T3 Exams Cumulative

A patient has been admitted after the insertion of a pacemaker because of bradycardia. She asks what third-degree heart block is, and the nurse replies "Coronary blood vessel occlusion causing slow contraction of the right ventricles." "Increased pressure in the pulmonary vessels." "Sclerosis of cardiac valves causing slow pulse." "A defect in AV junctions slows and impairs conduction of impulses from the SA node to the ventricles."

"A defect in AV junctions slows and impairs conduction of impulses from the SA node to the ventricles." Atrioventricular block occurs when a defect in the AV junction slows or impairs conduction of impulses from the SA node to the ventricles.

The nurse is teaching a patient about nitroglycerin prior to discharge to home. Which instruction will the nurse provide the patient? "Report any headaches following self-administration to your healthcare provider." "Carry the medication with you at all times." "Carry the medication in a pocket directly next to the body." "Store nitroglycerin in a clear glass container with a tight lid." Nonhospitalized patients should carry nitroglycerin at all times.

"Carry the medication in a pocket directly next to the body." Headache is an expected adverse effect. Heat causes the medication to deteriorate, so being carried next to the body would cause it to become ineffective. Tablets are degraded by sunlight.

Which statement indicates the client needs further teaching regarding taking warfarin and food selection? 1 "Eggs provide a good source of iron, which is needed to prevent anemia." 2 "Yellow vegetables are high in vitamin A and should be included in the diet." 3 "Milk and other high-calcium dairy products are necessary to counteract bone density loss." 4 "Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting."

"Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting." Foods high in vitamin K should be avoided because vitamin K is part of the body's blood clotting mechanism and will counter the effects of warfarin. Foods containing protein and iron are permitted because they are unrelated to blood clotting. Foods containing vitamin A are permitted because vitamin A is unrelated to blood clotting. Foods containing calcium are permitted because calcium is unrelated to blood clotting.

A nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit information about the cause of this disease? "Has your child had any diarrhea?" "Did your child recently complain of a sore throat?" "Have you noticed any rashes on your child?" "Did your child sustain any injuries to the kidney area?"

"Did your child recently complain of a sore throat?" Rationale: Group A beta hemolytic streptococcal infection is a cause of glomerulonephritis. Often the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The questions to the mother in options 1, 3, and 4 are unrelated to a diagnosis of glomerulonephritis.

A nurse is collecting data on a child with a diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the mother of the child? "Has the child been vomiting?" "Does the child complain of chest pain?" "Has the child complained of a sore throat within the past few weeks or months?" "Has the child had any diarrhea?"

"Has the child complained of a sore throat within the past few weeks or months?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether any family members have had a sore throat or unexplained fever within the past 2 months. Although options 1, 2, and 3 may be asked during data collection, they would not be the initial concerns for a child with rheumatic fever.

The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask? "Do you think you should wait that long for your tooth extraction?' "Is your dentist board certified?" "Do you have a toothache?" "Have you contacted your physician about your dental appointment?"

"Have you contacted your physician about your dental appointment?" Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction.

During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure? "I have to urinate every 2 hours, even during the night." "I have to sleep in my recliner and I have this hacking cough. " "I have no appetite and I have lost 3 lb in the last week." "I go barefoot most of the time because my feet are so hot."

"I have to sleep in my recliner and I have this hacking cough. "

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit following the procedure. The nurse provides instructions to the client regarding the procedure and home care measures. Which of the following statements by the client indicates an understanding of the instructions? "I need to adhere to my dietary restrictions." "I am so relieved that my heart is repaired." "I am so relieved that I can eat anything that I want to now." "I need to cut down on cigarette smoking."

"I need to adhere to my dietary restrictions."

A nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further reinforcement of information if the client makes which of the following statements? "I should cough into tissues and throw them away carefully." "It's very important to wash my hands after I touch my mask, tissues, or body fluids." "It's important to cover my mouth if I laugh, sneeze, or cough." "I should have food placed on disposable plates, forks, and knives."'

"I should have food placed on disposable plates, forks, and knives."' Rationale: Because tuberculosis is transmitted by droplets, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or facemasks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing, and dispose of tissues the carefully.

Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)? "I don't drink alcohol or caffeine." "I eat a banana every morning with breakfast." "I try to eat a well-balanced, low-fat diet." "I try to eat more green leafy vegetables, especially broccoli, spinach, and kale."

"I try to eat more green leafy vegetables, especially broccoli, spinach, and kale." Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.

A client is seen in the health care clinic and a diagnosis of acute sinusitis is made. The nurse reinforces home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further education? "I will need surgery to drain the sinuses." "I should try to sleep with the head of the bed elevated." "I should apply heat such as a wet pack over the sinuses." "I should drink large amounts of fluids."

"I will need surgery to drain the sinuses." Rationale: The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of hot wet packs over the affected sinuses to promote comfort and help resolve the infection. Large amounts of fluids are important to help liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. Surgery may be performed to improve drainage in chronic conditions if other measures are not helpful.

A patient has nephrotic syndrome. Which of these statements made by the patient indicates that she understands the dietary modifications? "Carbohydrate restriction will be difficult." "I will need to drink more milk to get my calcium." "I will need to increase protein and decrease sodium intake." "Potassium restriction won't be hard since I don't like fruit."

"I will need to increase protein and decrease sodium intake."

Which response would the nurse give to a client who asks what does a positive PPD test and a negative chest x-ray mean, in relation to his or her tuberculosis (TB) exposure? 1 "I will teach you how to monitor for signs and symptoms of developing TB." 2 "You will require two chest x-rays per year to rule out active TB." 3 "I need to perform a repeat PPD test." 4 "You will need to stop working for 6 months of therapy."

"I will teach you how to monitor for signs and symptoms of developing TB." A client with TB without signs or symptoms of the disease is unlikely to have active TB. The client does have a latent infection of TB, and the disease can develop if he or she becomes immunocompromised. Therefore, the client needs to be taught about the signs and symptoms of the disease. The signs and symptoms are productive cough for 3 or more weeks, unintentional weight loss, and weakness. A repeat chest x-ray is only needed if the client develops signs or symptoms of active TB. A repeat PPD test is unnecessary. This test has already demonstrated client exposure. A negative chest x-ray indicates that the client does not have active disease and is not infectious. Therefore, the client can continue to work.

A female client is scheduled to have a chest x-ray. Which question is most important to ask the client during data collection? "Can you hold your breath easily?" "Are you able to hold your arms above your head?" "Is there any possibility that you could be pregnant?" "Are you wearing any metal chains or jewelry?"

"Is there any possibility that you could be pregnant?"

Which statement regarding rheumatoid arthritis (RA) is true? 1 "It is a systemic condition." 2 "It affects only the hips and hands." 3 "It involves bone spur formation." 4 "It affects males and females equally.

"It is a systemic condition." RA is a systemic condition that involves inflammation of synovial membranes and destruction of bones, ligaments, tendons, cartilage, and joint capsules. RA affects a number of joints, including the wrists, knees, and knuckles. Osteoarthritis involves bone spur formation. Females are more likely to be affected by RA than are males, at a ratio of 3:1.

A client schedules an appointment for managing his laryngitis. Until the client can be examined later that morning, what nursing advice would be most helpful? "Sucking ice chips should help" "Rest your voice" "Drink plenty of hot liquids" "Rub mentholatum on your throat"

"Rest your voice"

A patient who has just begun taking an angiotensin converting enzyme (ACE) inhibitor calls the nurse and reports feeling very dizzy when standing up and asks if the medication should be discontinued. What is the nurse's best response? "Stop taking the medication immediately." "Rise to a sitting or standing position slowly; your symptoms will resolve." "Cut the pill in half and take a reduced dosage." "I will schedule you to visit the healthcare provider today."

"Rise to a sitting or standing position slowly; your symptoms will resolve." Dizziness is a common initial adverse effect of this medication, which is usually transient. The patient should be instructed to rise from a lying position slowly to avoid orthostatic hypotension and avoid falling. Medications should not be stopped immediately unless a serious adverse effect occurs. Because this is a common occurrence with ACE inhibitors, there is no need for a visit to the healthcare provider. A change in dosage will not alter the effect and should not be made without the advice of the primary care provider.

Which response by the nurse is appropriate for a client with emphysema who is questioning why he or she has a barrel chest? 1 "The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size." 2 "This is caused by large amounts of mucus in your lungs from inflammation." 3 "Your airways are narrowed in response to stimuli in your environment." 4 "The left side of your heart is weak and is causing fluid in your lungs."

"The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size." Emphysema is a form of chronic obstructive pulmonary disease (COPD). It causes a decrease in lung elasticity due to chronic irritation primarily from smoking. The loss of elasticity leads to overstretching of the alveoli and hyperinflation of the lungs. Chronic bronchitis also is a form of COPD. It causes large amounts of thick mucus to form from chronic inflammation primarily due to smoking. Hyperresponsiveness to environmental stimuli and the resultant bronchospasm and edema are related to asthma. Right-sided heart failure can result from COPD but is not the cause of the barrel chest. Left-sided heart failure causes pulmonary edema but is not the cause of the barrel chest.

A nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following statements should the nurse make to the mother? "The fluid retention should be controlled by medication and diet." "The child will always have this appearance, and preparing the child for the body image change is important." "Children always look a little bit fat, so don't be concerned." "Dress the child in loose-fitting clothing to hide the extra weight."

"The fluid retention should be controlled by medication and diet." Rationale: Most children experience remission with treatment and corticosteroids. Diuretics may also be a component of the treatment plan, and a restricted sodium diet is recommended. It is important to give the parent information in a matter-of-fact manner and address the issue that is the parent's concern. Options 1, 2, and 4 are inaccurate and inappropriate statements to the mother.

A client with chronic renal failure asks the nurse why he is anemic. Which of the following responses by the nurse is best? "We will need to review your dietary intake of iron-rich foods" "The increased metabolic waste products in your body depress the bone marrow" "It is most likely that you have hereditary traits for the development of anemia" "There is a decreased production by the kidneys of the hormone erythropoietin"

"There is a decreased production by the kidneys of the hormone erythropoietin"

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response? "Oh don't worry, the weather is supposed to be sunny and clear today." "I know about your concerns. Your family can stay with you every night if you want to." "Yes the equipment is a little scary. Can we talk about how the cardiac monitor works?" "Would you like a mild sedative to help you relax?"

"Yes the equipment is a little scary. Can we talk about how the cardiac monitor works?"

A client who has undergone femoral-popliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." The appropriate nursing response is which of the following? "There are many people with the same problem, and they are doing just fine." "You have the best physician in the city, and the physician will not let anything happen to you." "You are concerned about losing your leg?" "There is nothing to worry about."

"You are concerned about losing your leg?" Rationale: The appropriate response is the one that uses the therapeutic technique of restatement.

The client is to receive Lopressor (metoprolol tartrate) 0.05 grams po every day. Each scored tablet contains 50 mg. How many tablets would the client receive? 1 1/2 1/2 1 2

1

A nurse collects a urine specimen for a urinalysis from a client recently diagnosed with a polycystic disease of the kidneys. The nurse documents that the urine is dilute and that the specific gravity of the urine is low. Based on this documentation, which of the following specific gravity results was present? 1.020 1.010 1.000 1.030

1.000 Rationale: Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. Options 2, 3, and 4 indicate a normal range for specific gravity.

A nurse is suctioning a client through a tracheostomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than: 25 seconds 30 seconds 10 seconds 35 seconds

10 seconds

An older client has been treated for dehydration and pneumonia. The nurse evaluates that the client's dehydration has been successfully treated if the blood urea nitrogen (BUN) level drops to: 32 mg/dL 5 mg/dL 19 mg/dL 46 mg/dL

19 mg/dL Rationale: The normal BUN for the older adult is 8 to 21 mg/dL. Thus option 1 is correct. Values such as those in options 3 and 4 are high and reflect continued dehydration. Option 2 reflects a lower than normal value, which can occur with fluid overload.

The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between: 3 and 4. 2 and 3. 4 and 5. 1 and 2.

2 and 3. The desired INR for the monitoring of anticoagulant therapy is between 2 and 3.

The nurse needs to obtain a sterile urine specimen for culture and sensitivity from a client with an indwelling urinary catheter. Choose all of the following that would apply to this situation. 1. Disconnect the catheter from the drainage tubing and let the urine drip into the sterile bottle 2. Use a needle and syringe to withdraw urine from the tubing port 3. Inject the specimen from the syringe into the sterile bottle 4. Place a towel under the bag, and open the drainage valve at the bottom of the drainage bag 5. Remove the old Foley, then using a straight catheter, recatheterize the patient.

2. Use a needle and syringe to withdraw urine from the tubing port 3. Inject the specimen from the syringe into the sterile bottle

A nurse is planning to reinforce instructions to the client about how to stand on crutches. In the written instructions, the nurse plans to tell the client to place the crutches: 8 inches to the front and side of the client's toes 3 inches to the front and side of the client's toes 15 inches to the front and side of the client's toes 20 inches to the front and side of the client's toes

8 inches to the front and side of the client's toes The classic tripod position is taught to the client before giving instructions on gait. Thecrutches are placed anywhere from 6 to 10 inches in front and to the side of the client,depending on the client's body size. This provides a wide enough base of support to the clientand improves balance.

What is the most common cause of atelectasis? Alveoli distal to the affected bronchiole become overdistended with trapped air and they rupture A bronchiole becomes blocked with secretions and distal alveoli collapses Pressure inside the affected portion of the lung has become less than pressure outside the body Bronchi within the affected portion of the lung become chronically dilated

A bronchiole becomes blocked with secretions and distal alveoli collapses

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin grains 1/150 sublingually. 5 minutes later the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? Wait an additional 15 minutes, then give a second nitroglycerin tablet. Apply 10 L of oxygen via nasal cannula. Call for a 12-lead electrocardiogram (ECG) to be performed. Administer another nitroglycerin tablet.

Administer another nitroglycerin tablet.

What will the nurse advise the patient to do to avoid the development of tolerance to nitroglycerin? Store the drug in a dark container, free from light and moisture. Administer subsequent doses parenterally. Use the sublingual form only. Allow for a daily 8- to 12-hour nitrate free period.

Allow for a daily 8- to 12-hour nitrate free period. An 8- to 12-hour nitrate free period will eliminate the development of tolerance to nitroglycerin. Route of administration and medication storage methods do not affect tolerance.

The end structures of the bronchial tree are saclike structures that resemble a bunch of grapes wherein gas exchange takes place. Trachea Bronchioles Pharynx Alveoli

Alveoli

This is a chronic progressive rheumatic disorder that affects primarily the spine, resulting in the spine fusing and fixation of the joint: Gouty arthritis Ankylosing spondylitis Rheumatoid arthritis Osteoarthritis

Ankylosing spondylitis AKS is a chronic, progressive disorder of the sacroiliac and hip joints, the synovial joints of the spine, and the adjacent soft tissues

Patients with Fibromyalgia syndrome can benefit pharmacologically from: Antidepressants Antipsychotic medication Allopurinol Beta blockers

Antidepressants Antidepressants can help with pain and neuropathy

The amount of water that is eliminated with the urine is regulated by a complex mechanism within the nephron and influenced by a hormone from the posterior pituitary gland called Antidiuretic hormone (ADH) ACTH. Renin hormone. Pitocin.

Antidiuretic hormone (ADH)

Which student action requires intervention by the educator when tracheal suctioning is performed? 1 Maintains a sterile field 2 Applies suction during insertion of the catheter 3 Preoxygenates with 100% oxygen for 1 minute 4 Tests suction pressure at 100 mm Hg before inserting catheter

Applies suction during insertion of the catheter Suction should be applied during withdrawal, not insertion, of the catheter. A sterile field is required for tracheal suctioning, but not oral suctioning. Preoxygenation will be completed for 30 seconds to 3 minutes. Pressure must be tested before suctioning and be within the range of 80 to 120 mm Hg.

When the client with glomerulonephritis reports having a headache that is rated a 7 on a scale of 0 to 10, what nursing action should be performed next? Assess the client's blood pressure Change the client's position Administer the prescribed analgesic Reduce the environmental stimuli

Assess the client's blood pressure

What does a nurse teach an adult male who has had a tonsillectomy? Do not eat or drink anything for the first 48 hours. Avoid coughing vigorously and clearing the throat during the first week postoperatively. Apply a heating pad to the neck during the first 24 hours. Eat solid foods during the first 24 hours.

Avoid coughing vigorously and clearing the throat during the first week postoperatively. The nurse should teach the patient to avoid attempting to clear the throat immediately after surgery and to avoid coughing, sneezing, or vigorous nose blowing for 1 to 2 weeks. Maintain IV fluids until the nausea subsides, at which time the patient may begin drinking ice-cold clear liquids. The diet is advanced to custard and ice cream and then to a normal diet as soon as possible. Apply an ice collar to the neck for comfort and to reduce bleeding by vasoconstriction.

A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse instructs the client to: Drink warm hot chocolate in place of coffee. Drink only warm tea throughout the day. Restrict fluid intake to 1000 mL daily. Avoid foods that are citrus, spicy and highly seasoned.

Avoid foods that are citrus, spicy and highly seasoned.

There are two divisions of the skeleton and these are: Arial and Appendicular Axial and Arial Arial and Appendage Axial and Appendicular

Axial and Appendicular

Which indicator would the nurse expect in a client with end-stage renal disease? Select all that apply. One, some, or all responses may be correct. 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypertension 5 Polycythemia

Azotemia Hypertension Azotemia is an increase in nitrogenous waste in the blood and is common in end-stage renal disease. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the rennin-angiotensin-aldosterone system. Excessive nephron damage in end-stage renal disease causes oliguria not polyuria. Excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not end-stage renal disease. Anemia (not polycythemia) occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.

A nurse is planning a dietary menu for a client with congestive heart failure (CHF) being treated with digoxin (Lanoxin) and furosemide (Lasix). Which of the following would be the best dinner choice from the daily menu? Baked pollack, mashed potatoes, and carrot-raisin salad Beef vegetable soup, macaroni and cheese, and a dinner roll Beef ravioli, spinach souffle and Italian bread Roasted chicken breast, brown rice, and stewed tomatoes

Baked pollack, mashed potatoes, and carrot-raisin salad

The physician tells the nurse that a patient is hypokalemic. He has been taking a thiazide medication for treatment of his high blood pressure. The nurse should instruct him to increase his dietary intake of which of the following? Bananas and citrus fruits Green leafy vegetables Sodium Low-fat products

Bananas and citrus fruits Thiazide may lead to significant loss of potassium. The patient should take the medication with a full glass of orange juice (unless not permitted by his or her diet). Other potassium-rich foods include bananas.

