fatty acid deficiency. I 3. Hyperglycemia.
138. 4. Infection is the greatest concern to the nurse. Infection occurs more frequently because of the num- ber of procedures performed on clients that require this therapy and people they come in contact with in the hospital. Infection can be reduced if proper infec- tion control techniques are used and human contact is reduced. Deficiencies and toxicities of nutrients are rare because of the use of standard protocols and orders for TPN formulas. Hyperglycemia can occur with TPN administration; however, all clients receiv- ing TPN have their serum glucose concentration monitored frequently, and the hyperglycemia can eas- ily be managed by adding insulin to the TPN solution. An infection is a much more serious complication.
139. When assessing for signs of a blood transfu- sion reaction in a client with dark skin, the nurse should assess for which of the following? I 1. Hypertension. I 2. Diaphoresis. I 3. Polyuria. I 4. Warm skin.
139. 2. The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.
141. After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the fol- lowing interventions into the client's care? I 1. Clamp the urinary appliance at night. I 2. Empty the urinary appliance when one-third full. I 3. Administer prophylactic antibiotics. I 4. Change the urinary appliance daily.
141. 2. The urinary appliance should be emptied before the pouch is one-third full to prevent urinary reflux. The appliance should be attached to a leg bag at night to allow for adequate drainage. It is not appropriate to administer prophylactic antibiotics when incorporating positive self-care activities into the client's routine can prevent most urinary tract infections. The urinary appliance is not changed daily. If no leakage occurs and the client's skin remains free from irritation, the appliance can be left in place for 1 week or more.
142. When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure? I 1. Oxygenate the client before suctioning. I 2. Insert the suction catheter about 2 inches into the cannula. I 3. Use a bolus of sterile water to stimulate cough. I 4. Use clean gloves during the procedure.
142. 1. Preoxygenating the client before suctioning helps prevent the development of hypoxia dur- ing the procedure. The suction catheter is inserted about 5 to 6 inches into the cannula. A bolus of 3 to 5 mL of sterile normal saline solution may be inserted into the cannula before suctioning to stimu- late coughing and loosen secretions. The nurse uses sterile technique when suctioning a client.
154. After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the fol- lowing nursing actions is most appropriate? I 1. Realizing that the client is developing toler- ance to the meperidine, the nurse administers the meperidine every 3 hours. 2. The nurse urges the client to take the acet- aminophen with codeine to prevent addiction to the meperidine. 3. The nurse requests an order from the physi- cian to change the dose to an equianalgesic dose of morphine. 4. The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
154. 3. Current pain guidelines recommend the removal of meperidine from formularies and the substitution of morphine commonly administered by patient-controlled analgesia. Meperidine can be ordered for severe pain but its use is limited by the high incidence of neurotoxicity (seizures) associated with the accumulation of its metabolite, normeperi- dine. It is contraindicated in clients with acute pain lasting more than 2 days and in those for whom large daily doses (more than 600 mg) are needed. It would be inappropriate to urge the client to take the acetaminophen and codeine to prevent addiction. Addiction is a psychological condition in which a client is driven to take drugs for reasons that are not therapeutic. The client is in pain and her need for the morphine is therapeutic. Although the client may obtain some relief from relaxation exercises, this alone is not sufficient to provide pain relief.
157. The physician has prescribed amiodarone (Cordarone) for a client with cardiomyopathy. The nurse should monitor the client's rhythm to determine the effectiveness of the medication in controlling: I 1. Sinus node dysfunction. I 2. Heart block. I 3. Severe bradycardia. I 4. Life-threatening ventricular dysrhythmias.
157. 4. Cardiomyopathy means that the myo- cardium is weak and irritable. Amiodarone is an antiarrhythmic and acts directly on the cardiac cell membrane. In this situation, amiodarone is used to increase the ventricular fibrillation threshold. Amio- darone is contraindicated in sinus node dysfunc- tion, heart block, and severe bradycardia.
159. An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increas- ingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse con- sider as most critical in contributing to skin break- down in this client? I 1. Nutritional status. I 2. Urinary incontinence. I 3. Episodes of confusion. I 4. Right-sided paralysis.