Which nursing intervention reduces myocardial oxygen demand? Being calm, quiet and rested and elevating the head of the bed 30 to 45 degrees Supplying a portable oxygen unit during strenuous activity Encouraging participation in cardiac workout like aerobics Positioning patient in supine position

Being calm, quiet and rested and elevating the head of the bed 30 to 45 degrees Bed rest and semi-Fowler's position reduce myocardial oxygen demands.

While backpacking with a youth group, a 17-year-old falls and sustains an injury to the lower leg. A nurse who is accompanying the group suspects a fracture of the tibia. How should the nurse apply a splint to immobilize the suspected fracture? Below the knee to above the hip Above the ankle to below the knee Below the ankle to above the knee Above the knee to below the hip

Below the knee to above the hip Fracture causes instability in a bone that ordinarily is continuous between its proximal and distal attachments. To limit further injury, joints above and below the injured bone must be stabilized.

A client with myocardial infarction and suspected blood clot on the leg is a candidate for alteplase (Activase) thrombolytic therapy. The nurse assisting in the care of this client is aware that it will be necessary to monitor for which frequent adverse effect if the client receives this treatment? Muscle weakness Infection Bleeding Allergic reaction

Bleeding Rationale: Alteplase is a thrombolytic medication, which means that it breaks down or dissolves clots. Because of its action, the principal adverse effect is bleeding. Local or systemic infection could occur with poor aseptic technique during medication administration, but it is rare. Allergic reaction is not a frequent response. Muscle weakness is not an adverse effect of this medication.

Which nursing assessment confirms that the angiotensin II receptor blocker (ARB) that a patient is taking is effective? LDL cholesterol levels have decreased. Blood pressure has decreased. Weight loss of more than 2 lb/wk. Urinary output is decreased

Blood pressure has decreased. The primary therapeutic outcome expected from angiotensin II receptor antagonists is reduction of blood pressure to within a normal range. Angiotensin II receptor antagonists bind angiotensin II receptor sites in the vascular smooth muscle, brain, heart, kidneys, and adrenal gland. The blood pressure-elevating (vasoconstricting) and sodium-retaining effects of angiotensin II are thus blocked. Weight loss, although advisable for treatment of hypertension, is not affected by ARBs. ARBs do not affect cholesterol levels. Urine output is not affected by ARBs.

Of the following laboratory tests, which one is most important for the nurse to monitor when caring of the client with glomerulonephritis? Serum amylase Blood glucose Blood urea nitrogen (BUN) Complete blood count (CBC)

Blood urea nitrogen (BUN) The blood urea nitrogen test (BUN) is primarily used along with creatinine level to evaluate kidney function and to monitor clients with acute or chronic kidney dysfunction or failure. It indicates how effective the glomeruli are removing nitrogen wastes from the blood.

A nurse is caring for a hospitalized client following cystoscopy and is monitoring for signs of complications associated with the procedure. Which of the following, if noted in the first few hours following the procedure, indicates the need to notify the registered nurse? Pink-tinged urine Yellow-colored urine Bloody urine with clots Clear urine

Bloody urine with clots Rationale: The client may have clear, yellow, or pink-tinged urine after cystoscopy. Bloody urine with clots is always an abnormal finding and should be reported immediately.

Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.) Bradycardia Vomiting Visual disturbance Ringing in the ears Headache Hematuria

Bradycardia Vomiting Visual disturbance Hematuria

Calcium is a mineral found in many foods that can slow bone loss during the aging process. The following are high in calcium: Broccoli, yogurt, cheese Oranges, yogurt, potatoes Oranges, bananas, apricots Skim milk, eggs, banana

Broccoli, yogurt, cheese Fresh oranges, bananas, and eggs are not good calcium choices. Broccoli and green vegetables, as well as yogurt, are considered calcium-rich foods.

The bones serves as storage for which two minerals? Magnesium and chloride Calcium and phosphorus Copper and iodine Sodium and potassium

Calcium and phosphorus

A nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VTach) followed by ventricular fibrillation (Vfib) the client suddenly loses conciousness. Which intervention should the nurse do first? Go the nurse's station quickly and call a code Run to get the defibrillator from an adjacent nursing unit Call for help and initiate CPR Start oxygen by cannula at 10L/min and lower the head of the bed

Call for help and initiate CPR

Patients on diuretics who become hypokalemic should make sure they include which foods in their daily diet? Carrots, summer squash, green beans Apples, pineapple, watermelon Winter squash, cauliflower, lettuce Bananas, oranges, cantaloupe

Carrots, summer squash, green beans The use of most diuretics, with the exception of the potassium-sparing diuretics, requires adding daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges, cantaloupe, winter squash).

A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication: May be discontinued independently if symptoms are gone in 3 months Causes red-orange discoloration of sweat, tears, urine, and feces Should be double-dosed if one dose is skipped Should always be taken with food or antacids

Causes red-orange discoloration of sweat, tears, urine, and feces Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses

A patient is taking amiodarone (Cordarone) for hypertrophic cardiomyopathy and begins to complain of dizziness. What will the nurse instruct the patient to do? Increase the dosage per healthcare provider directions. Change positions slowly. Decrease the medication dosage for 1 week, and then resume the original order. Discontinue the medication immediately.

Change positions slowly.

Which interventions are health promotions to prevent pneumonia? (Select all that apply.) Check for placement before administering tube feedings. Allow new stroke patients to feed themselves to encourage self-care. Position patient flat on their back to prevent aspiration. Encourage elder patients to receive influenza and pneumococcal vaccines. Provide for good health habits (nutrition, hygiene, exercise).

Check for placement before administering tube feedings. Encourage elder patients to receive influenza and pneumococcal vaccines. Provide for good health habits (nutrition, hygiene, exercise).

Which action will the nurse include in the plan for care for a client after a bronchoscopy examination? 1 Check for the gag reflex. 2 Send the client for a chest x-ray examination. 3 Assess breathing every 30 minutes. 4 Have the client avoid the Valsalva maneuver

Check for the gag reflex. After bronchoscopy, the nurse will assess for return of the gag reflex before providing anything by mouth. A chest x-ray examination is not needed after bronchoscopy but would be prescribed after diagnostic procedures such as thoracentesis. Breathing should be assessed at least every 15 minutes for 2 hours after bronchoscopy. The Valsalva maneuver is safe to perform after bronchoscopy.

The patient is receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP). He complains of a "spasmlike" pain over his lower abdomen. Which of these actions should the nurse perform first in response to this complaint? Administer the prescribed analgesic. Inform the nurse in charge. Check the catheter and drainage system for obstruction. Decrease the continuous bladder irrigation flow.

Check the catheter and drainage system for obstruction.

Mr. Jelly is undergoing continuous ambulatory peritoneal dialysis (CAPD). The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes that drainage has stopped and only 500ml has drained; the amount of dialysate instilled was 1500 ml. Which of the following interventions would be done first? Instruct the patient to take deep breaths Check the catheter for kinks or obstruction Clamp the catheter and instill more dialysate at the next exchange time Call the physician

Check the catheter for kinks or obstruction

A client with a fractured femur is placed in skeletal traction. The nurse should do which of the following to monitor for nerve injury? Check the pin sites for drainage Check the blood pressure Monitor the client's ability to perform active range-of-motion (ROM) exercises to the affected extremity. Check the neurovascular status of the affected extremity.

Check the neurovascular status of the affected extremity. Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse would assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active ROM exercises with an extremity that is fractured and in traction.

Which action by the nurse is the priority when excessive bubbling is observed in the water-seal chamber of a chest tube? 1 Strip the chest tube catheter. 2 Check the system for air leaks. 3 Decrease the amount of suction pressure. 4 Recognize that the system is functioning correctly.

Check the system for air leaks. Excessive bubbling indicates an air leak, which must be eliminated to permit lung expansion. Striping the chest tube catheter is contraindicated because it can increase the pressure in the pleural space and cause a pneumothorax. Decreased suction pressure results in limiting bubbling in the suction control, not the water-seal chamber. Excessive bubbling in the water-seal chamber is not expected; the system is malfunctioning.

A nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which of the following foods? Cheese Ice cream Garden peas Strawberries

Cheese

What happens when there is a decrease in the oxygen level in the blood? The alveoli diffuse more oxygen into the blood Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates The pituitary stimulates the respiratory system to increase respiratory rate The parietal pleura increases the negative pressure

Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations.

A client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which is the most commonly reported initial symptom? Chest pain that occurs suddenly with dyspnea Sudden chills and fever Hot, flushed feeling Dyspnea noted when deep breaths are taken

Chest pain that occurs suddenly with dyspnea

The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine? Dark amber Hematuria Clear amber with mucus shreds and threads Dark bile-colored

Clear amber with mucus shreds and threads

The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor(s)? Pregnancy Cocaine use Vitamin B1 deficiencies Viral infections

Cocaine use

Which instruction by the nurse is inappropriate for teaching the proper technique for the collection of a sputum specimen? Bring the sputum up from the lungs. Notify the staff as soon as the specimen is collected so it can be sent to the laboratory without delay. Maintain adequate fluid intake. Collect specimens after meals.

Collecting specimens before meals will avoid possible emesis from coughing after eating.

The nurse would determine that tracheal suctioning is needed if which of the following is noted? Arterial oxygen level of 90 mm Hg Respiratory rate of 18 breaths/min, up from 16 breaths/min Two hours elapsed since the last suctioning Congested breath sounds and audible crackles on the lung fields and coughing

Congested breath sounds and audible crackles on the lung fields and coughing Rationale: Suctioning is indicated only when the client has adventitious breath sounds or has accumulation of secretions. It is not performed routinely according to time elapsed since the last suctioning ("two hours elapsed since the last suctioning"). Arterial blood gas results and respiratory rate ("arterial oxygen level of 90 mm Hg" and "respiratory rate of 18 breaths/min, up from 16 breaths/min") are not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.

A female patient diagnosed with osteoarthritis has numerous questions for the nurse about the disorder. In answering her questions, what does the nurse relay regarding osteoarthritis? Usually treated with high-dose steroids A chronic, progressive disorder of the sacroiliac and hip joints most commonly seen in young men Considered to be a consequence of aging (degenerative) A metabolic disease resulting from an accumulation of uric acid in the blood

Considered to be a consequence of aging (degenerative)

A client with acute glomerulonephritis had a urinalysis sent to the laboratory. The report reveals that there is hematuria and proteinuria present in the urine. The nurse interprets that these results are: Inconsistent with glomerulonephritis Indicative of impending renal failure Unclear, and no conclusion can be drawn Consistent with glomerulonephritis

Consistent with glomerulonephritis

What kind of indwelling catheter will help flush urine out for a patient with enlarged prostate gland? Pezzer Coude' Malecot Straight cath

Coude

A nurse is caring for a client who has a chest tube. While collecting data from the client, the nurse notices that the chest tube has accidentally been removed from the client's chest. Which of the following is the first action the nurse should take? Cover the insertion site with petroleum sterile gauze. Check the client's respiratory status. Notify the provider Tape or clamp all connections

Cover the insertion site with petroleum sterile gauze.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/minute. The nurse responds that this would be harmful because it could: Decrease the client's oxygen-based respiratory drive and over-inflate the already inflated alveoli Decrease the client's carbon dioxide-based respiratory drive Be drying to nasal passages Increase the risk of pneumonia from drier air passages

Decrease the client's oxygen-based respiratory drive and over-inflate the already inflated alveoli

A patient, age 34, is diagnosed with infective endocarditis. The nurse identifies the nursing diagnosis of Activity intolerance related to generalized weakness for him. Which intervention does the nurse plan while he is febrile? Activity as tolerated Allowing moderate activity if heart rate is not above 100 Monitoring vital signs during ambulation Decreased activity and rest

Decreased activity and rest During the acute phase, it is essential to maintain the patient on decreased activity and provide a calm, quiet environment.

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which of the following typical characteristics? Brown pigmentation of surrounding skin Accompanied by very slight pain Deep and painful Dark, pink base

Deep and painful Rationale: Arterial leg ulcers tend to be deep and painful. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease. Options 1, 2, and 3 are not characteristics of an arterial leg ulcer.

The patient is on the cardiac monitor undergoing a diagnostic procedure. Suddenly, the health care provider says, "The patient is having ventricular fibrillation!" Which piece of equipment is the most vital? Bag-valve mask Temporary pacemaker Crash cart Defibrillator

Defibrillator

A patient with allergic rhinitis is prescribed an antihistamine. To prevent which of the following conditions should the nurse instruct the patient to suck on a sugarless hard candy? Drowsiness and sedation Dryness of the oral mucosa and the throat Altered sensation of taste Thickening of the bronchial secretion

Dryness of the oral mucosa and the throat

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client? Increased oxygen saturation with exercise Hypocapnia A shortened expiratory phase of respiration Dyspnea on exertion and activity

Dyspnea on exertion and activity

Chronic renal failure (CRF) affects both patients and their families because of the financial predicament and facing the death of a loved one. Which would be an appropriate nursing intervention to address these concerns? Allow family privacy to resolve their issues. Have the physician speak to the family. Refer the family to a support group. Encourage open discussion with social services.

Encourage open discussion with social services. Encourage verbalization of financial concerns and long term care options with representative from social services.  Support groups are not designed to assist with financial concerns.

Which can reduce the risk of skin impairment secondary to urinary incontinence? Frequent offer of toileting and meticulous skin care Limiting the use of medication (diuretics, etc.) Catheterization of the elderly patient Decreasing fluid intake

Frequent offer of toileting and meticulous skin care

Which nursing action would the nurse prioritize before administering digitalis to the client? 1 Administer medication with a full glass of water 2 Inform the client dizziness is common with digitalis 3 Hold digitalis if heart rate is less than 60 beats per minute 4 Do not administer if heart rate is greater than 100 beats per minute

Hold digitalis if heart rate is less than 60 beats per minute The nurse should obtain and record the apical pulse for 1 full minute prior to administering digitalis. Digitalis should be held if the apical pulse is less than 60 beats per minute. Dizziness is not a common adverse reaction the client may experience with digitalis therapy. Administering the medication with a full glass of water is important. However, taking the apical pulse before administration is the priority. Digitalis is a cardiac glycoside intended to slow and strengthen myocardial contraction. If the client's heart rate is greater than 100 beats per minute, the drug would be administered as ordered.

How should the nurse advise a patient with an international normalized ratio (INR) of 5.8? Increase fluid intake to 2000 mL/day. Add more leafy green vegetables to patient diet. Make arrangements to go to the emergency room immediately. Hold the next dose of anticoagulant and notify health care provider immediately.

Hold the next dose of anticoagulant and notify health care provider immediately. The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction.

Diagnosing carpal tunnel syndrome (CTS) includes test like Tinel's and Phalen's maneuver. Phalen's is: Presence of pain in the calf of the affected leg on dorsiflexion of the foot Increased tingling with a gentle tap over the tendon sheath on the ventral surface of the central wrist Stimulating the facial muscles in the cheek region causes twitching or spasm of the facial muscles. Holding the wrists against each other in forced palmar flexion for 1 minutes causes numbness and tingling

Holding the wrists against each other in forced palmar flexion for 1 minutes causes numbness and tingling

Which laboratory result would be of concern to the nurse for a client receiving digoxin therapy for cardiomyopathy? 1 Hypokalemia 2 Hypernatremia 3 Increased hematocrit 4 Increased white blood cell (WBC) count

Hypokalemia If a client has hypokalemia, this increases his or her risk for digoxin toxicity. This occurs through binding Na+, K+, and ATPase. This process enhances the chance for toxicity. Hypernatremia is not related to digoxin therapy. It typically results from dehydration such as in the use of diuretics. An increased hematocrit is not related to digoxin therapy. It indicates dehydration or polycythemia vera (this causes the body to produce too many red blood cells [RBCs]). An increased WBC count typically is related to infection, not digoxin toxicity.

You are caring for a recently admitted patient who has suffered a pelvic fracture. Which of the following is the most serious physical assessment finding for the nurse to report? Hypotension, tachycardia, and hematuria Patient's complaints of pain when being turned in bed Normoactive bowel sounds Headache

Hypotension, tachycardia, and hematuria

A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? Take a set of vital signs Immobilize the leg before moving the client Reassure the client that everything will be fine. Call radiology department

Immobilize the leg before moving the client When a fracture is suspected it is imperative that the area is splilnted before the client is moved. Emergency help should be called if the patient is not hospitalized. Saunders p.856

Which purpose of Buck traction would a nurse recall when caring for a client with an intertrochanteric fracture of the femur who is awaiting surgery? 1 Reduces the fracture 2 Immobilizes the fracture 3 Maintains abduction of the leg 4 Eliminates rotation of the femur

Immobilizes the fracture A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery, and Buck traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment and is not the purpose of Buck traction. External rotation of the femur may still occur with Buck traction.

The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times? Late in the afternoon In the morning At bedtime With any meal

In the morning Diuretics should be scheduled for morning administration to avoid causing the patient nocturia.

A client seeks treatment in the physician's office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this sclerotherapy is done?" In formulating a response, the nurse informs the client that sclerotherapy consists of: Injecting an agent into the vein that causes them to shrink Tying off the vein at the lower end to prevent stasis from occurring Surgical removal of the veins Tying off the vein at the upper end to prevent stasis from occurring

Injecting an agent into the vein that causes them to shrink Answer: A Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries, and then removal of the vein with the use of hook and wires via multiple small incisions in the leg.

When caring for a client who has TB, the nurse is required to wear: a gas mask N-95 mask Hazmat suit surgical mask and gown

N-95 mask

The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful? If there is no blood in his sputum In 8 hours after a period of nothing by mouth When the gag reflex returns In 24 hours, but must take cold liquids for the rest of the day

When the gag reflex returns

As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and creatinine. nitrates. uric acid. nitrogen.

creatinine

Renin is produced in a specialized region/structure of the kidney which greatly affects blood pressure is called the: glomerulus juxtaglomerular apparatus Loop of Henle renal capsule

juxtaglomerular apparatus

Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as urachal-peritoneal. costovertebral. diaphragm-vertebral. retroperitoneal.

retroperitoneal

Nephrotic syndrome is characterized by: edema nocturia proteinuria hyperuricemia hypoalbuminemia

proteinuria

The following constituent of the urinalysis test indicates possible renal disease, muscle exertion, or dehydration positive blood proteinuria positive glucose bacteriuria

proteinuria Protein in the urine usually indicates possible renal disease, muscle exertion, or dehydration. Positive glucose indicates diabetes. Positive bilirubin indicates liver disease with obstruction or damage. Positive bacteria indicates urinary infection.

The circulation of the lungs is through the pulmonary arteries and pulmonary veins. coronary arteries and coronary veins. celiac arteries and celiac veins. carotid arteries and jugular veins.

pulmonary arteries and pulmonary veins.

Restlessness, diaphoresis, severe dyspnea, tachypnea, blood-tinged frothy sputum, audible wheezing, and crackles are signs and symptoms of respiratory failure. pulmonary edema. heart failure. peripheral edema.

pulmonary edema. Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; cold extremities.

A patient, age 69, has emphysema. On assessing him, the nurse notes the presence of a "barrel chest." This pathology results from a(n) increase in the lateromedial area from hypertrophy of mucous glands in the bronchi. decrease in anteroposterior diameter caused by chronic dilation of the bronchi. increased anteroposterior diameter caused by overinflation of the alveoli. widening of the sternocostal area

increased anteroposterior diameter caused by overinflation of the alveoli.

The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having: indigestion. hepatitis A. menopausal complications. urinary infection.

indigestion Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI.

After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of: congestive heart failure. aortic stenosis. heart block. infective endocarditis.

infective endocarditis.

It is 2 days after a difficult patient's urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. The most likely explanation for his behavior is that he has no other responsibilities to keep him occupied. is used to having things done his way. is having problems accepting the urinary diversion. has an obsessive-compulsive disorder.

is having problems accepting the urinary diversion. Patient teaching centers on tasks of lifestyle adaptation: care of the stoma, nutrition, fluid intake, maintaining self-esteem in light of altered body image, modifying sexual activities, and early detection of complications.

The method that employs shock waves to shatter/pulverize kidney stones is: cystoscopy lithotripsy dialysis cystectomy

lithotripsy

A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. An important aspect in nursing interventions of the patient with an ileal conduit is limiting acid-ash foods. instructing the patient to void when with defecation is felt. maintenance of skin integrity. prevention of tissue rejection.

maintenance of skin integrity.

The nurse notes the amount and color of the urine of the patient with urolithiasis (presence of stones). While using standard precautions, the nurse's next action would be to discard the urine. save the urine for physician assessment. add the urine to a 24-hour collector. make sure to strain all urine.

make sure to strain all urine. All urine should be strained. Because stones may be any size, even the smallest speck must be saved for assessment.

The patient/client is to receive Augmentin (amoxicillin/clavulanate potassium) 0.25 g po every 8 hours. The medication Augmentin (amoxicillin/clavulanate potassium) is available as an oral suspension 125 mg per 5 mL. How many teaspoons should the nurse instruct the patient/client to take? 3 1 4 2

2

Tuberculosis (TB) is treated with multiple drugs to which organisms are susceptible. How many drugs are usually preferred to increase the therapeutic effectiveness? Four Three One Two

Four At least four drugs, in combination, are used to prevent the emergence of organisms resistant to the others, thus increasing the therapeutic effectiveness.

Osteoarthritis involves development of nodes to a unilateral side of the body specially the fingers. What is the term use when nodes develop at the distal part of the fingers? Tophi Heberden's Bouchard's Scar tissue

Heberden's

A client with chronic renal failure (CRF) is receiving epoeitin alfa (EPOGEN). The nurse is reviewing the laboratory results and notes that which of the following results indicates a therapeutic effect of the medication? Platelet count 400,000 cells/mm3 Hematocrit level 32% WBC count 6,000/mm3 BUN level 15 mg/dl

Hematocrit level 32%

When a patient on Lasix, a loop diuretic, complains of weakness and irregular pulse, there may be an electrolyte deficiency of magnesium. calcium. potassium. sodium.

potassium. The loop diuretic prototype, furosemide (Lasix), affects electrolytes to cause hypokalemia,the deficiency of the electrolyte can cause arrhythmias and muscle weakness.

When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger: that is a good perfusion and temperature on the same side as the fracture in a sling. while exercising the arm to stimulate circulation. on the same side as the blood pressure cuff.

that is a good perfusion and temperature

Which of the following is a normal constituent of urine? glucose protein red blood cells urea

urea

A patient, age 22, is admitted with acute asthma. It is important to monitor his oxygen saturation levels. The quickest way to assess his saturation of oxygen is to do a pulmonary function test. use pulse oximetry. get arterial blood gases. do a pulse pressure assessment.

use pulse oximetry.

A nurse is performing an admission assessment on a client with a diagnosis of bladder cancer. Which of the following would the nurse most likely expect to note on data collection of this client? Urgency Burning on urination Frequency Hematuria

Hematuria Rationale: Gross, painless hematuria is most frequently the first manifestation of bladder cancer. As the disease progresses the client may experience burning, frequency, and urgency.

Which manifestation is a common early sign of cancer of the urinary system? 1 Dysuria 2 Retention 3 Hesitancy 4 Hematuria

Hematuria Research statistics indicate that hematuria is the most common early sign of cancer of the urinary system. This is probably because of the urinary system's rich vascular network. Dysuria, retention and hesitancy are not specific for bladder cancer and are usually associated with an enlarged prostate in the male.

When teaching the client about topical nasal decongestant sprays with steroid, the nurse should warn that overuse of such medication is likely to result in what adverse effect? Ulceration of the nasal mucous membrane Decreased ability to fight microorganisms Rebound congestion with nasal stuffiness Nasal irritation with rhinorrhea

Rebound congestion with nasal stuffiness

During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure? "I go barefoot most of the time because my feet are so hot." "I have to sleep in my recliner and I have this hacking cough." "I have to urinate every 2 hours, even during the night." "I have no appetite and I have lost 3 lb in the last week."

"I have to sleep in my recliner and I have this hacking cough." Left ventricular failure is often among the first of signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.

A nurse is caring for a client who witness a bombing incident is nervous and hyperventilating. The nurse would monitor the client for signs of which of the following acid-base imbalances? Metabolic alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis

Respiratory alkalosis Rationale: A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called a respiratory alkalosis.

The nurse identifies the nursing diagnosis of Ineffective tissue perfusion related to decreased arterial blood flow for a patient with chronic arterial insufficiency. In evaluating the patient outcomes after patient teaching, which statement by the patient does the nurse recognize as indicating a need for further instruction? "I will change my position every hour and avoid long periods of sitting with my legs crossed." "I will wear loose clothing that doesn't bind across my legs or waist." "For about 40 minutes each day, I will walk to the point of pain, then rest, then walk again once I'm ok until I develop pain again." "I will drink hot coffee several times a day to increase the circulation and warmth in my feet."

"I will drink hot coffee several times a day to increase the circulation and warmth in my feet."

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided? "I will ask the client to brush the teeth and rinse the mouth before expectorating." "I will use a sterile container from the supply area." "I will have the client take a breath and gather his saliva before shallow coughing." "I will send the specimen immediately to the laboratory."

"I will have the client take a breath and gather his saliva before shallow coughing." Rationale: Because of the nature of the test, the sputum must be collected in a sterile (not a clean) container. The client should brush the teeth and rinse the mouth to decrease the number of contaminating organisms. The client should take a few deep breaths, and then cough forcefully (not spit) into the container. The specimen should be sent directly to the laboratory. It should not be allowed to stand for long periods at room temperature to prevent overgrowth of contaminating organisms.

A nurse has given a 77-year-old female client instructions on how to do active range-of-motion (ROM) exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which of the following statements? "It hurts, but things always have to hurt at my age." "I'm doing this so I can go home soon." "If I don't do this, that therapist gets really angry at me." "I'm doing these exercises so I can be more independent and begin to fasten my buttons and dress myself again."

"I'm doing these exercises so I can be more independent and begin to fasten my buttons and dress myself again."

The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse's most helpful response would be: "If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital." "Use oxygen at home to relieve pain when nitroglycerin is not successful." "Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved." "When nitroglycerin is not relieving the pain, lie down and rest."

"If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital."

A patient has sustained a fractured femur in a car accident. The physician has stated concern about the possibility of a fat embolism. The patient's wife asks the nurse about the cause of a fat embolism. The nurse's most appropriate response would be "We don't know the cause. We just know that it sometimes happens." "Floating fat sometimes causes problems." "The break in the bone forces molecules of fat into the bloodstream." "Arterial blood flow is interrupted at the site of injury."

"The break in the bone forces molecules of fat into the bloodstream."

Which client statement indicates an understanding of the nurse's instructions regarding a Holter monitor? 1 "The only times the monitor should be taken off is for showering and sleep." 2 "The monitor will record my activities and symptoms if an abnormal rhythm occurs." 3 "The results from the monitor will be used to determine the size and shape of my heart." 4 "The monitor will record any abnormal heart rhythms while I go about my usual activities."

"The monitor will record any abnormal heart rhythms while I go about my usual activities." The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

A patient with angina pectoris is being discharged with nitroglycerin tablets. Which of the instructions does the nurse include in the teaching? "Continue with your activity. If the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 20 minutes, then go lie down." "When your chest pain begins, lie down and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes." "Place one nitro tablet under your tongue. If a burning sensation and headache occur, call your doctor immediately." "Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital."

"When your chest pain begins, lie down and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes." Sit and stand slowly after taking nitroglycerin. Place nitroglycerin tablets under the tongue at the onset of anginal pain; the second tablet can be taken after 5 minutes and the third tablet after another 5 minutes if pain is unrelieved. Then, if pain is not relieved, go to the hospital.

A client had abdominal aortic aneurysm graft procedure 2 days ago. This morning, the client says, "I don't feel any better than I did before surgery." The appropriate response by the nurse is: "This is a normal frustration; it'll get better." "It's only the second day post-op. Cheer up." "You are concerned that you don't feel any better after surgery." "You will feel better in a week or two."

"You are concerned that you don't feel any better after surgery." Rationale: Paraphrasing is restating the client's message in the nurse's own words. Option 3 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding.

The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into: atrial fibrillation and possible emboli. ventricular tachycardia and death. sinus bradycardia and fatigue. sinus tachycardia and syncope.

ventricular tachycardia and death. PVCs are capable of progressing into ventricular tachycardia and death.

The nurse assessing an 11-year-old who is having an asthma attack heard high-pitched, whistling adventitious sounds of: crackles. friction rub. vesicular wheezes.

wheezes.

Approximately how much volume of urine would stimulate the conscious desire to urinate? 250 ml 750 ml 150 ml 1500 ml

250 ml

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. Allow the wet cast 24-48 hours to dry. The cast needs to be kept clean and dry. Keep the cast and extremity elevated. Use a hair dryer set on a warm to hot setting to dry the cast. Expect tingling and numbness in the extremity.

Allow the wet cast 24-48 hours to dry. The cast needs to be kept clean and dry. Keep the cast and extremity elevated.

A nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. The nurse is aware that this finding: Indicates the need for autotransfusion May represent hemorrhage and requires further assessment and checking the patient's vital signs Is expected following this type of surgery Represents a malfunction of the chest tube drainage system

May represent hemorrhage and requires further assessment and checking the patient's vital signs

Which of the following clients is at greatest risk for developing acute renal failure? A dialysis patient receiving blood transfusion A teenager who has an appendectomy A pregnant woman who has a fractured femur A client with diabetes and who is dehydrated

A client with diabetes and who is dehydrated

Mrs. Prendell has an ileal conduit for the treatment of bladder cancer. Which of the following postoperative assessment findings must be reported to the physician immediately? A dusky-colored stoma Slight bleeding from the stoma Urine output more than 30 ml/hr A red, moist stoma

A dusky-colored stoma

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client? Increased oxygen saturation with exercise Hypocapnia A hyperinflated chest on x-ray A widened diaphragm noted on chest x-ray

A hyperinflated chest on x-ray

An alkaline ash diet is prescribed for the client with renal calculi. Which of the following diet menus does the nurse advise the client to select? Pasta with shrimp, tossed salad, and a plum A spinach salad, milk, and a banana Peanut butter sandwich, milk, and prunes Chicken, rice, and cranberries

A spinach salad, milk, and a banana

A client has just undergone a renal biopsy. In planning care for this client, the nurse would avoid which intervention? Ambulate in the room and hall for short distances. Encourage fluids to at least 3 L in the first 24 hours. Administer opioid analgesics as needed. Test urine for blood hourly.

Ambulate in the room and hall for short distances. Rationale: After renal biopsy, bedrest is maintained for at least 24 hours. The client's vital signs and puncture site are assessed frequently during this time. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce possible clot formation at the biopsy site. Opioid analgesics often are needed to manage the renal colic pain that some clients feel after this procedure.

A tuberculin test (Mantoux test) is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse evaluates the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which of the following findings did the nurse note to make this interpretation? An area of induration at the test site measuring 7 mm Redness and swelling at the test site with an induration measuring 3 mm An area of induration at the test site measuring 2 mm Redness and swelling at the test site without induration

An area of induration at the test site measuring 7 mm Rationale: Normally, an area of induration greater than 15 mm is considered positive in low-risk individuals. However, an area of induration that measures 5 mm or greater in people with HIV infection is considered positive. Redness and swelling do not indicate a positive test result.

_____________ is a term for severe generalized edema. Anasarca Cirrhosis Ascites Presbycussis

Anasarca

_____________ is a term for severe generalized edema. Presbycussis Ascites Cirrhosis Anasarca

Anasarca The patient with nephritic syndrome has severe generalized edema (anasarca), anorexia, fatigue, and impaired renal function.

A client who has chronic glomerunephritis has deteriorated to the early stages of renal failure. When receiving shift report from the nurse, what information correlates with renal failure? Weight loss Hypotension Fever Anemia

Anemia

Mr. Crickett has long-standing hypertension and diabetes mellitus. He is admitted withBP 90/60, P 100, T 98°F, and dyspnea. Physical assessment includes 4+ pitting edema of bilateral lower extremities and ascites. His lab values include a low albumin level and proteinuria. His urine output averages at 40 ml per hour. Which diagnosis applies? Nephrotic syndrome Pyelonephritis Urolithiasis Polycystic Kidney Disease

Nephrotic syndrome

A patient has undergone a bipolar hip repair (hemiarthroplasty). She should be instructed to avoid crossing her legs. begin full weight-bearing as soon as able and tolerated. sit in whatever position is most comfortable. sit in a firm, straight-backed chair at a 120-degree angle.

avoid crossing her legs. Instructing the patient not to cross the legs is important because crossing the legs can adduct the affected extremity and dislocate the hip.

A patient, age 44, has chronic osteomyelitis. He should be taught to: increase dietary intake of calcium and vitamin D. decrease activity levels. avoid trauma to the affected bone. take antibiotics prophylactically.

avoid trauma to the affected bone. The patient must avoid trauma to the affected bone because pathological fracture is common.

The nurse has reinforced instructions with a patient with pleural effusion about strategies to promote comfort during recuperation. The nurse evaluates that the patient has understood the instructions if the patient states that he or she will do which of the following? Splint the chest wall during coughing and deep breathing Try to take only small, shallow breaths Take as much pain medication as possible Lie as much as possible on the unaffected side

Splint the chest wall during coughing and deep breathing

A client has an inoperable abdominal aortic aneurysm (AAA). The nurse reinforces with the client about the need for: Bedrest Maintaining a low-fiber diet Antihypertensives Restricting fluids

Antihypertensives Answer: A Rationale: The medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to have bed rest prescribed. A low-fiber diet is not helpful and will cause constipation.

A patient comes into the clinic complaining of a nonproductive cough and muscle aches that she has had for 5 days. She has no sore throat, temperature elevation, or swollen lymph nodes. She is coughing so much that she is unable to sleep at night. The physician might order which of the following? Antitussive Antibiotic Expectorant Decongestant

Antitussive

A nurse is required to care for a 34 y/o, who is being given digoxin. Which of the following pulse rates indicates that the nurse should withold the drug and alert the primary health care provider? Apical rate less than 60 beats per minute Radial pulse rate more than 100 beats per minute Radial pulse rate less than 90 beats per minute Apical rate less than 70 beats per minute

Apical rate less than 60 beats per minute

A nurse is assigned an adult client who needs oropharyngeal suctioning. Which of the following actions should the nurse take? Apply suction only after the catheter is being withdrawn from the oropharyngeal site Insert catheter in line with the center of the tongue Perform continuous suction for 25 to 35 seconds Set wall suction between 120 to 150 mmHg

Apply suction only after the catheter is being withdrawn from the oropharyngeal site

A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. The nursing instructor intervenes if the student performed which incorrect action? Using sterile technique to perform the procedure Applying suction during withdrawal of the catheter Hyperventilating the client with 100% oxygen before suctioning Applying suction during insertion of the catheter

Applying suction during insertion of the catheter

A nurse has an order to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique while completing this procedure? Discard a urine specimen collected at the start time. Place the specimen on ice. Ask the client to void, save the specimen, and document the start time. Ask the client to save urine voided at the end of the collection time.

Ask the client to void, save the specimen, and document the start time. Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder. Therefore, the first urine is discarded. Fifteen minutes prior to the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine collection should be refrigerated or placed on ice to prevent changes in urine.

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client? Pushing down on the mattress of the bed while administering care Having another nurse tilt the client to the side Asking the client pull up on a trapeze to lift the hips off the bed Asking the client to lift up by digging into the mattress with the unaffected leg

Asking the client pull up on a trapeze to lift the hips off the bed If the client in skeletal traction may not turn from side to side, the nurse should have the clientpull up on a trapeze and try to lift the hips off the bed for skin care, bed pan use, and linenchanges. If the client is unable to pull up on a trapeze, the nurse can push down on themattress with one hand while administering care with the other.

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? Midsternum equal with the nipple line At the midclavicular line at the fifth left intercostal space At the midline of the chest just below the xiphoid process At the midaxillary line on the left side of the chest

At the midclavicular line at the fifth left intercostal space Rationale:The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

Which patient teaching would help to prevent venous stasis? (Select all that apply.) Massage extremities to help maintain blood flow. Avoid crossing the legs at the knee. Dangle legs when sitting. Elevate legs when lying in bed or sitting. Wear elastic stockings when ambulating.

Avoid crossing the legs at the knee. Elevate legs when lying in bed or sitting. Wear elastic stockings when ambulating.

A nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which of the following food items from the dietary menu? Spaghetti and sweet sausage in tomato sauce, vanilla pudding with 2% milk Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet Pork chop, baked potato, cauliflower in cheese sauce, ice cream Baked salmon, steamed broccoli, herbed rice, sliced strawberries

Baked salmon, steamed broccoli, herbed rice, sliced strawberries Rationale: A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 2 is the only option that identifies low-fat and low-cholesterol foods.

A client has a history of left-sided heart failure. The nurse would look for the presence of which of the following to determine whether the problem is currently active? Bilateral lung crackles Presence of ascites Pedal edema bilaterally Jugular vein distention

Bilateral lung crackles Rationale: The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Breath sounds are an accurate indicator of left-sided heart function. Peripheral edema, jugular vein distention, and ascites all can be present due to insufficiency of the pumping action of the right side of the heart.