159. 4. The most common factor in skin break- down is immobility. Right-sided paralysis, in which the client cannot perceive the need to change position and lacks control over movement of the extremities, is the condition most likely to lead to skin breakdown. It is essential that the nurse plan to change the client's position at least every 2 hours. Nutritional status and urinary incontinence can con- tribute to skin breakdown, but neither is the most critical factor. Confusion does not directly influence skin breakdown.
162. When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow? I 1. Clean the incision and drain site separately. I 2. Clean from the incision to the drain site. I 3. Clean from the drain site to the incision. I 4. Clean the incision and drain site simultane- ously.
162. 1. When cleaning the skin around an inci- sion and drain, the nurse should clean the incision and drain separately to avoid contaminating either wound. This is applying the principle of working from the least contaminated area to the most con- taminated area. In this case, both areas are fresh wounds and should be kept separate.
164. The nurse is instructing an unlicensed assis- tive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has under- stood the nurse's instructions? 1. "I will turn the client every 4 hours." 2."I will keep the client's head elevated." 3. "I should suction the client every 2 hours." 4. "I will have the client take 5 to 10 deep breaths every hour."
164. 4. Having the client deep-breathe hourly is the most appropriate action for the assistant to take to help prevent pulmonary complications. The cli- ent should be turned at least every 2 hours. Keeping the client's head elevated will not prevent pulmo- nary complications. Suctioning the client is not an assistant's responsibility, nor does it prevent pulmo- nary complications.
165. Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tis- sue perfusion related to interruption of arterial flow? Select all that apply. I 1. Extremities warm to touch. I 2. Improved respiratory status. I 3. Decreased muscle pain with activity. I 4. Participation in self-care measures. I 5. Lungs clear to auscultation.
165. 1, 3. The outcomes to achieve for a nursing diagnosis of Ineffective tissue perfusion involve evidence of adequate blood flow to the area. The temperature of the involved extremity is an important indicator for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indi- cates adequate blood flow. Pain is also an indicator of blood flow. Pain, such as muscle pain, suggests isch- emia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Thus, a decrease in muscle pain with activity would suggest improvement in blood flow to the area. Improved respiratory status and clear lungs are unrelated to ineffective tissue perfusion. Although participation in self-care measures is always helpful, this outcome is more appropriate for a nursing diagnosis of Activity intolerance, Fatigue, or Self-care deficit.
166. The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications? I 1. Essential fatty acid deficiency. I 2. Dehydration. I 3. Rebound hypoglycemia. I 4. Malnutrition.
166. 3. When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition is not the reason for tapering the infusion rate; the client's hydration and nutritional status and ability to main- tain adequate intake must be established before total parenteral nutrition is discontinued.
169. To prevent development of peripheral neu- ropathies associated with isoniazid administration, the nurse should teach the client to: I 1. Avoid excessive sun exposure. I 2. Follow a low-cholesterol diet. I 3. Obtain extra rest. I 4. Supplement the diet with pyridoxine (vitamin B6).
169. 4. Isoniazid competes for the available vitamin B6 in the body and leaves the client at risk for developing neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed to address this issue. Avoiding sun expo- sure is a preventive measure to lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's risk of developing atherosclerotic plaque. Rest is important in maintaining homeosta- sis but has no real impact on neuropathies.
171. Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to moni- tor to determine whether to increase or decrease the exercise level? I 1. Pulse rate. I 2. Blood pressure. I 3. Body temperature. I 4. Respiratory rate.
171. 1. The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor his pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to decrease exercise if chest pain or dyspnea occurs.
174. A client with type I diabetes mellitus is scheduled to have surgery. The client has been NPO since midnight. In the morning, the nurse notices that the client's daily insulin has not been ordered. Which action should the nurse do first? I 1. Obtain the client's blood glucose at the bedside. Contact the physician for further orders regarding insulin dosage. Give the client's usual morning dose of insulin. Inform the Post Anesthesia Care Unit (PACU) staff to obtain the insulin order.