What is the purpose of the cilia? Stimulate cough reflex Warm and cools inhaled air Sweep debris toward nasal cavity Produce mucus

Sweep debris toward nasal cavity The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves.

Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? Fruits and fruit juices Beef, pork, chicken Brain, liver, kidney Lettuce, corn, potatoes

Brain, liver, kidney Gout is a metabolic disease resulting from an accumulation of uric acid in the blood caused by an ineffective metabolism of purines

The nurse is providing instruction to a patient who was recently prescribed an ACE inhibitor for hypertension. Which is an adverse effect of this medication? Chronic cough Nervousness Hypokalemia Constipation

Chronic cough Chronic cough may develop in as many as one-third of patients receiving ACE inhibitors. Constipation, hypokalemia, and nervousness are not adverse effects of this medication.

A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-pound weight loss during the last 3 months. The physician suspects renal cancer. In obtaining a nursing history from this patient, the nurse recognizes which factor as a significant risk factor for renal cancer? Chronic cystitis High caffeine intake Use of artificial sweeteners Cigarette smoking

Cigarette smoking Risk factors include smoking; familial incidence; and preexisting renal disorders such as adult polycystic kidney disease and renal cystic disease secondary to renal failure.

Which characteristic would the nurse assess for in each specimen of urine for in a client with a urinary tract infection? 1 Clarity 2 Viscosity 3 Glucose level 4 Specific gravity

Clarity Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Viscosity is a characteristic that is not measurable. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.

A female client has an order for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse would give which instruction so that the specimen is collected properly? Wipe the labia front to back with toilet paper and void into the sterile specimen container. Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen. Cleanse the labia using cleansing towels, position the container, and begin to void. Void into the container, saving the full amount of urine.

Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen. Rationale: The client should cleanse the labia, begin to void, and then "catch" the sample midstream. Proper cleansing and voiding techniques are necessary so that the specimen does not become contaminated from external sources. The use of toilet paper (option 4) contaminates the specimen because of improper cleansing. The method described in option 1 is not midstream.

Which goal of therapy would the nurse anticipate when administering allopurinol to a client with gout? 1 Increase bone density 2 Decrease synovial swelling 3 Decrease uric acid production 4 Prevent crystallization of uric acid

Decrease uric acid production Allopurinol interferes with the final steps in uric acid formation by inhibiting the production of xanthine oxidase. This drug prevents the formation of uric acid and does not affect bone density. Allopurinol has no effect on the swelling of the synovial membranes. This medication prevents the synthesis of uric acid, not its crystallization.

Which goal is the priority for a client with asthma who is being discharged from the hospital? 1 Is able to obtain pulse oximeter readings 2 Demonstrates use of a metered-dose inhaler 3 Knows the health care provider's office hours 4 Can identify the foods that may cause wheezing

Demonstrates use of a metered-dose inhaler Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have before discharge. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Not all asthma is associated with food allergies.

In preparing your client for an intravenous pyelogram (IVP), it is important to implement which of the following? Provide client teaching about radiation problems Determine any history of allergies especially to iodine or shellfish Encourage the client to eat a full meal Explain to the client that he will be given an oral preparation of a radiopaque dye

Determine any history of allergies specially to iodine or shellfish Asking for allergies is a good way to determine if the patient have allergies and appropriate safety measures are in place.

A nurse is reviewing the medical record of a client with a diagnosis of renal failure. Which disorder, if noted on the client's record, would the nurse identify as a risk factor or common cause for this disorder? Hypoglycemia Orthostatic hypotension Diabetes mellitus Coronary artery disease

Diabetes mellitus Risk factors associated with renal failure include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization and infection.

A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? Digoxin Warfarin Amiodarone Potassium chloride

Digoxin Rationale:Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.

Which drug will be administered to a patient being admitted with severe digoxin intoxication? Spironolactone (Aldactone) Digitalis glycoside Amiodarone (Cordarone) Digoxin immune Fab (Digibind)

Digoxin immune Fab (Digibind) The antidote for digoxin intoxication is digoxin immune Fab (Digibind). Amiodarone is an antidysrhythmic and would not treat digoxin intoxication. Spironolactone is a diuretic and does not treat digoxin intoxication. Giving more of the same type of drug does not treat drug intoxication.

What is the rationale for administering fibrinolytic agents, such as streptokinase, within hours of the onset of myocardial infarction? Dissolves/Lyses the blood clot. Enhances myocardial oxygenation. Inhibits clotting mechanisms. Promotes platelet aggregation.

Dissolves/Lyses the blood clot.

Which responses would the nurse expect a client to exhibit when a therapeutic effect of digoxin is achieved? 1 Diuresis and decreased pulse rate 2 Increased blood pressure and weight loss 3 Regular pulse rhythm and stable fluid balance 4 Corrected heart murmur and decreased pulse pressure

Diuresis and decreased pulse rate Digoxin slows the heart rate, which is reflected in a slowing of the pulse; it also increases kidney perfusion, which promotes urine formation, resulting in diuresis and decreased edema. Digoxin would decrease, not increase, the blood pressure; digoxin does promote weight loss through diuresis. Although digoxin produces diuresis as a result of improved cardiac output, which increases fluid output, it would not regulate an irregular pulse. Digoxin would not correct a heart murmur or decrease pulse pressure.

Edema and pulmonary congestion are treated with: Diuretics, restriction of sodium diet and fluid intake Increase in fluids, no activity restrictions Bed rest, normal diet, weights four times daily Unlimited activity, high protein diet, weights weekly

Diuretics, restriction of sodium diet and fluid intake Edema and pulmonary congestion are treated with diuretics, a sodium-restricted diet, and restriction of fluid intake. Weigh the patient daily to monitor fluid retention.

A patient receives a prescription for anticoagulant medication for treatment of arterial emboli. What dietary information should the nurse give? Eat fruits such as citrus and bananas that provide potassium Do not increase intake of dark-green vegetables because of vitamin K Avoid eating saturated fats by limiting use of butter, oils, and red meats. Take extra dairy products to ensure calcium intake and vitamin D

Do not increase intake of dark-green vegetables because of vitamin K

A nurse is assisting in monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room following a thoracotomy with wedge resection. Select the expected findings (Select all that apply). Drainage system is maintained below the client's chest Excessive bubbling in the water seal chamber 50 mL of drainage in the drainage collection chamber Occlusive dressing is in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Vigorous bubbling in the suction control chamber

Drainage system is maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing is in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

In the clients suspected of having benign prostatic hypertrophy (BPH), the most frequent signs observed are: Flank pain, chills Dysuria, nocturia Hematuria, groin discomfort Bladder stones, malaise

Dysuria, nocturia

A nurse is reviewing the client's record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse would most likely expect to note which of the following? Decreased hemoglobin level Elevated blood urea nitrogen (BUN) and creatinine level Decreased white blood cell (WBC) count Decreased red blood cell (RBC) count

Elevated blood urea nitrogen (BUN) and creatinine level Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin and RBC count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease.

A 56-year-old patient was admitted to the emergency department with a myocardial infarction. Cardiac enzymes were drawn. In a patient with a myocardial infarction, which laboratory values would be abnormal? Elevated levels creatine phosphokinase (CK-MB), lactic dehydrogenase (LDH), myoglobin and troponin 1 Elevated levels of ESR, decreased levels of CK, LDH, and troponin 1 Decreased levels of CK-MB, LDH, and troponin 1 Decreased levels of levels of CK, LDH, myoglobin and increased troponin 1

Elevated levels creatine phosphokinase (CK-MB), lactic dehydrogenase (LDH), myoglobin and troponin 1

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1 Apply a thoracic binder for support. 2 Encourage coughing and deep breathing. 3 Defer pain medication the first day after injury. 4 Position the client face down on a soft mattress.

Encourage coughing and deep breathing. Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and help motivate the client to cough and deep breathe. The prone position may diminish breathing for both lungs and is contraindicated.

Which nursing intervention does the nurse add to the care plan to help a patient with thick sputum mobilize and expectorate those secretions? Inhale cool mist from a vaporizer for 24 hours. Drink salty fluids such as broth and bouillon. Encourage drinking about 3 to 4 L of water a day. Sit in a tub of hot water three times a day.

Encourage drinking about 3 to 4 L of water a day. Encourage fluids to liquefy secretions and aid in their expectoration.

Which action will the nurse implement to decrease the risk of clot formation in an older patient on bed rest? Encourage passive leg exercises and turning. Assess peripheral pulses. Position pillows behind the knees. Limit fluid intake.

Encourage passive leg exercises and turning. Using active or passive leg exercises for a patient on bed rest will prevent clot formation. Assessing pulses is not a preventive measure. Adequate hydration promotes fluidity of the blood and decreases the risk of clot formation. Placing pressure against the popliteal space will increase the risk of clot formation.

A patient recently prescribed felodipine (Plendil) for treatment of hypertension is experiencing dizziness when rising to a standing position. Which action will the nurse take? Inform the patient to discontinue the medication. Encourage the patient to sit down if feeling faint. Instruct the patient to monitor weight daily. Advise the patient to increase dietary sodium.

Encourage the patient to sit down if feeling faint.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid doing which of the following? Keeping the head of the bed elevated Encouraging the client to breathe fast and shallowly Monitoring the flow rate of supplemental oxygen Assisting the client to turn, cough, and deep breathe

Encouraging the client to breathe fast and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels due to insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse would take which of the following priority precautions, knowing that bleeding is a potential complication? Observe the site once per shift. Ensure that small clamps are attached to the AV shunt dressing. Check the results of blood tests as they are ordered. Check the shunt for the presence of a bruit and thrill.

Ensure that small clamps are attached to the AV shunt dressing. Rationale: An AV shunt is a cannula with two ends that are tunneled subcutaneously into an artery and a vein. An AV shunt is a less common form of access site but carries a risk for bleeding when it is used. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site should also be observed at least every 4 hours. Once per shift is insufficient. Checking for blood results, bruit, and thrill all apply to the care of this client but do not focus on bleeding

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs or symptoms? Fever and sore throat Vaginal itching Burning on urination Skin scratches

Fever and sore throat Rationale: Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on doing which of the following while caring for the client? Provide for diversion such as television or newspaper. Perform pin site care. Explain to the client the upcoming pin care procedure. Ensure that the weights on the traction setup are hanging free.

Ensure that the weights on the traction setup are hanging free. Rationale: When a client has skeletal traction, the priority is to assess the traction setup. The nurse must ensure that the weights on the traction setup are hanging free. If the weights are resting on or against any support, the purpose of the traction is defeated. Options 1, 2, and 4 are a component of care; however, option 3 is the priority.

Which preoperative teaching is most important for the nurse to include when completing laryngectomy education? 1 Establishing a means for communicating postoperatively 2 Explaining that there will be a feeding tube postoperatively 3 Demonstrating how to care for a permanent laryngeal stoma 4 Teaching how to cough to expectorate bronchial secretions effectively

Establishing a means for communicating postoperatively Communication is a priority; it facilitates interaction, limits anxiety, and promotes safety. A nasogastric tube can cause trauma to the suture lines; total parenteral nutrition may be used. Demonstrating how to care for a permanent laryngeal stoma is done postoperatively as the client begins to accept the laryngectomy. After a laryngectomy the client cannot cough; expectoration occurs through the stoma.

Which response would the nurse expect when caring for a client receiving furosemide (Lasix) to relieve edema? 1 Retention of sodium ions 2 Negative nitrogen balance 3 Excessive loss of potassium ions 4 Increase in the urine specific gravity

Excessive loss of potassium ions Furosemide is a potent diuretic used to provide rapid diuresis. It acts in the loop of Henle and causes depletion of electrolytes such as potassium and sodium. Furosemide inhibits the reabsorption of sodium. Furosemide does not affect protein metabolism. The specific gravity of the fluid more likely will be low with edema.

A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to: Provide for decreased oxygen tension in the alveoli. Dilate the terminal bronchioles. Expel and clear mucus from the airways. Exercise the muscles of respiration.

Expel and clear mucus from the airways. Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client.

A nurse reads a client's Mantoux skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that the client has: Systemic tuberculosis Pulmonary tuberculosis No evidence of tuberculosis Exposure to tuberculosis

Exposure to tuberculosis Rationale: A client who tests positive on a Mantoux skin test has either been exposed to tuberculosis or has inactive (dormant) tuberculosis. The client must then be tested by chest x-ray and sputum culture to confirm the diagnosis.

A nurse is providing instructions to the client regarding the complications of peritoneal dialysis. The nurse instructs the client which manifestation is most likely associated with the onset of peritonitis? Fatigue Clear dialysate output Leaking around site Fever

Fever Rationale: The signs of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. Leaking around the catheter site is not an indication of peritonitis. Fatigue may be associated with peritonitis, but fever is the most likely sign.

A client seeks treatment in the emergency room for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a: Sprain Strain Fracture Contusion

Fracture Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use

A patient with hypertension for 10 years has been told by his health care provider that he has developed nephrotic syndrome, causing generalized edema. Which of the following diuretics will work in the treatment of his condition? Polythiazide, a thiazide diuretic Spironolactone, a potassium-sparing diuretic Furosemide, a loop diuretic Metolazone, a sulfonamide diuretic

Furosemide, a loop diuretic Loop diuretics work well on patients with very low glomerular filtration rates, because they are so efficient in limiting the reabsorption of sodium. They are often used for patients with kidney disease and to treat chronic heart failure, cirrhosis of the liver, and nephrotic syndrome of kidney disease in which a powerful diuretic is required.

A client with heart disease who is taking digoxin (Lanoxin) complains of having no appetite, nauseous. The nurse notes that the client also has a low serum potassium (K+) level. The nurse checks the results of the digoxin level obtained this morning, anticipating that the level is likely to be: Within therapeutic range High Low Uncertain

High Rationale: A high digoxin level would indicate digoxin toxicity, which is compatible with the client's complaint of anorexia and the low serum K+ level (which can precipitate digoxin toxicity). After drawing this initial conclusion, the next step would be for the nurse to notify the registered nurse or another health care provider for further action.

A nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for a renal biopsy, when other tests such as computerized tomography (CT) and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that a renal biopsy: Gives specific cytological information, malignancy determination about the lesion Provides an outline of the renal vascular system Determines if the mass is growing rapidly or slowly Helps differentiate between a solid mass and a fluid-filled cyst

Gives specific cytological information, malignancy determination about the lesion Rationale: Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. The nurse interprets that the boot: Has not yet dried Has been applied too tightly Is improving venous return Is controlling leg edema

Has been applied too tightly Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation to the foot and teaches the client to do the same.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer, expecting to note that it: Has little granulation tissue Has brown pigmentation surrounding it and edematous Has a pale-colored base Is deep, with even edges

Has brown pigmentation surrounding it and edematous Answer: Rationale: Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and there is evidence of granulation tissue. There is a brown pigmentation to the skin, from the accumulation of metabolic waste products due to venous stasis. The client also exhibits peripheral edema

A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which of the following on return from the dialysis treatment (Disequilibrium syndrome)? Headache, decreasing level of consciousness, and seizures Restlessness, irritability, and generalized weakness Hypotension, bradycardia, and hypothermia Hypertension, tachycardia, and fever

Headache, decreasing level of consciousness, and seizures

A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which of the following on return from the dialysis treatment? Hypotension, bradycardia, and hypothermia Restlessness, irritability, and generalized weakness Hypertension, tachycardia, and fever Headache, decreasing level of consciousness, and seizures

Headache, decreasing level of consciousness, and seizures Rationale: Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis, with a higher residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and the onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates.

A nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which of the following data obtained by the nurse would not place the client at increased risk for disturbed thought processes? Unfamiliar hospital setting Eyeglasses left at home Hearing aid available and in working order Stress induced by the fracture

Hearing aid available and in working order Confusion in the older client with hip fracture could result from the unfamiliar hospital setting, stress from the fracture, concurrent systemic diseases, cerebral ischemia, or side effects of medications. Use of eyeglasses and hearing aids enhances the client's interaction with the environment, and can reduce disorientation

Which sign is common for early laryngeal cancer? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

Hoarseness Hoarseness is caused by the inability of the vocal cords to move adequately during speech when a tumor exists. Aphasia refers to an expressive or receptive communication deficit as a result of cerebral disease; it is not related to laryngeal cancer. Dyspnea is a late, not early, adaptation that occurs with laryngeal cancer when a tumor is large enough to obstruct air flow. Dysphagia is a late, not early, adaptation that occurs when the tumor is large enough to compress the esophagus.

A nurse is admitting a client with chronic renal failure (CRF) to the nursing unit. The nurse monitors the client for which most frequent cardiovascular sign that occurs in CRF? Hypertension Hypotension Bradycardia Tachycardia

Hypertension Rationale: Hypertension is the most common cardiovascular finding in the client with CRF. It is due to a number of mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the CRF client because of increased cardiac workload in conjunction with fluid overload.

A client sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain, it is cool to touch and cap refill is 6 seconds. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by: The newness of the fracture Impaired tissue perfusion The anxiety of the client Infection under the cast

Impaired tissue perfusion Pain that is not relieved by rest, elevation, ice, and analgesics should be rported to the health care provider because it may be the result of impaired tissue perfusion, tissue brakdown, or necrosis. Saunders p.857

Which of the following can cause a low pulse oximetry reading? (Select all that apply) Inadequate peripheral extremity circulation Hyperthermia Nail polish Edema Increased hemoglobin level

Inadequate peripheral extremity circulation Nail polish Edema

A patient with newly diagnosed hypertension tells the nurse he uses a lot of salt on his foods and has not been able to lose the 30 pounds that he has gained in the last 10 years. He does not understand why he has hypertension, since he is not an anxious person. Which nursing diagnosis does the nurse identify for this patient? Risk of noncompliance related to lifestyle patterns Ineffective health maintenance related to the lack of knowledge of disease process and management Disturbed body image related to diagnosis of hypertension Anxiety related to complexity of management regimen and lifestyle changes associated with hypertension

Ineffective health maintenance related to the lack of knowledge of disease process and management Hypertension is a blood pressure higher than 140/90 mm Hg, which increases and individual's risk of developing cardiovascular disease. Adhering to medical therapy for control of elevated blood pressure helps to modify the individual's risk.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in: Injury to the brachial plexus nerves Impaired range of motion while the client ambulates Skin breakdown in the area of the axilla A fall and further injury

Injury to the brachial plexus nerves Crutches are measured so that the tops are three or four fingerbreadths or 1 to 2 inches fromthe axilla. This ensures that the client's axilla are not resting on the crutch or bearing theweight of the body. This could result in injury to the nerves of the brachial plexus.

A nurse is preparing a client for the administration of a Mantoux test. The nurse determines that which body area is the most appropriate area for injection of the medication? Dorsal aspect of the upper arm near a mole Dorsal aspect of the upper arm that has a small amount of hair Inner aspect of forearm that is not heavily pigmented Inner aspect of forearm that is close to a burn scar

Inner aspect of forearm that is not heavily pigmented Rationale: Intradermal injections are most commonly given in the inner aspect of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is removed from hairy areas or lesions, which could interfere with reading the results.

Which action would be a part of the nurse's plan of care to prevent future development of renal calculi in a client with ureteral colic? 1 Interventions to decrease the serum creatinine level 2 Excluding milk products from the diet 3 Instructing the client to drink 8 to 10 glasses of water daily 4 A goal of 2000 mL/24 hours urinary output

Instructing the client to drink 8 to 10 glasses of water daily Increasing fluid intake dilutes the urine and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate or calcium oxalate basis. Producing only 2000 mL of urine per 24 hours is inadequate as urine output should be maintained at 3000 to 4000 mL to limit calculus formation.

Which rationale explains why a client with tuberculosis who is prescribed isoniazid would also be prescribed vitamin B6? 1 B6 improves the nutritional status of the client. 2 It enhances the tuberculostatic effect of isoniazid. 3 B6 accelerates the destruction of dormant tubercular bacilli. 4 It counteracts the peripheral neuritis that isoniazid may cause.

It counteracts the peripheral neuritis that isoniazid may cause. One of the most common side effects of isoniazid is peripheral neuritis, and vitamin B6 will counteract this problem. Improving the nutritional status is not the specific reason B6 is given. It counters the side effects of isoniazid and it does not act to enhance its action. It does not speed the destruction of the causative organism.

A client diagnosed with gout has been started on medication therapy with allopurinol (Zyloprim). The nurse teaches the client which of the following points about this medication? The medication takes effect immediately. It is important to drink 3 L of fluid per day. Take the medication on an empty stomach. Development of a rash frequently occurs with this medication.

It is important to drink 3 L of fluid per day. It is important to increase fluid intake while taking medications to decrease uric acid levels and flush it out of the body.

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse would encourage the client to: Report to the physician the development of fever or redness and heat at the site Not eat or drink anything until the following morning Resume regular full activity the following day Keep the shoulder completely immobilized for the rest of the day

Keep the shoulder completely immobilized for the rest of the day Rationale: Following arthroscopy, signs and symptoms of infection such as fever or inflammation (redness or heat) should be reported to the physician. The client may resume the usual diet immediately. The arm does not have to be completely immobilized once sensation has returned, but the client is usually encouraged to refrain from strenuous activity for at least a few days.

Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-molecular-weight heparin product? Expel the air bubble from the prefilled syringe. Administer the medication into the deltoid muscle. Massage the site after injection to increase absorption. Leave the needle in place for 10 seconds after injection.

Leave the needle in place for 10 seconds after injection. The needle is left in place for 10 seconds after injection. Air is not expelled from the prefilled syringe. This medication is not administered intramuscularly. The site should not be massaged to increase absorption.

A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? Right hand, placing the cane in front of the right foot Right hand, and 6 inches lateral to the right foot Left hand, and 6 inches lateral (side) to the left foot Left hand, placing the cane in front of the left foot

Left hand, and 6 inches lateral (side) to the left foot The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.

The nurse is caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter wires by implementing which intervention? Having the physical therapist do active range of motion to the right arm Assisting the client to get out of bed and ambulate with a walker Limiting movement and abduction of the left arm Limiting movement and abduction of the right arm

Limiting movement and abduction of the right arm

Treatment for active tuberculosis includes which of the following? Long-term treatment with at least 4 drug combination for about 6-9 months Chemoprophylaxis with bacteriostatic medications The need to develop drug-resistant organisms Chemotherapy in patients at high risk for developing infection

Long-term treatment with at least 4 drug combination for about 6-9 months Antitubercular drugs are classified as primary or secondary agents to describe the way they are used in treating tuberculosis. The combination of drugs helps to slow the development of bacterial resistance.

A client who has had a radical neck dissection related to laryngeal cancer begins to bleed at the incision site. Which action by the nurse would be contraindicated? Positioning patient on Fowler's position Monitoring the client's airway Calling the physician immediately Lowering the head of the bed to a flat position

Lowering the head of the bed to a flat position

The nurse is treating a patient who had a pacemaker inserted 8 years ago for the correction of atrial fibrillation. Which diagnostic test may no longer be available to the patient because of this older model implanted device and may pose as a safety issue? Thallium scan MRI PET CT scan

MRI Patients who have pacemakers placed in the last several years can have MRI testing without difficulty. A model that has been in place for some time might be affected by the large magnets in the MRI cabinet. In either case, the patient should always report the use of a pacemaker before having an MRI.

The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to: Dilate the major bronchi. Maintain and promotes inflation of the alveoli. Enhance ciliary action in the tracheobronchial tree. Increase surfactant production.

Maintain and promotes inflation of the alveoli. Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of such devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. "Dilate the major bronchi," "increase surfactant production," and "enhance ciliary action in the tracheobronchial tree" are not reasons for sustaining inflation.

A nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for signs of what acid-base imbalance? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis.

When auscultating a client's heart, the nurse understands that the first heart sound is produced by the closure of which valves? 1 Mitral and tricuspid 2 Aortic and tricuspid 3 Mitral and pulmonic 4 Aortic and pulmonic

Mitral and tricuspid Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). Aortic and tricuspid valves and mitral and pulmonic valves do not close simultaneously. Aortic and pulmonic valves are the semilunar valves; closure of these valves produces the second heart sound (S2).

According to the Arthritis Foundation, the symptom of RA include the following: (Select ll that apply) Morning stiffness The same joints on both sides of the body are affected Formation of tophi or urate crystals on the big toe Characterized by remission and exacerbation

Morning stiffness The same joints on both sides of the body are affected Characterized by remission and exacerbation

Which of the following diets would be prescribed to the patient who just had bronchoscopy? NPO until gag refllex returns Diet as tolerated Clear liquid for now Bland, avoiding temperature extremes such as coffee or ice cream

NPO until gag refllex returns Patient after bronchoscopy should be kept on NPO until return of gag reflex and bowel sounds. Clear and soft diet first and if tolerated may resume to previoius diet as not to vause aspiration to the irrited throat.

A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets this as: Borderline Needs to repeat the test Positive Negative

Negative

A nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking the: Client's mobility status Renal system Neurological and respiratory systems Cardiovascular system

Neurological and respiratory systems The early signs of the complication of fat embolism include changes in the client's mental status or signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment is likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs of fat embolism.

A nurse is caring for the client who is at risk for lung cancer due to an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer? Nonproductive dry hacking cough Hoarseness Hemoptysis Pleuritic pain

Nonproductive dry hacking cough Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.

A nurse is caring for a client who is at risk for lung cancer due to an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer? Pleuritic pain Hoarseness Nonproductive hacking cough Hemoptysis

Nonproductive hacking cough Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause? Obstruction that can be caused by accumulation of secretions in the client's lungs Endotracheal tube cuff leak Loose connection in the system Disconnection from the ventilator

Obstruction that can be caused by accumulation of secretions in the client's lungs

A nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse notifies the registered nurse and plans to take which action? Stop the peritoneal dialysis Add antibiotics to the next several dialysis bags Obtain a culture and sensitivity of the drainage per orders Temporarily institute hemodialysis

Obtain a culture and sensitivity of the drainage per orders Rationale: When the drainage becomes cloudy, peritonitis is suspected. A culture and sensitivity is obtained, and broad-spectrum antibiotics are added to the dialysis solution, pending culture and sensitivity results. The dialysis solution may also be heparinized to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or reoccurring, but the nurse does not make this decision. The peritoneal dialysis is not stopped.

A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding? Record the approximate amount of blood lost Record the last episode of epistaxis Obtain or check the blood pressure Inquire about a diarrhea

Obtain or check the blood pressure Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis.

A nurse has an order to obtain a sample for urinalysis from a client with an indwelling urinary catheter. The nurse would avoid which of the following, which could contaminate the specimen? Clamping the tubing of the drainage bag Aspirating a sample from the port on the tubing attached to the drainage bag Wiping the port on the tubing with an alcohol swab before inserting the syringe Obtaining the specimen from the urinary drainage bag

Obtaining the specimen from the urinary drainage bag Rationale:A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, and does not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. Options 2, 3, and 4 are correct actions.

A nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. What equipment would the nurse plan to have at the bedside when the client returns from surgery? Epinephrine Tracheostomy with the next larger size Obturator Oral airway

Obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times in case the tracheostomy tube is dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgement occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed.

The course of ARF is divided into phases, what are the phases? Oliguria Diuresis Recovery Hematuria Azotemia

Oliguria Diuresis Recovery

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: On return from dialysis During dialysis The day after dialysis Just prior to dialysis

On return from dialysis

A nurse assists in preparing a care plan for the client who will be returning from surgery following a right wedge resection. Included in the plan is that in the postoperative period the nurse should avoid positioning this client: On the left side On the right side In semi-Fowler's position In low-Fowler's

On the right side

A patient has been having increased bilateral leg cramps for a few weeks. The health care provider has diagnosed her with peripheral vascular disease (PVD). In caring for this patient, a nurse would expect her to be started on a vasodilator drug that has which of the following effects? Blocks closed vessels, allowing collateral circulation to other vessels Decreases arterial blood flow, allowing more blood to reach the vessels Slows venous circulation, allowing arterial blood to flow more easily to vessels Opens arteries by relaxing smooth muscle, allowing more blood to reach the vessels

Opens arteries by relaxing smooth muscle, allowing more blood to reach the vessels Vasodilator drugs relax the smooth muscle of peripheral arterial blood vessels and help lead to better circulation to the arms and legs.

During the nursing history and physical assessment of a patient with left-sided heart failure, which finding might the nurse expect related to the patient's diagnosis? Anorexia with weight loss of 3 pounds in 1 week Orthopnea with bubbling crackles throughout the lungs Periorbital and facial edema Increased urinary output, especially during waking hours

Orthopnea with bubbling crackles throughout the lungs

Which finding would a nurse find inconsistent when monitoring a client with renal failure for signs of fluid excess? 1 Increased weight 2 Distended neck veins 3 Orthostatic hypotension 4 Abnormal breath sounds

Orthostatic hypotension Hypertension (not hypotension) is an indicator of fluid volume excess. Fluid excess causes weight gain. One liter of water weighs approximately 2.2 lb. Fluid excess increases the intravascular volume leading to jugular vein distention. Fluid excess causes fluid in the alveoli that leads to crackles, which are a sign of pulmonary edema.

Which condition occurs in part as a result of deficiencies in vitamin D and calcium? 1 Osteoporosis 2 Osteoarthritis 3 Ankylosing spondylitis 4 Fibromyalgia syndrome

Osteoporosis Osteoporosis makes bones brittle and fragile as a result of deficiencies in vitamin D and calcium. Osteoarthritis involves degeneration of cartilage as a result of bone spur formation and wear and tear. Ankylosing spondylitis is marked by positive results on HLA-B27 marker testing, a family history of the disease, and gastrointestinal manifestations. Fibromyalgia syndrome is associated with tenderness at multiple characteristic sites.

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse would avoid which of the following to maintain client safety after this procedure? Pillows under the length of the legs Logrolling technique for repositioning Overhead trapeze Head of bed flat

Overhead trapeze Following spinal fusion, the head of bed is generally kept in a flat position. The client is logrolled from side to side as ordered. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.

Which manifestation is associated with osteoarthritis? 1 Inflammation of the big toe 2 Pain and stiffness of the joints 3 Tophi around the rim of the ear 4 Generalized achiness in the lower back

Pain and stiffness of the joints Pain and stiffness of the joints is a clinical manifestation of osteoarthritis. Inflammation of the big toe and the appearance of tophi around the rim of the ear are clinical manifestations of gout. Generalized achiness of the lower back is a clinical manifestation of fibromyalgia syndrome.

The patient, age 30, has a history of renal calculi and is admitted to the hospital with gross hematuria and severe colicky left flank pain that radiates to his left testicle. An intravenous pyelogram confirms the presence of a 4-mm renal calculus in the proximal left ureter. Physician orders include morphine 1mg q4h prn, strain all urine, and encourage fluids to 4,000 mL/day. In planning care for this patient, the nurse gives the highest priority to which nursing diagnosis? Ineffective health maintenance related to lack of knowledge about prevention of stones Pain related to irritation of a stone Anxiety related to unclear outcome of condition Risk for injury related to disorientation

Pain related to irritation of a stone Nursing diagnoses include, but are not limited to, patient pain related to mobility of renal calculus.

The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient's right leg and dorsiflexes the foot? Muscular spasm, which would be a sign of hypocalcemia Pain, which would be a positive Homans' sign Rigidity, which would be a sign of ankylosis Crepitus, which would be a sign of a joint disorder

Pain, which would be a positive Homans' sign A positive Homans' sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed.

A hemodialysis client with a left arm fistula is at risk for arterial insufficiency syndrome. The nurse monitors this client for which manifestation of this disorder? Edema and red discoloration of the left arm Pallor, cool to touch, diminished pulse, and pain in the left hand Aching pain, pallor, and edema of the left arm Warmth, redness, and pain in the left hand

Pallor, cool to touch, diminished pulse, and pain in the left hand Rationale: Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain would more likely characterize a problem with infection. Options 3 and 4 are not characteristics of steal syndrome.

The nurse is working with a client receiving an intravenous heparin sodium drip. The nurse should review which of the following laboratory studies to determine the therapeutic effect of heparin for the client? Partial thromboplastin time (PTT) Prothrombin time (PT) Bleeding time Thrombin time

Partial thromboplastin time (PTT) Rationale: The PTT will assess the therapeutic effect of heparin, and the PT is one test that will assess for the therapeutic effect of warfarin (Coumadin). Thrombin time and bleeding time are hematological studies that may be prescribed for clients with coagulopathy or other disorders.

Mr. Jumpell is hospitalized with spinal cord injuries sustained from a motor vehicleaccident. He appears restless and in assessing his condition, you find his blood pressure tobe 160/90; his skin is moist and flushed. His urine output is 100 ml when he wascatheterized four hours ago. The first appropriate nursing action to: Call the physician and obtain an order for an antihypertensive medication Encourage the patient to drink lots of fluids to flush out the urinary calculi Place the patient in the supine position and provide cooling measures forhyperthermia secondary to pyelonephritis Perform an intermittent urinary catheterization per orders to relieve the patient of signs of neurogenic bladder

Perform an intermittent urinary catheterization per orders to relieve the patient of signs of neurogenic bladder

A physician is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to: Breathe in and out rapidly. Breathe deeply and rapidly. Perform the Valsalva maneuver by holding breath. Exhale immediately.

Perform the Valsalva maneuver by holding breath.

A client has been taking isoniazid (INH) for 1 ½ month. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: Peripheral neuritis Small blood vessel spasm Hypercalcemia Impaired peripheral circulation

Peripheral neuritis Rationale: A common side effect of isoniazid (INH) is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized with pyridoxine (vitamin B6) intake.

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? Using a rough file to smooth the cast edges Petaling the cast edges with adhesive tape Massaging the skin at the rim of the cast Applying lotion to the skin at the rim of the cast

Petaling the cast edges with adhesive tape Rationale:The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast.

A client with acute renal failure (ARF) has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse evaluates this therapy as effective if which of the following values is noted on follow-up laboratory testing? Phosphorus 3.9 mg/dL Calcium 9.8 mg/dL Sodium 142 mEq/L Potassium 4.9 mEq/L

Phosphorus 3.9 mg/dL Rationale: Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to cause excretion of potassium through the gastrointestinal tract. Each of the electrolyte levels noted in the question falls within the normal reference range for that electrolyte. The potassium level is measured following administration of this medication to note the extent of its effectiveness.

The nurse identifies the problem of a potential complication—pulmonary edema—for a patient in acute congestive heart failure (CHF). For which early symptom of this problem does the nurse assess? Bradycardia Lethargy and faintness Pink, frothy sputum Decreased urinary output

Pink, frothy sputum Frothy sputum is produced from air mixing with the fluid in the alveoli; the sputum is blood-tinged from blood cells that have exuded into the alveoli.

The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention? Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock. Place patient in side-lying position to reduce the symptoms of atrial fibrillation. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.

Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? Begin assembling medications that are anticipated to be given. Call the respiratory therapy department to request a ventilator. Suction the client vigorously. Place the client in high-Fowler's position.

Place the client in high-Fowler's position.

Which of the following interventions would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? Administer oral analgesics as needed. Place the left arm in a dependent position for 24 hours. Monitor site for swelling, bleeding, hematoma. Monitor vital signs every 4 hours.

Place the left arm in a dependent position for 24 hours.

A nurse is assisting a client who underwent radical neck surgery to get out of bed. The nurse provides the most support to the client who is afraid to move the head by doing which of the following? Placing a hand behind the client's head to support while getting up Raising the head of the bed 90 degrees Applying a soft cervical collar Assisting the client to roll to the side of the bed and sit up slowly

Placing a hand behind the client's head to support while getting up Rationale: The nurse provides the most support to the surgical site by placing a hand behind the client's head. Options 1 and 4 involve little assistance or support by the nurse. Option 3 is unnecessary and could occlude a tracheostomy if one is in place.

A nurse is assisting in planning a diet for the client with acute renal failure (ARF). The nurse plans to restrict which of the following dietary components from this client's diet? Carbohydrates Potassium Fat Vitamins

Potassium In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis. Options 1, 2, and 3 are not normally restricted in the client with ARF.

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results? Bicarbonate 24 mEq/L Sodium 142 mEq/L Chloride 103 mEq/L Potassium 5.4 mEq/L

Potassium 5.4 mEq/L Rationale: The normal serum electrolyte ranges for adults are sodium, 136 to 145 mEq/L; potassium, 3.5 to 5.1 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified above is the serum potassium, which would be the one of most concern to the nurse.

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results? Bicarbonate 24 mEq/L Chloride 103 mEq/L Potassium 6.4 mEq/L Sodium 142 mEq/L

Potassium 6.4 mEq/L Rationale: The normal serum electrolyte ranges for adults are sodium, 136 to 145 mEq/L; potassium, 3.5 to 5.1 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified above is the serum potassium, which would be the one of most concern to the nurse.