174. 1. The nurse should contact the physician and clarify whether the client's usual insulin dose should be given before surgery; having the blood glucose level is objective information that the physi- cian may need to know before making a final deci- sion as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision- making on this issue until after the surgery.
175. A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? I 1. Butterfly dressing. I 2. Montgomery strap. I 3. Fine mesh gauze dressing. I 4. Petrolatum gauze dressing.
175. 4. Immediately after chest tube removal, a petrolatum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air move- ment in either direction. Bandages or straps are not applied directly over wounds. Mesh gauze allows air movement.
178. A diabetic client has been diagnosed with hypertension and the physician has prescribed atenolol (Tenormin), a beta blocker. When perform- ing discharge teaching, it is important for the client to recognize that the addition of Tenormin can cause: I 1. A decrease in the hypoglycemic effects of insulin. I 2. An increase in the hypoglycemic effects of insulin. I 3. An increase in the incidence of ketoacidosis. I 4. A decrease in the incidence of ketoacidosis.
178. 2. There is a direct interaction between the effects of insulin and those of beta blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta blocker is added to the client's medication regi- men. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of insulin.
19. The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching? I 1. "I will avoid being out in the sun for long periods." 2. "I should stop applying it once the infected area heals." 3. "I'll call the physician if the condition worsens." 4. "I should apply it to large open areas."
19. 4. The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are pos- sible. The nurse should instruct the client to avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client should be instructed to apply the cream or ointment for only the length of time prescribed because a superin- fection can occur from overuse. The client should contact the physician if the condition worsens after use.
143. An 80-year-old client with severe kidney damage is placed on life support and dialysis. Care decisions are being made by his wife, who is show- ing signs of early Alzheimer's disease. The client's daughter arrives from out of town with a copy of the client's living will, which states that the client did not want to be on life support. The nurse should: 1. Immediately inform the physician about the living will. 2. Suggest to the daughter that she discuss her father's wishes with her mother. 3. Prepare to remove the client from life support. 4. Make a copy of the living will and give it to the client's wife.
2 (143. 2. The most appropriate action is to encour- age the daughter to talk to her mother about the end- of-life issues first to reach a consensus or agreement. This is a family decision. Immediately informing the physician or preparing to remove the client from life support would be premature if the family is not in agreement. Although a copy of the living will should be on the client's chart, it is up to the daugh- ter to show it to her mother.)
15. Which of the following medications should be available to provide emergency treatment if a cli- ent develops tetany after a subtotal thyroidectomy? I 1. Sodium phosphate. I 2. Calcium gluconate. I 3. Echothiophate iodide. I 4. Sodium bicarbonate.
2 (15. 2. The client with tetany is suffering from hypocalcemia, which is treated by administering an I.V. preparation of calcium, such as calcium glucon- ate or calcium chloride. Oral calcium is then nec- essary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid.)
144. Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply. 1. Is older than 65 years. 2. Has had symptoms of the stroke less than 3 hours. 3. Has a blood pressure within normal limits. 4. Does not have active internal bleeding. 5. Has not had an alcoholic beverage within the last 8 hours.
2, 3, 4 (144. 2, 3, 4. Contraindications for t-PA or alteplase recombinant therapy include current active inter- nal bleeding, 3 hours or longer since the onset of symptoms of a stroke, and severe hypertension. Age greater than 65 years or having had an alcoholic beverage are not contraindications for the therapy.)
24. The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate (Garamycin)? I 1. 2 hours before the administration of the next I.V. dose. I 2. 3 hours before the administration of the next I.V. dose. I 3. 4 hours before the administration of the next I.V. dose. I 4. Just before the administration of the next I.V. dose.
24. 4. To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next I.V. dose of gentamicin sulfate.
28. A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that: 1. Lifelong daily medicine is necessary. 2. The medication is expensive, and the dose can be reduced in a few months. The medication can be gradually withdrawn in 1 to 2 years. The medication can be discontinued after the client's thyroid-stimulating hormone level is normal.
28. 1. Thyroid replacement is a lifelong main- tenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medica- tion cannot be discontinued after the thyroid-stimu- lating hormone (TSH) level is normal; the dose will be maintained at the level that normalizes the TSH concentration.