Which finding indicates that sodium polystyrene sulfonate (Kayexalate) administered to a client with chronic renal failure is effective? 1 Constipation 2 Improved mental status 3 Sodium increases to 137 mEq/L 4 Potassium decreases to 4.2 mEq/L

Potassium decreases to 4.2 mEq/L This resin exchanges sodium ions for potassium in the large intestine to lower the serum potassium level. A value of 4.2 mEq/L is in the expected range for potassium. Frequent, loose stools is a common side effect. Mental status improvement is not a therapeutic effect of the drug. Sodium retention is an adverse effect. A value of 137 mEq/L is in the expected range for sodium.

A client receiving total parenteral nutrition (TPN) has a history of congestive heart failure. The physician has ordered furosemide (Lasix) 40 mg orally daily to prevent fluid overload. The nurse monitors which laboratory value to identify an adverse effect from this medication? Sodium level Magnesium level Potassium level Glucose level

Potassium level

A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection? Diminished distal pulse Dependent edema Coolness and pallor of the extremity Presence of a "hot spot" on the cast

Presence of a "hot spot" on the cast Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast, or the presence of "hot spots," which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.

A nurse is assessing the patency of a arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? Presence of bruit and thrill over the fistula Absence of a bruit on auscultation of the fistula Presence of a radial pulse in the left wrist Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

Presence of bruit and thrill over the fistula A functioning fistula should be palpated for thrill and auscultate for bruit to determine patency before cannulation.

Which is the hallmark of pulmonary edema? Productive coughing with frothy pink-tinged sputum Wheezing, dyspnea and cyanosis Hemoptysis, fever and night sweats Orthopnea and cyanosis

Productive coughing with frothy pink-tinged sputum

A series of examinations and diagnostic tests are ordered to determine whether a client has cancer of the prostate gland. What diagnostic test should the nurse schedule per orders before any rectal examination? Needle biopsy of the prostate gland Transrectal ultrasound examination Kidneys, ureters, bladder x-ray Prostate specific antigen test (PSA)

Prostate specific antigen test (PSA)

A trauma patient arrives in the emergency department via EMS. He is bleeding profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will most likely administer which medication that counteracts the action of heparin? Enoxaparin (Lovenox) Protamine sulfate Warfarin sodium (Coumadin) Vitamin K

Protamine sulfate Protamine sulfate is the antidote to heparin. With the patient's risk of fluid volume deficit as a result of trauma, the primary intervention would be to counteract the effects of heparin to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract hemorrhage. Lovenox is chemically related to heparin and would not counteract hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin (Coumadin), not heparin.

A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to the removal of the larynx. What is an appropriate nursing intervention? Provide a pad and pencil or magic slate to write on Refrain from conversations with the patient to reduce stress level Ignore and offer books or jigsaw puzzles for entertainment Complete care quickly

Provide a pad and pencil or magic slate to write on

A nurse is caring for a client with tuberculosis who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which of the following as the best strategy to assist the client in coping with the disease? Encourage the client to visit with the pastoral care department chaplain. Ask family members if they wish a psychiatric consult. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Allow the client to deal with the disease in an individual fashion.

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

Which reason would the nurse give for why women are at a greater risk than men for contracting a urinary tract infection? 1 Altered urinary pH 2 Hormonal secretions 3 Juxtaposition of the bladder 4 Proximity of the urethra to the anus

Proximity of the urethra to the anus Because a woman's urethra is closer to the anus than a man's is, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in women and men.

When the nurse monitors the client, what complication has the highest potential for developing in those undergoing peritoneal dialysis? Ruptured aorta Abdominal hernia Pulmonary edema Abdominal peritonitis

Pulmonary edema Peritonitis is the most serious and common complication in 60-80% of client's in long-term peritoneal dialysis.

Which complication is most common after hip surgery? 1 Pneumonia 2 Hemorrhage 3 Wound infection 4 Pulmonary embolism

Pulmonary embolism A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow. The occurrence of pneumonia is rare because of early activity after surgery. In addition, the operative area is not in proximity to the diaphragm and lungs; therefore, it does not impede deep breathing. Postoperative hemorrhage with hip surgery is rare because bleeding at the operative site is not covert. The incidence of wound infection is no greater than with other postoperative clients.

Which clinical finding would the nurse expect when completing the admission assessment on a client admitted with an abdominal aortic aneurysm and surgery scheduled in the morning? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass

Pulsating abdominal mass As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Signs of shock are not definitive for an abdominal aortic aneurysm unless the aneurysm ruptures. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not definitive for an abdominal aortic aneurysm.

Which test is a quick and reliable aid to diagnosis latent TB? TB tine test QFT-G Sputum smears PPD skin test

QFT-G Sputum smears, cultures and PPD skin test are still done. However, QFT-G offers a quick and reliable diagnosis for the patient and health care provider. The results of QFT-G are greater specificity and results are available 24 hours after the blood is collected.

A nurse has taught a client about the use of a respiratory inhaler. Which statement by the client indicates a need for further teaching? "I need to remove the cap and shake the inhaler well before use." "I need to wait between puffs if more than one puff has been prescribed." "I need to inhale quickly the mist and also quickly exhale." "I need to press the canister down with my finger as I breathe in."

Rationale: The client should be instructed to hold his or her breath for at least 5 to 10 seconds before exhaling the mist.

A nurse is caring for a client who had an above the knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage and has fallen off. The nurse immediately: Applies a dry sterile dressing and elevates it on one pillow Re-wraps the stump with an elastic compression bandage Calls the physician Applies ice to the site

Re-wraps the stump with an elastic compression bandage If the client with amputation has a cast or elastic compression bandage that falls off, the nursemust immediately wrap the stump with another elastic compression bandage. Otherwise,excessive edema will rapidly form, which could cause a significant delay in rehabilitation.

Which indicator would the nurse use to determine effectiveness after administration of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels

Relief of anginal pain Cardiac nitrates relax smooth muscles of the coronary arteries. They dilate and deliver more blood to heart muscle leading to relief of ischemic pain. Cardiac output may improve because of improved oxygenation of the myocardium, but improved cardiac output is not a basis for evaluating the drug's effectiveness. Dilation of blood vessels and a subsequent drop in blood pressure may occur, but decreased blood pressure is not a basis for evaluating the drug's effectiveness. Superficial vessels dilate and lower the blood pressure creating a flushed appearance, but dilation of superficial blood vessels is not a basis for evaluating the drug's effectiveness.

Mr. S. Tony came to ED with family, complaining of low-grade fever, sudden onset of sharp, severe pain originating in the lumbar area and radiating around the side and down toward the testicle, hematuria with urinary frequency and alternating retention. Morphine for pain was ordered and the patient was further assessed to be having what, basing from the initial signs and symptoms? Glomerulonephritis Renal calculi Cystitis Hydronephrosis

Renal calculi

A nurse is caring for a client who had a Mantoux skin test 48 hours ago on admission to the nursing unit and reads the result of the skin test as positive. Which action by the nurse is the priority? Call the employee health service department. Document the finding in the client's record. Call the radiology department for a chest x-ray. Report the findings.

Report the findings.

A client is to begin a 6-month course of therapy with isoniazid (INH). A nurse plans to teach the client to: Increase intake of Swiss or aged cheese Avoid vitamin supplements during therapy Drink alcohol in small amounts only Report yellowing of the eyes or skin immediately

Report yellowing of the eyes or skin immediately

A client with an abdominal aortic aneurysm (AAA) is not a candidate for surgery because the aneurysm is not yet large enough. The client is fearful that the aneurysm will rupture, causing death. The nurse plans to assist the client in coping with this fear by emphasizing what the client can do for self-monitoring. Which of the following items would be unnecessary for the nurse to include in discussions with the client? Importance of follow-up computerized tomography (CT) scans Antiviral prophylaxis before invasive procedures Reporting abdominal or back pain Management of hypertension

Reporting abdominal or back pain Rationale: Psychosocial care of the client with medical management of an AAA includes listening to the client's concerns and reinforcing the rationales for ongoing medical surveillance. This includes periodic CT scanning to monitor the size of the aneurysm and careful adherence to medication and diet therapy for hypertension. The client is instructed to report any sensation of abdominal fullness or abdominal or back pain to the physician without delay.

A nurse has just been given an order to administer albuterol (Proventil HFA) to a client. The nurse evaluates the effectiveness of the medication by noting which of the following before and during therapy? Resolving dyspnea and clear lung sounds Nausea and vomiting Urine output and blood urea nitrogen Headache and level of consciousness

Resolving dyspnea and clear lung sounds

What is the client experiencing when blood gases indicate a pH level of 7.30, partial pressure of oxygen (PO2) at 60 mm Hg, partial pressure of carbon dioxide (PCO2) at 55 mm Hg, and a bicarbonate (HCO3) level of 23 mEq/L? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis

Respiratory acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), hemoglobin (Hgb), and hematocrit (Hct) are related to anemia.

A nurse is caring for a client following pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by noting the presence of: Hypothermia Hematoma in the left groin Respiratory distress Discomfort in the left groin

Respiratory distress Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Discomfort is expected. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction.

What should the home health nurse include in assessment in the plan of care for an 82-year-old female with severe kyphosis from ankylosis? Sleep cycle Respiratory effort Urinary output Nutritional status

Respiratory effort Respiratory effort can be affected by the compression of the ribcage resulting in kyphosis with AKS and scoliosis.

A nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of Impaired Gas Exchange. The nurse should monitor for which item as the best indicator of an adequate respiratory status? Respiratory rate of 18 breaths per minute and regular Oxygen saturation of 89% Moderate amounts of tracheobronchial secretions Moderate amounts of frank blood suctioned from the tube

Respiratory rate of 18 breaths per minute and regular

What is the major cause of cardiac valve disease? Obesity Pregnancy Rheumatic fever Long history of malnutrition

Rheumatic fever Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease.

Which of the following are considered primary drugs (first-line) to treat tuberculosis? (Select all that apply): Ciprofloxacin (Cipro) Rifampin (Rifadin) Levofloxacin (Levaquin) Ethambutol (Myambutol) Isoniazid (Nydrazid)

Rifampin (Rifadin) Ethambutol (Myambutol) Isoniazid (Nydrazid)

Which position is the most beneficial for a patient after surgery for creation of a tracheostomy? Lithotomy Trendelenburg Semi-fowler's Dorsal recumbent

Semi-fowler's

Which statement defines phantom limb pain? 1 Pain or discomfort in a body part that has been replanted 2 Sharp, burning sensation indicating the need for amputation 3 Discomfort or pain in the unaffected limb 4 Sensation of pain that feels like it is coming from the amputated body part

Sensation of pain that feels like it is coming from the amputated body part Phantom pain is the sensation of pain in the limb or body part that has been removed. These pain sensations originate from the brain and spinal cord but are perceived as coming from the removed body part. Replanted pain sensations are not referred to as phantom pain. A sharp, burning sensation preceding the removal of a body part is not phantom limb pain. Phantom pain is related to the removed limb, not the unaffected limb.

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which of the following complications due to the history of diabetes? Edema of the stump Separation of wound edges and infection Pain Hemorrhage

Separation of wound edges and infection Rationale: Clients with diabetes mellitus are at greater risk of wound infection and delayed wound healing due to this disorder. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.

Which symptom is the most important to report if a client has a history of pneumothorax? 1 Substernal chest pain 2 Episodes of palpitation 3 Severe shortness of breath 4 Dizziness when standing up

Severe shortness of breath Severe shortness of breath may indicate a recurrence of the pneumothorax because one lung is unable to meet the oxygen demands of the body. A pneumothorax causes sharp chest pain on the involved side, not substernally. Usually palpitations reflect a cardiac, not a respiratory, problem. Dizziness when standing up is not specific to a pneumothorax; this is orthostatic hypotension, which may be related to a variety of medical problems.

An emergency room nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign if noted in the client would indicate the presence of a pneumothorax? Bradypnea Shortness of breath The presence of a barrel chest A low respiratory rate

Shortness of breath Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side.

A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits: Peripheral cyanosis and hypotension Chest pain and shortness of breath Decreasing oxygen saturation and bradypnea Shortness of breath and tracheal deviation from midline or shifting

Shortness of breath and tracheal deviation from midline or shifting

What should a person with unstable angina avoid? Walking outside Swimming in warm pool Shoveling snow Eating red meat

Shoveling snow The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress.

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Stating that the hot cutting blades cause burns only very rarely Showing the client the cast cutter and explaining how it works Telling the client that the saw makes a frightening noise Reassuring the client that no one has had an arm lacerated yet

Showing the client the cast cutter and explaining how it works Rationale:The action by the nurse that would be the most helpful is to show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side.

How should a patient be positioned after a thoracentesis is completed and the dressing applied? Prone Semi-Fowler High Fowler Side lying on unaffected side

Side lying on unaffected side

Which part of the skeleton is categorized as axial? Select all that apply. One, some, or all responses may be correct. 1 Skull 2 Sternum 3 Vertebrae 4 Pelvic girdle 5 Shoulder girdle

Skull Sternum Vertebrae Shoulder girdle The skeleton is divided into the axial and appendicular skeletons. The axial skeleton includes the skull, sternum, and vertebrae. The appendicular skeleton includes the pelvic and pectoral (shoulder) girdles.

A patient with TB is undergoing initial therapy in the treatment. The nurse has to administer three or more drugs in combination to the patient. The patient wishes to know the reason for administering a combination of drugs. Which of the following explanations does the nurse offer related to the combination of medications? Prevents him from being isolated Slows down bacterial resistance. Prevents the incidence of liver dysfunction. Slows body's resistance to medication.

Slows down bacterial resistance.

The nurse is teaching a patient about dietary implications while on warfarin (Coumadin) therapy. Which salad is highest in vitamin K? Potato Spinach Fruit Pasta

Spinach

The immediate medical management of any fracture is: Observe patient for signs of shock. Administer analgesics for pain. Apply heat to control pain. Splint and elevate the involved part.

Splint and elevate the involved part. Immediate management includes splinting and elevation of the involved part to prevent edema. After the immediate management, analgesic for pain, application of cold to prevent edema, and observing for signs of shock must be part of the plan of care.

A client with a persistent upper respiratory infection develops acute bronchitis. Aside from the characteristics of the client's cough, what other pertinent assessment findings should the nurse document? Any self-treatment measures used by the client Family history of respiratory disease Current vital signs The appearance of respiratory secretions

The appearance of respiratory secretions

A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse reviews the results of which diagnostic test that will confirm this diagnosis? Bronchoscopy Chest x-ray Sputum Culture PPD skin test

Sputum Culture

Which of these terms describes an asthma attack that persists and does not respond to treatment? Status asthmaticus Asthma crisis Intrinsic asthma Persistent asthma

Status asthmaticus

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? Try to manually reduce the fracture. Assist the person with getting up and walking to the sidewalk. Leave the person for a few moments to call an ambulance. Stay with the person, calm him down and encourage the person to remain still while asking other witnesses to call for help

Stay with the person, calm him down and encourage the person to remain still while asking other witnesses to call for help

A nurse is preparing to assist a physician with the insertion of a chest tube. The nurse anticipates that which of the following supplies will be required for the chest tube insertion site? Sterile petrolatum gauze Sterile Kerlix dressing Povidone-iodine gauze Sterile 4 x 4 gauze pad

Sterile petrolatum gauze Rationale: The first layer of the chest tube dressing is petrolatum (Vaseline) gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine may be used to clean the insertion site before insertion of the chest tube. Sterile dressings will be used to cover the Vaseline gauze.

A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should: Notify the registered nurse immediately. Continue to suction the client at a quicker pace. Stop the procedure and oxygenate the client. Ensure that the suction is limited to 15 seconds.

Stop the procedure and oxygenate the client. Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop (especially cardiac irregularities), the nurse should stop the procedure and oxygenate the client.

Which are the medications considered first line anti-infectives against pulmonary tuberculosis? (Select all that apply) Streptomycin Ethambutol INH Pyrazinamide Rifampin

Streptomycin Ethambutol INH Pyrazinamide Rifampin

Which patient assessment indicates the most severe respiratory distress? Substernal retraction, SaO2 84% Substernal retraction, SaO2 90% Symmetrical chest wall expansion, SaO2 88% Abdominal breathing, SaO2 97%

Substernal retraction, SaO2 84% Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.

Which independent nursing measures are effective in helping ease a patient to expectorate thick secretions? (Select all that apply) Suctioning Providing hydration Positioning in sitting position Assisting to deep breathe first before coughing Starting and pushing IV fluids

Suctioning Providing hydration Positioning in sitting position Assisting to deep breathe first before coughing Independent nursing intervention to help a patient to expectorate would include positioning, assisting to cough, suctioning, and providing hydration IV therapy; provision of a mucolytic agent requires a physician's order and is not an independent nursing action..

A client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed would include which of the following in a list provided to the client? Summer squash Instant oatmeal Boiled shrimp Tomato soup

Summer squash

The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client? Boiled shrimp Summer squash Tomato soup Instant oatmeal

Summer squash Rationale: Foods that are lower in sodium are fruits and vegetables ("summer squash") because they do not contain physiological saline. Highly processed or refined foods ("tomato soup" and "instant oatmeal") are higher in sodium unless they are specifically noted as "low sodium." Saltwater fish and shellfish are higher in sodium.

When providing discharge teaching to a patient with endocarditis regarding prevention of infections, what would the nurse stress? Avoid crowds. Take antibiotics as prescribed. Use only aspirin for mild pain. Weigh yourself daily.

Take antibiotics as prescribed.

Mr. Shunter receives hemodialysis treatments through an arteriovenous (AV) shunt in the left arm. Which of the following interventions is appropriate? Keep patient on bed rest Take the blood pressure on the right arm Irrigate the fistula every 4 hours Monitor input and output hourly

Take the blood pressure on the right arm

A patient is prescribed an inhalational corticosteroid therapy along with bronchodilator therapy. Which of the following points should the nurse include in the patient teaching plan? The corticosteroid drug provides rapid relief during an asthma attack. Take the corticosteroid several minutes after the bronchodilator dose. Stop corticosteroid therapy immediately if you notice any adverse effects. Before each dose of corticosteroid, rinse the mouth thoroughly with water.

Take the corticosteroid several minutes after the bronchodilator dose.

A client has a new order to take guaifenesin (Humibid) every 4 hours as needed. The nurse giving medication instructions to the client tells the client to be sure to: Take the tablet with a full glass of water and increase fluid intake. Take an extra dose if the cough is accompanied by fever. Be aware of irritability as a side effect. Crush the sustained-release tablet if immediate relief is needed.