138. A client is recovering from abdominal sur- gery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastroin- testinal tract? I 1. Compression. I 2. Lavage. I 3. Decompression. I 4. Gavage.
3 (138. 3. After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointes- tinal tract until peristaltic action returns. Compres- sion may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings.)
31. A client is to receive epoetin (Epogen) injec- tions. What laboratory value should the nurse assess before giving the injection? I 1. Hematocrit. I 2. Partial thromboplastin time. I 3. Hemoglobin concentration. I 4. Prothrombin time.
31. 1. Epoetin (Epogen) is a recombinant DNA form of erythropoietin, which stimulates the pro- duction of RBCs and therefore causes the hemat- ocrit to rise. The elevation in hematocrit causes an elevation in the blood pressure; therefore, the blood pressure is a vital sign that should be checked. The partial thromboplastin time, hemoglobin level, and prothrombin time are not monitored for this drug.
36. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to: I 1. Take NSAIDs at least three times per day. I 2. Exercise the joints at least 1 hour after taking the medication. I 3. Take antacids 1 hour after taking NSAIDs. I 4. Take NSAIDs with food.
36. 4. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.
39. A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which the following conditions should the nurse assess to determine whether the activity is appropriate for the client? I 1. Edema. I 2. Cyanosis. I 3. Dyspnea. I 4. Weight loss.
39. 3. Physical activity is gradually increased after a myocardial infarction while the client is still hospi- talized and through a period of rehabilitation. The cli- ent is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symp- toms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but doesn't necessar- ily indicate overexertion. Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indi- cates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.
32. When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply. 1. Checking the hemoglobin levels before administering subsequent doses. 2. Shaking the vial thoroughly to mix the con- centrated white, milky solution. 3. Keeping the multidose vial refrigerated between scheduled twice-a-day doses. 4. Administering the medication through the I.V. line without other medications. 5. Adjusting the initial doses according to the client's changes in blood pressure. 6. Educating the client to avoid driving and per- forming hazardous activity during the initial treatment.
4, 5, 6 (32. 4, 5, 6. Erythropoietin is administered to decrease the need for blood transfusions by stimu- lating RBC production. The medication should be administered through the I.V. line without other medications to avoid a reaction. The hematocrit, a simple measurement of the percent of RBCs in the total blood volume, is used to monitor this therapy. When initiating I.V. erythropoietin therapy, the nurse should monitor the hematocrit level so that it rises no more than four points in any 2-week period. In addition, the initial doses of erythropoietin are adjusted according to the client's changes in blood pressure. The nurse should tell the client to avoid driving and performing hazardous activity during the initial treatment due to possible dizziness and headaches secondary to the adverse effect of hyper- tension. The hematocrit, not the hemoglobin level, is used for monitoring the effectiveness of therapy. The vial of erythropoietin should not be shaken)
44. A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be: I 1. A return demonstration of palpating the radial pulse. I 2. A return demonstration of how to take the medication. I 3. Verbalization of why the client has atrial fibrillation. I 4. Verbalization of the need for the medication.
44. 1. The goal of the education program is to instruct the client to take his pulse; therefore, the expected outcome would be the ability to give a return demonstration of how to palpate the heart rate.
46. Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly? I 1. Vertigo. I 2. Tinnitus. I 3. Muscle stiffness. I 4. Ataxia.
46. 2. The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Musc
48. The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse imple- ment first? I 1. Call the physician. I 2. Irrigate the NG tube. I 3. Check the function of the suction equipment. I 4. Reposition the NG tube.
48. 3. When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the physician should be called.
51. The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments? I 1. Interstitial compartment. I 2. Intravascular compartment. I 3. Extracellular compartment. I 4. Intracellular compartment.
51. 1. The clinical findings of edema are con- sistent with fluid excess in the interstitial com- partment. The extracellular compartment consists of fluid in two locations, the interstitial (tissue) spaces and plasma (intravascular) spaces. Fluid shifts within the extracellular compartment can occur either from the plasma space to the interstitial space, or from the interstitial space to the plasma space. When fluid shifts from the plasma space into the interstitial space, usually as a result of abnormal retention of fluids in such conditions as heart failure or renal failure, edema results. The intracellular compartment consists of fluid within the cells.