Take the tablet with a full glass of water and increase fluid intake. Rationale: Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

Which action by a 70-year-old female would limit further progression of osteoporosis? 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk and milk products

Taking supplemental calcium and vitamin D Research demonstrates that postmenopausal women require at least 1500 mg of calcium a day. This is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis and does not provide vitamin D unless the food is fortified. Calcium absorption is impeded when large amounts of magnesium are present because magnesium and calcium absorption are competitive. Vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which most important action in delivering holistic nursing care to this client? Explains to the client to decrease use to reduce damage to the heart Tells the client it is important to stop before myocardial infarction occurs he dies Teaches about the effects of cocaine on the heart and offer referral for further help Reports the client to the police for illegal drug use

Teaches about the effects of cocaine on the heart and offer referral for further help Rationale: To provide the most holistic care, the nurse should teach the client about the effects of cocaine on the heart and also offer referral for further help with this possible addiction.

Prevention of acute respiratory complications in surgical patients is a nursing goal that involves which intervention? Keeping at-risk patients in an upright position during the postoperative course. Teaching all preoperative patients how to use incentive spirometer and how to cough and deep breathe effectively. Obtaining baseline arterial blood gases for all preoperative patients over the age of 65. Obtaining baseline pulmonary function tests for all preoperative patients.

Teaching all preoperative patients how to use incentive spirometer and how to cough and deep breathe effectively.

An x-ray of the injured teenager's leg reveals a comminuted fracture of the distal tibia. What nursing explanation can best help this client understand the injury that has occurred? There is no open break in the skin One bone end is driven into the other A portion of the bone is split away The bone is splintered into pieces

The bone is splintered into pieces A comminuted fracture means that there are pieces, fragments, or splinters of bone in the area where the bone is broken.

A young female client with acute pyelonephritis is scheduled for a voiding cystourethrogram. The nurse determines that this client would most likely benefit from increased support and teaching about the procedure because The client must void while the micturition process is filmed. Radioactive material is injected into the bladder with a syringe. Radiopaque contrast is injected into the bloodstream with a syringe. The client must lie on an x-ray table in a cold, barren room.

The client must void while the micturition process is filmed. Rationale: Having to void in the presence of others can be very embarrassing for clients, and may actually interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation, and gives the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure.

A nurse in an ambulatory clinic is preparing to administer a Mantoux skin test to a client who may have been exposed to an individual with tuberculosis (TB). The client reports having had the Bacille Calmette Guerin (BCG) vaccine before moving to the United States from a foreign country. The nurse interprets that: The client's Mantoux test will be negative and will require sputum culture to diagnose. The client is at more risk of acquiring TB and needs immediate medication therapy. The client has no risk of acquiring TB and needs no further workup. The client's Mantoux test will be positive and will require chest x-ray for evaluation.

The client's Mantoux test will be positive and will require chest x-ray for evaluation.

On your patient's third post-op day, the intermittent bubbling stops and the fluctuation in the water seal container stops and the patient is not in any kind of distress. The most probable cause of this finding is: The tubing needs to be irrigated The tubing is too loose at the insertion site There is a leakage of air in the seal The lungs might have re-expanded

The lungs might have re-expanded

This is a tube-like structure that extends to the mid-chest, where it divides into the right and left bronchi. It contains C-shaped cartilaginous rings that keep it from collapsing: Nares Pharynx Larynx Trachea

Trachea

Which information would a nurse include when teaching a client who is to begin continuous ambulatory peritoneal dialysis (CAPD)? 1 Peritoneal dialysis is done in an ambulatory care clinic. 2 Hemodialysis and peritoneal dialysis are provided continuously. 3 The peritoneal membrane allows passage of toxins into the dialysate. 4 A quarter of a liter of dialysate is maintained inter- and intraperitoneally.

The peritoneal membrane allows passage of toxins into the dialysate. Dialysate is introduced into the peritoneal cavity where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane. The client can dialyze alone in any location without the need for machinery and continuous technical supervision. Hemodialysis is not necessary with this procedure. Each exchange involves 2 to 3 L of dialysate intraperitoneally (not interperitoneally) for a specified time (dwell time) before being drained.

A client with bladder cancer had his bladder removed and an ileal conduit was created for urine diversion. While changing this patient's pouch, the nurse observes that the bag was tight and the area around the stoma is red, weeping, and painful. What should the nurse conclude? The pouch faceplate or barrier is tight and does not fit the stoma A skin barrier was applied properly Stoma dilation was not performed The skin was not lubricated before the pouch was applied

The pouch faceplate or barrier is tight and does not fit the stoma

A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? Uses the diaphragm of the stethoscope Asks the client to normally breathe Asks the client to sit upright The student auscultates and places the stethoscope on the client's gown

The student auscultates and places the stethoscope on the client's gown

A nurse checks the water seal chamber of a closed chest drainage system and notes as the patient is breathing, fluctuations or tidaling is present in the chamber. The nurse analyzes this finding as indicative of which of the following? The tubing is kinked. An air leak is present. The system is functioning as expected. The lung has re-expanded.

The system is functioning as expected. Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation. Fluctuations of 5 to 10 cm (2 to 4 inches) during normal breathing are common. The absence of fluctuations could mean that the tubing is obstructed by a kink, the client is lying on the tubing, or dependent fluid has filled a loop of tubing. Expanded lung tissue can also block the chest tube eyelets during expiration. The absence of fluctuations could also mean that air is no longer leaking into the pleural space.

A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the air leak chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring? The suction to the system is shut off. There is an air leak somewhere in the system. The system must have a crack in it. The pneumothorax is resolving.

There is an air leak somewhere in the system.

A young mother tells the nurse that her 6-month-old baby has a cough and that she is giving the baby an OTC cough and decongestant preparation. Which of the following statements would the nurse teach this young mother? These products are safe if given diluted. These products are safe in infants over 6 months. These products are not safe for infants. Over-the-counter medication is safe for infants.

These products are not safe for infants. In 2007, the FDA announced that over-the-counter cold products should not be used in infants because they are unsafe.

What is the rationale behind administering calcium channel blockers to patients with angina? They dilate blood vessels. They decrease heart rate. They increase cardiac contractility. They promote fluid excretion.

They dilate blood vessels.

Which agents are preferred for the initial treatment of hypertension? ACE inhibitors and angiotensin receptor antagonists Calcium ion agonists and central-acting alpha agonists Thiazide diuretics and beta-adrenergic blockers Direct vasodilators and peripherally acting adrenergic antagonists Preferred agents include diuretics and beta-adrenergic blockers.

Thiazide diuretics and beta-adrenergic blockers ACE inhibitors, angiotensin receptor antagonists, calcium ion agonists, and central-acting alpha agonists are alternative agents. Direct vasodilators and peripherally acting adrenergic antagonists are adjunctive agents.

The nurse is caring for a patient with a diagnosis of pleural effusion. The physician is most likely to order a ______________ to remove fluid from around the lungs so that the patient may breathe more easily. Thoraxtenesis Amniocentesis Paracentesis Thoracentesis

Thoracentesis

A client has a newly fractured fibula, which is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch walking gait before discharge? Four-point alternate gait Swing-through gait Two-point gait Three-point gait

Three-point gait The client with a new fracture that is casted with a plaster cast needs to avoid weight-bearing movements. Option 2 is the only option that identifies a gait that allows non-weight-bearing movement on the affected extremity. The client should not bear weight on the affected extremity until the physician evaluates the client on the follow-up examination.

Mr. AFB received a PPD skin test in the clinic on Tuesday. He should return to the clinic to have the results read on which of the following days? On weekends Thursday and Friday Wednesday and Thursday Friday and Saturday

Thursday and Friday

Which blood level would the nurse expect will increase first in a myocardial infarction? 1 Alanine aminotransferase (ALT) 2 Serum aspartate aminotransferase (AST) 3 Total lactate dehydrogenase (LDH) 4 Troponin T (cTnT)

Troponin T (cTnT) Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver and is found in lesser quantities in the kidneys, heart, and skeletal muscles. It is primarily used to diagnose and monitor liver, not heart disease. AST (serum glutamic-oxaloacetic transaminase, SGOT) is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.

How would the nurse position a client with epistaxis? 1 Supine 2 Side-lying 3 Upright leaning forward 4 Sitting with the head tipped backward

Upright leaning forward A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the possibility of aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the possibility of aspiration or swallowing blood.

Which indicator of a urinary tract infection (UTI) would the nurse provide as part of the discharge instructions to a male client after ureterolithotomy with a history of recurrent UTIs? 1 Urgency or frequency of urination 2 The inability to maintain an erection 3 Pain radiating to the external genitalia 4 An increase in the alkalinity of the urine

Urgency or frequency of urination Urgency or frequency of urination occur with a urinary tract infection because of bladder irritability. Burning on urination and fever are additional signs of a UTI. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus and not an infection. An increase in alkalinity or acidity of urine is not a sign of a UTI.

Which diagnostic tests would the nurse expect to be prescribed to confirm diagnosis of a urinary tract infection in a client recovering from deep partial-thickness burns who develops chills, fever, flank pain, and malaise? 1 Urinalysis and urine culture and sensitivity 2 Cystoscopy and bilirubin level 3 Creatinine clearance and albumin/globulin (A/G) ratio 4 Specific gravity and pH of the urine

Urinalysis and urine culture and sensitivity The client's manifestations may indicate a urinary tract infection, and a culture of the urine will identify the microorganism. A cystoscopy is too invasive as a screening procedure. Altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function and A/G ratio reflects liver function. An increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine and are associated with urinary tract infection, but it will not identify the causative organism.

A nurse is teaching the client with a below-the-knee amputation (BKA) measures to protect the residual limb, or stump. The nurse would be sure to include which of the following points in discussions with the client? Apply lotion daily to prevent cracking of the skin of the residual limb. Put a clean nylon sock on the residual limb daily. Use a mirror to inspect all areas of the residual limb. Toughen the skin of the residual limb by rubbing it with alcohol.

Use a mirror to inspect all areas of the residual limb.

A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further instruction if the client states to: Use a strong adhesive tape to anchor the catheter dressing. Use meticulous aseptic technique for dialysate bag changes. Monitor own weight daily. Take own vital signs daily.

Use a strong adhesive tape to anchor the catheter dressing.

A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. Which appropriate nursing intervention does the nurse include in developing a plan of care? Use protective undergarments. Assist the patient to the bathroom every half hour. Insert an indwelling catheter immediately. Restrict fluids after the evening meal.

Use protective undergarments. Use of protective undergarments may help to keep the patient and the patient's clothing dry. Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance.

The nurse is listening to a 56-year-old client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse? Administer the digoxin; the heart rate would be considered normal because of the client's age. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. Administer half the prescribed dose to avoid a further decrease in heart rate. Withhold the digoxin, and reevaluate the heart rate in 4 hours.

Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. Rationale: The normal heart rate is 60 to 100 beats/min in an adult. If the nurse notes a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output so this would also be assessed.

Prior to the administration of a beta-adrenergic blocker, the nurse notes the patient to have a heart rate of 52 beats/min, peripheral edema, crackles in the bases of the lungs, and mottled skin. Which is the priority nursing action? Obtain a serum blood level. Withhold the medication and notify the healthcare provider. Reevaluate the patient in 2 hours. Administer the medication as ordered.

Withhold the medication and notify the healthcare provider. These symptoms warrant the nurse's withholding the dose and then notifying the healthcare provider. The medication should not be administered if the patient's heart rate is low or the patient is experiencing symptoms of heart failure and poor perfusion. The patient should be assessed frequently after the medication is held and the healthcare provider is notified, but action needs to be taken immediately. Therapeutic blood levels for beta-adrenergic medications are not typically measured.

A client taking theophylline (Theo-24) has a serum theophylline level of 15 mcg/mL. The nurse interprets that this result is: In excess of the therapeutic range. Below the therapeutic range. Within the therapeutic range. Near the top of the therapeutic range.

Within the therapeutic range. Rationale: The normal therapeutic range for theophylline levels is 10 to 20 mcg/mL. A level greater than 20 mcg/mL is considered toxic. The value of 15 mcg/mL places the client in the middle of the therapeutic range.Test-Taking Strategy: Specific knowledge regarding the therapeutic drug level for this medication is needed to answer this question. Recalling that the normal therapeutic range is 10 to 20 mcg/mL will direct you to option 2. Review the therapeutic range for theophylline if you had difficulty with this question.

Which of the following instructions is given to clients with chronic pyelonephritis? Use narcotics on a regular basis for up to 6 months Have a urine culture every 2 weeks for up to 6 months Stay on bedrest for up to 3 weeks You may need antibiotic treatment for several weeks for the treatment of the infection

You may need antibiotic treatment for several weeks for the treatment of the infection

A patient, age 79, fell at home and suffered an intracapsular fracture of his left hip. The orthopedic surgeon inserted a prosthetic implant for a bipolar hip replacement. The physician has instructed the nurse to turn him every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs from rubbing together. abducted so the prosthesis does not become dislocated. abducted to prevent additional pain for the patient with turning. together so they don't separate while turning.

abducted so the prosthesis does not become dislocated. Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis.

The movement of an extremity away from the midline of the body is called flexion. abduction. adduction. extension.

abduction Abduction is movement of an extremity away from the midline of the body.

A patient, age 54, is on a postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia. In planning for her care, the nurse suspects the patient may have bacterial pneumonia. atypical pneumonia. aspiration pneumonia. viral pneumonia.

aspiration pneumonia. Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock.

The patient who undergoes total hip replacement may be prescribed prophylactic drugs such as heparin or warfarin (Coumadin). The rationale for this is that it: decreases the risk of systemic infection. decreases the risk of hemorrhage. decreases the risk of thrombus formation. facilitates the wound-healing process.

decreases the risk of thrombus formation. Treatment will include administration of anticoagulants, such as heparin or warfarin (Coumadin), which decreases the risk of deep vein thrombus.

When a patient has experienced a pneumothorax, chest auscultation reveals: deep slowed respirations with equal chest movement. respiratory rate less than 16 breaths per minute. bilateral unequal breath sounds, with no breath, sounds over the affected area. equal breath sounds over the affected area.

bilateral unequal breath sounds, with no breath, sounds over the affected area. Findings on auscultation are bilaterally unequal breath sounds, with no breath sounds over the affected area. A larger pneumothorax causes respiratory distress, including rapid shallow respirations, air hunger, dyspnea, and oxygen desaturation.

Freely movable joints are also called as: amphiarthrosis fibrous joints diarthrosis catilaginous joints

diarthrosis

The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for: weight reduction. avoiding cold remedies. reduction of alcohol intake. cessation of smoking.

cessation of smoking. The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.

The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse's immediate course of action would be to: reteach him about his medications. have a serious talk with him and his family about compliance. arrange for home visits after discharge. collect more information to identify his reasons for noncompliance. Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance.

collect more information to identify his reasons for noncompliance.

A 28-year-old male patient has a fractured left humerus. He has a cast on his arm. The nurse observes pallor, coolness, and a decrease in capillary refill time to his left hand and fingers. These observations are likely to indicate early infection. hemorrhage. compartment syndrome. shock.

compartment syndrome. Collection of objective data involves assessment of the patient's ability to flex the fingers or toes, coolness of the extremity, and absence of pulse in the affected extremity all of which indicate the impaired circulation symptomatic of compartment syndrome. Assessment of skin color for signs of pallor or cyanosis is made.

A patient has heart failure. His physician's orders include complete bed rest. The nurse knows that this order means he complete bedrest and must remain as quiet as possible, with any task requiring physical effort, will be done for him. is confined to bed but may assume responsibility for all of his personal care. is confined to bed but is allowed to go to the bathroom as needed. is encouraged to rest as much as possible but can ambulate.

complete bedrest and must remain as quiet as possible, with any task requiring physical effort, will be done for him.

Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of (Select all that apply.) 1,000 to 2,000 mL fluids per 24 hours. diminished neurologic sensation combined with decreased bladder capacity. the effects of medications such as diuretics. increased hormonal changes and muscle strength. weakened musculature in the bladder and urethra.

diminished neurologic sensation combined with decreased bladder capacity. the effects of medications such as diuretics. weakened musculature in the bladder and urethra.

The patient has end-stage renal disease (ESRD) and is admitted with a blood urea nitrogen (BUN) level of 93 mg/dL. An excessive elevation of BUN could result in constipation edema. catabolism. disorientation.

disorientation. If the BUN is elevated, preventive nursing measures should be instituted to protect the patient from possible disorientation or seizures.

The nurse would assess closely for signs of right-sided heart failure which include: (Select all that apply.) edema of feet and ankles. distended jugular veins. cough. shortness of breath. orthopnea. increasing abdominal girth.

edema of feet and ankles. distended jugular veins. increasing abdominal girth.

An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. The chest radiograph reveals an accumulation of fluid in the pleural space, which the physician removes by performing a thoracentesis. The nurse correctly records the purulent exudate pus as: emphysema. effusion. empyema. sputum.

empyema. If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

The leaf-shaped cartilage that covers the larynx during swallowing is the ______________. adam's apple larynx epiglottis trachea

epiglottis

The patient, age 43, has cystitis with dysuria. She is receiving Pyridium to decrease her pain. Her urine is reddish-orange. The nurse should send a specimen to the laboratory for analysis. increase fluid intake. report this immediately. explain to the patient that this is normal.

explain to the patient that this is normal.

Pediatric patients, especially girls, are susceptible to urinary tract infections because genetically females have a weaker immune system. females have a short and proximal urethra in relation to the vagina. girls have a weakened musculature and sphincter tone. girls are more sexually active than males.

females have a short and proximal urethra in relation to the vagina.

The nurse is caring for a 27-year-old woman on the postpartum unit one day following a C-section. To prevent clot formation, the nurse will: position the patient with knees flexed. implement deep breathing and coughing exercises. initiate use of fitted thromboembolic disease deterrent (TED) stockings. maintain complete bed rest.

implement deep breathing and coughing exercises. Deep breathing and coughing exercises should be part of regular postoperative nursing care to prevent clot formation. Knees should not be flexed. TED stockings require a physician's order. Early, regular ambulation should be encouraged after surgery.

In teaching a patient how to decrease the chance of further problems with urolithiasis, avoiding any other contraindications, the nurse would encourage him to avoid contact sports. take one baby aspirin daily. restrict his protein intake. increase his fluid intake.

increase his fluid intake. Fluid intake should be encouraged to at least 2,000 mL of fluid in 24 hours, unless contraindicated.

The patient is on a postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by measuring total output and deducting the amount of irrigating solution used. measuring the total output and deducting the total of the irrigating and intravenous solutions. measuring and recording all fluid output in the drainage bag. adding the total of the intravenous and irrigating solutions and then deducting the amount of output.

measuring total output and deducting the amount of irrigating solution used. To determine urine output, the nurse will subtract the amount of irrigation fluid used with the Foley catheter output to calculate urine output.