52. An expected physiologic response to a low potassium level is: I 1. Cardiac dysrhythmias. I 2. Hyperglycemia. I 3. Hypertension. I 4. Increased energy.
52. 1. Low potassium can cause an imbalance at the cellular level that leads to dysrhythmias and cardiac arrest. Hyperglycemia is caused by elevated blood sugar. Hypertension is unrelated to potassium levels. Increased energy is unrelated to potassium levels.
53. When teaching unlicensed assistive person- nel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that? I 1. "It is not necessary to wash your hands as long as you use gloves." I 2. "Handwashing is the best method for prevent- ing cross-contamination." I 3. "Waterless commercial products are not effec- tive for killing organisms." I 4. "The hands do not serve as a source of infection."
53. 2. Handwashing with the correct technique is the best method for preventing cross-contamination. The hands serve as a source of infection. Water- less commercial products containing at least 60% alcohol are as effective at killing organisms as handwashing.
6. A 22-year-old client is brought to the emer- gency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the fol- lowing is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? 1. The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. The physician will get a consultation from another physician and proceed with place- ment of the ICP catheter until the family arrives to sign the consent. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. The physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed with- out a consent.
6. 4. In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which means he is comatose. The cli- ent has deteriorated to a level where he cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The cli- ent's fiancée cannot sign his consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The physi- cian should insert the catheter in this emergency. He does not need to get a consultation from another physician. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin.
67. The nurse should assess the client with severe diarrhea for which acid-base imbalance? I 1. Respiratory acidosis. I 2. Respiratory alkalosis. I 3. Metabolic acidosis. I 4. Metabolic alkalosis.
67. 3. A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.
69. A 7-year-old child is admitted to the hospital with the medical diagnosis of acute rheumatic fever. Which of the following laboratory blood findings confirms that the child has had a streptococcal infection? I 1. High leukocyte count. I 2. Low hemoglobin count. I 3. Elevated antibody concentration. I 4. Low erythrocyte sedimentation rate.
69. 3. Exactly why rheumatic fever follows a streptococcal infection is not known, but it is theo- rized that an antigen-antibody response occurs to an M protein present in certain strains of streptococci. The antibodies developed by the body attack certain tissues such as in the heart and joints. Antistrep- tolysin O titer findings show elevated or rising anti- body levels. This blood finding is the most reliable evidence of a streptococcal infection.
85. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below. The nurse identifies that this rhythm is: I 1. Atrial fibrillation. I 2. Ventricular tachycardia. I 3. Premature ventricular contractions. I 4. Third-degree heart block.
85. 4. Third-degree heart block occurs when atrial stimuli are blocked at the atrioventricular junction. Impulses from the atria and ventricles are conducted independently of each other. The atrial rate is 60 to 100 bpm; the ventricular rate is usually 10 to 60 bpm.
92. Which of the following findings should the nurse note in the client who is in the compensatory stage of shock? I 1. Decreased urinary output. I 2. Significant hypotension. I 3. Tachycardia. I 4. Mental confusion.
92. 3. In the compensatory stage of shock, the client exhibits moderate tachycardia. If the shock continues to the progressive stage, decreased urinary output, hypotension, and mental confusion develops as a result of failure to perfuse and ineffective com- pensatory mechanisms. These findings are indications that the body's compensatory mechanisms are failing.
93. A client has been prescribed hydrochloro- thiazide (HydroDIURIL) to treat heart failure. For which of the following symptoms should the nurse monitor the client? I 1. Urinary retention. I 2. Muscle weakness. I 3. Confusion. I 4. Diaphoresis.
93. 2. Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and dia- phoresis are not side effects of hydrochlorothiazide.
95. The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen? 1. Promptly send the specimen to the laboratory. 2. Send the specimen with the next pickup. 3. Send the specimen the next time a nursing assistant is available. 4. Store the specimen in the refrigerator until it can be sent to the laboratory
95. 1. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.