These structures of the brain are responsible for the nervous control of breathing and regulates the basic rhythm and depth of respirations. medulla oblongata and pons carotid artery and aorta coronary sinus and alveoli brachiocephalic vein and superior vena cava

medulla oblongata and pons

A patient is receiving a thiazide diuretic for hypertension. For prevention of complications, it is particularly important that the nurse encourage emptying of the bladder. increase fluid intake. measure output. monitor serum potassium levels.

monitor serum potassium levels. The thiazide diuretic, chlorothiazide (Diuril), affects electrolytes to cause hypokalemia (extreme potassium depletion in blood).

The microscopic structure and the basic unit of the kidney that filters blood and forms urine is the: renal pelvis nephron afferent arteriole juxtaglomerular apparatus

nephron

The patient has COPD. To teach him pursed-lip breathing, the nurse should instruct him to inhale slowly through his: mouth, then exhale quickly through pursed lips. mouth, then make his exhalation last three times as long as his inhalation. nose, making his inhalation last three times as long as his exhalation. nose, then exhale slowly through pursed lips.

nose, then exhale slowly through pursed lips.

A patient, age 59, has Buerger's disease. The most important aspect of patient compliance in order to decrease signs and symptoms of Buerger's disease is not smoking. a low-fat diet. weight loss. keeping extremities warm.

not smoking. There is a very strong relationship between Buerger's disease and tobacco use. It is thought that the disease occurs only in smokers, and when smoking is stopped, the disease improves. None of the palliative treatments are effective if the patient does not stop smoking.

The physician orders a urinalysis and urine culture. To obtain the urine specimen, the nurse would first instruct the patient about bringing in an early morning specimen. limiting fluid intake to concentrate the urine. collecting the urine for a 24 hour period. obtaining a clean-catch specimen.

obtaining a clean-catch specimen. Urinalysis is completed on a clean-catch or catheterized specimen

Prolonged bed rest puts the older adult at risk for pathological fractures and renal calculi ankylosing spondylitis. gout. osteomyelitis.

pathological fractures and renal calculi Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathological fracture. This is a serious concern for an older adult in terms of regaining mobility.

If this client is typical of others with glomerulonephritis, what finding would the nurse expect to observe when conducting a head-to-toe physical assessment? skin hemorrhages absence of body hair flushed appearance peripheral edema

peripheral edema A common sign associated with glomerulonephritis is peripheral edema that ranges from slight ankle edema in the evening to generalized fluid retention that may compromise cardiac function.

The patient has been admitted for possible carcinoma of the larynx. The first sign or symptom that may be present in carcinoma of the larynx is often persistent hoarseness. pain in the larynx. hemoptysis. dysphagia.

persistent hoarseness.

A 62-year-old patient is seen in the emergency department with epistaxis. When a patient has epistaxis, the correct nursing interventions would be place the patient in Fowler's position with the head leaning forward. compress the nostrils tightly below the bone and hold for 1 minute. place hot compresses over the nose. place the patient in low-Fowler's position with the head hyperextended.

place the patient in Fowler's position with the head leaning forward.

The appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis would be to place the patient in any isolation precautions. place the patient in acid-fast bacillus (AFB) isolation or airborne precautions. place the patient in drainage and secretion precautions. maintain the patient in enteric isolation.

place the patient in acid-fast bacillus (AFB) isolation or airborne precautions. If TB is suspected, permission to place the patient in acid-fast bacilli (AFB) isolation precautions should be requested immediately.

One method of monitoring for signs and symptoms of fluid overload when administering diuretics is: record random weights throughout the day (same scale, clothes, staff member). record daily morning weights (same time, scale, clothes). assess abdomen every shift. eat a diet high in sodium.

record daily morning weights (same time, scale, clothes). Because patients receiving diuretics often have complicated disease conditions such as heart failure and pulmonary edema, record daily morning weights for the patient receiving diuretics. Diet should be low in sodium with no added salt in cooking.

The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, it is important to emphasize that after surgery he should expect incisional drainage. limited intake of fluids. red drainage from the catheter. a sodium-restricted diet.

red drainage from the catheter.

The outer portion of the kidney is called the adrenal cortex adrenal medulla renal medulla renal cortex

renal cortex

When caring for a patient who is 34 years old and has rheumatoid arthritis, the nurse should remember that pain is best controlled by use of narcotic analgesics. rest and exercise are both important parts of therapy and mobility. the patient should be discouraged from performing activities of daily living. exercise should be avoided to decrease pain.

rest and exercise are both important parts of therapy and mobility.

Which of the following makes a correct pathway of blood through the heart? right atrium, tricuspid valve, left atrium, aortic valve, left ventricle right atrium, pulmonary artery, mitral valve, left ventricle, aorta right atrium, left atrium, pulmonary artery, pulmonary veins, aorta right atrium, mitral valve, pulmonary veins, left ventricle, aorta

right atrium, pulmonary artery, mitral valve, left ventricle, aorta

Dependent edema of the extremities, enlargement of the liver, oliguria, jugular vein distention, and abdominal distention are signs and symptoms of: right-sided heart failure. valvular heart disease. cardiac dysrhythmias. left-sided heart failure.

right-sided heart failure.

A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient's condition as: negligible heart failure. moderate heart failure. congestive heart failure. severe heart failure.

severe heart failure. Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.

The nurse clarifies that the master pacemaker of the heart is the: atrioventricular (AV) node. left ventricle. bundle of His. sinoatrial (SA) node. The SA node is the master pacemaker of the heart.

sinoatrial (SA) node.

The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as: sinus tachycardia. atrial fibrillation. sinus bradycardia. ventricular tachycardia.

sinus tachycardia. Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats/min.

A patient has a diagnosis of heart failure. When the nurse walks into his room, he is in orthopneic position, meaning: sitting or standing in order to breathe deeply and comfortably. unable to respond to simple questions. complaining of sudden awakenings from sleep because of shortness of breath. complaining of pain in lower extremities.

sitting or standing in order to breathe deeply and comfortably. Orthopnea is an abnormal condition in which a person must sit or stand in order to breathe deeply and comfortably.

The concentration of dissolved substances in the urine is indicated by a laboratory test called: specific gravity urine culture creatine glomerular filtration rate

specific gravity

When preparing to teach a patient about continuous bladder irrigation, the nurse notes that the most frequently used irrigant is sterile isotonic saline. sterile water. heparinized normal saline. an antibiotic solution.

sterile isotonic saline.

Which of the following is NOT a function of the kidneys? regulation of blood volume storage of fat regulation of blood pressure elimination of wastes

storage of fat

A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include: indigestion, nausea, and eructation. substernal pain that radiates down the left arm. epigastric pain that radiates to the jaw. fatigue, shortness of breath, and dyspnea.

substernal pain that radiates down the left arm. The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw.

The substance that reduces the surface tension of alveolus and prevents it from collapsing after each breath is called_______________. pleural fluid turbinates chemoreceptors surfactant

surfactant

Tough cord of connective tissue that anchor muscles to the bones are called: rectus abdominis cartilage tendons red bone marrow

tendons

Which statement by a client with tuberculosis on a protocol that includes rifampin (RIF) indicates that the teaching about rifampin was effective? 1 "I need to drink a lot of fluid while I take this medication." 2 "I can expect my urine to turn orange from this medication." 3 "I should have my hearing tested while I take this medication." 4 "I might get a skin rash because it is an expected side effect of this medication."

"I can expect my urine to turn orange from this medication." Rifampin (RIF) causes body fluids, such as sweat, tears, and urine, to turn orange. It is not necessary to drink large amounts of fluid with this drug as it is not nephrotoxic. Damage to the eighth cranial nerve is not a side effect of rifampin. It is a side effect of streptomycin sulfate, which is sometimes used to treat tuberculosis. A skin rash is not a side effect of rifampin.

A nurse is reviewing the list of discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further instructions? "I don't need to be worried if the shape of my knee changes." "I need to tell my other doctors about the metal implant." "I need to report fever, redness, or increased pain." "I need to report bleeding gums or tarry stools."

"I don't need to be worried if the shape of my knee changes."

Which statement to the nurse teaching a client scheduled for a kidney transplant about the need for immunosuppressive medications indicates understanding of the teaching? 1 "I must take these medications for the rest of my life." 2 "I must take these medications until the surgery is over." 3 "I must take these medications until the anastomosis heals." 4 "I must take these medications during the intraoperative period."

"I must take these medications for the rest of my life." These drugs must be taken continuously to prevent rejection of the transplanted organ. The danger of rejection always exists. The client must take the medications longer than after the surgery or until the anastomosis heals or during the intraoperative period.

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? "I need to avoid getting the cast wet." "I can use a padded coat hanger end to scratch under the cast." "I need to cover the casted leg with warm blankets." "I will use my fingertips to lift and move the leg."

"I need to avoid getting the cast wet." A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching.

A client has just had an application of a nonplaster (fiberglass) leg cast, and the nurse is giving the client instructions on cast care at home. Which statement by the client indicates the need for further instructions? "I can use a damp cloth to wipe off surface dirt on the cast." "I should use a hair dryer set to the hot setting to dry my cast if it gets wet." "I should not use anything to scratch underneath the cast." "I need to avoid walking on wet or slippery floors."

"I should use a hair dryer set to the hot setting to dry my cast if it gets wet." Rationale: If a nonplaster cast gets wet, it should be dried with a hair dryer set only to a cool setting to prevent skin breakdown. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation. The client should also avoid walking on wet or slippery floors to prevent falls. It is acceptable to remove surface soil on a cast with a damp cloth.

A patient with rheumatoid arthritis asks the nurse about her condition. On what knowledge does the nurse base patient teaching? Most patients affected by rheumatoid arthritis are women older than age 65 years Exercise is discouraged for the patient with rheumatoid arthritis because the muscles and joints must rest. Rheumatoid arthritis is an autoimmune disorder Rheumatoid arthritis is an acute inflammatory condition that usually resolves in 2 to 4 weeks.

Rheumatoid arthritis is an autoimmune disorder

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor tells the student that she needs to read and learn about this disorder if the student incorectly states that which of the following is an associated risk factor? Long-term use of corticosteroids High-calcium diet consumption Family history of osteoporosis Postmenopausal age

High-calcium diet consumption Risk factors associated with osteoporosis include a diet that is deficient in calcium. Options 2, 3, and 4 include risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide (Lasix).

Rheumatoid arthritis is distinguished from osteoarthritis in that: Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease. People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis. Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis.

The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. This condition is known as scoliosis. spondylitis. lordosis. kyphosis.

lordosis. Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the "lordly or kingly" appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of thoracic spine.

When caring for the patient who is in shock, the nurse's priority is to provide adequate oral fluids to replace blood loss. oxygen to support respiratory function. sedatives to decrease anxiety and apprehension. external heat to combat shivering.

oxygen to support respiratory function. Respiratory assistance may be given by administering oxygen. IV fluids are required for rapid access to blood volume. Shock causes altered level of consciousness and does not require medication to decrease anxiety or apprehension.

A patient, age 72, has a left intertrochanteric fracture as a result of a fall. In planning ways to increase her safety, the nurse realizes it is most important to determine psychosocial history. nutritional status. pain level. preexisting health conditions.

preexisting health conditions. The patient's medical and surgical history is significant, as well as any family history of bone disease. Although pain level, nutritional status, and psychosocial history are important, they are not the most important.

A patient, age 45, has had a left intramedullary rod placed into his left femur. He is presenting with signs and symptoms of postoperative shock. The recommended position for a person going into shock is orthopneic. semi-Fowler's. Fowler's supine.

supine. The patient should remain flat in bed. Avoid the Trendelenburg position because it pushes the abdominal organs against the diaphragm, affecting the lung and heart.

A patient, age 89, has had a right below-the-knee amputation. He is progressing well but continues to complain of pain in the toes on his right foot. The physician told him that he is suffering from "phantom pain" in his amputated extremity. He asks the nurse to explain phantom pain. The most appropriate response would be "Phantom pain occurs when you start thinking about your loss. It's best to keep your mind occupied with other things." "I can't answer that. You'll have to ask the physician." "Phantom pain does not exist except in your mind." "Phantom pain occurs because the nerve tracts that register pain in the amputated limb continue to send a message to the brain."

"Phantom pain occurs because the nerve tracts that register pain in the amputated limb continue to send a message to the brain."

The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response? "You have fat deposits that are common with gouty arthritis." "You have calcium oxalate deposits that are seen in gouty arthritis." "The inflammation is from small accumulations of uric acid crystals, which are called tophi." "The small nodules are not related to the arthritis condition."

"The inflammation is from small accumulations of uric acid crystals, which are called tophi."

A client who is scheduled for surgery to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? "Skeletal traction is much more effective than skin traction in your situation." "You have concerns about skeletal versus skin traction for your type of fracture?" "Your fracture is very unstable. You will die if you don't have this surgery performed." "There is no reason to be concerned. I have seen lots of these procedures."

"You have concerns about skeletal versus skin traction for your type of fracture?" Option 4 identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Option 1 identifies a communication block that reflects a lack of the client's right to an opinion. It will also cause fear in the client. In option 2, the nurse is offering a false reassurance and this type of response will block communication. Option 3 is also a communication block and reflects a lack of the client's right to an opinion.

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? Adductor splint Abductor splint Overhead trapeze Bed pillow

Abductor splint Rationale:Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client: Leans forward slightly when advancing the walker Holds the walker using the handgrips Supports body weight on the hands while advancing the weaker leg Advances the walker with both legs at the same time

Advances the walker with both legs at the same time

The main purpose of traction is to: Select all that apply Align and stabilize a fracture Relieve muscle spasms Promote sleep and bed rest Prevent deformities Increase circulation to the rest of the body

Align and stabilize a fracture Relieve muscle spasms Prevent deformities

A nurse in the emergency room is caring for a client with a fractured arm. The nurse understands that which of the following is not necessary before reduction of the fracture in the casting room? Anesthesia consent Explanation of the procedure to the client Administration of an analgesic as ordered Consent for the procedure

Anesthesia consent Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed, because the procedure is painful. Administration of anesthesia may or may not be done, depending on severity. Closed reductions may be done in the emergency room without anesthesia. If anesthesia is used, the procedure is done in the operating room.

A 76-year-old female patient is being seen for osteoarthritis of the knee in the clinic. In discussing strengthening exercises, which exercises would you recommend? Jogging and running Climbing stairs 5 to 8 times daily Bicycling for short distances Walking up and down small elevations like hiking

Bicycling for short distances Bicycling or swimming is recommended for osteoarthritis of the hip or knee. Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations.

A nurse is caring for a client being treated for a fat embolus after multiple fractures. Which of the following data would the nurse determine as the most favorable indication of resolution of the fat embolus? Minimal dyspnea Oxygen saturation of 85% Clear chest x-ray Arterial oxygen level of 78 mm Hg

Clear chest x-ray A clear chest x-ray is a favorable indicator that a fat embolus is resolving. When fat embolism occurs, there is a "snowstorm" appearance to the chest x-ray. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.

A nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity because: Compartment syndrome may lead to irreversible nerve and muscle tissue injury. The skin under the cast is at high risk for infection The client is at high risk of neurovascular compromise until the cast is completely dry Alterations in the neurovascular status of the fingers may be early signs of fat embolism.

Compartment syndrome may lead to irreversible nerve and muscle tissue injury. The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. The skin under the cast is not necessarily at risk for infection. The signs of other complications, such as fat embolism and skin infection, are not monitored by assessment of the neurovascular status of the casted extremity, but by other observations. The risk of compartment syndrome is related to internal or external causes of increased pressure in muscle compartments, not a result of the cast being wet.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? Crutches and the left leg, then advance the right leg Left leg and right crutch, then right leg and left crutch Crutches and then both legs simultaneously Crutches and the right leg, then advance the left leg

Crutches and the left leg, then advance the right leg Rationale:A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait. Putting the crutches and the right leg down, then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then right leg and left crutch down describes a two-point gait.

A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which of the following would the nurse avoid to minimize the chance for further injury? Delays in responding to call light Side rails in the "up" position Use of night-light in hospital room and bathroom Call bell placed within reach

Delays in responding to call light Safe nursing actions intended to prevent injury to the client include keeping side rails up,having the bed in a low position, and providing a call bell that is within the client's reach.Responding promptly to the client's use of the call light minimizes the chance that the clientwill try to get up alone, which could result in a fall.

A nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right femur sustained from a fall 5 hours ago. The nurse develops a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. The nurse includes in the plan to monitor for which of the following? Pallor, paresthesia, and pulselessness of the right lower leg Fever and shaking chills Dyspnea and chest pain External rotation of the right leg

Dyspnea and chest pain The signs of fat embolism are associated with alterations in respiratory status or neurologicalstatus. Dyspnea, petechiae, and chest pain are signs of fat embolism. Option 1 is indicative ofa hip fracture. Option 2 indicates signs of infection, and option 4 indicates signs of severecirculatory impairment.

A nurse is assigned to care for a client with multiple trauma who is admitted to the hospital. The client has a leg fracture and a plaster cast has been applied. In positioning the casted leg, the nurse should: Elevate the leg for 3 hours and put it flat for 1 hour Keep the leg in a level position. Elevate the leg on pillows continuously for 24 to 48 hours Keep the leg level for 3 hours and elevate it for 1 hour

Elevate the leg on pillows continuously for 24 to 48 hours A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage

The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include? Estrogen replacement therapy is the cure and must be started to prevent rapid progression of her osteoporosis. With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.

Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids.

A nurse is discussing with clients primary prevention measures regarding osteoporosis. The nurse plans to tell the clients that which of the following is a primary prevention measure? Installing telephones in most rooms of the house Applying nonskid strips on areas that get wet Selecting shoes that have firm, nonskid soles Maintaining body weight at or slightly above minimum recommended levels

Maintaining body weight at or slightly above minimum recommended levels

A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy? Cut the cast off to release constriction. Apply a warm compress to the fingers to relieve swelling. Elevate the right hand to heart level to maintain arterial pressure and reduce edema. Notify the charge nurse of a probable compartment syndrome.

Notify the charge nurse of a probable compartment syndrome.

What should the nurse include in the plan of care for a patient following a myelogram? Position in a semi-fowler's or flat depending on the dye that was used for 8-12 hours to reduce potential of headache. Ambulate for brief periods to lessen post-myelogram headache. Limit fluids to increase absorption of the dye. Place patient flat on back to compress puncture site.

Position in a semi-fowler's or flat depending on the dye that was used for 8-12 hours to reduce potential of headache.

Which test result would the nurse anticipate when reviewing the laboratory reports of a client with end-stage renal disease? 1 Arterial pH 7.5 2 Hematocrit of 54% 3 Creatinine of 1.2 mg/dL 4 Potassium of 6.3 mEq/L

Potassium of 6.3 mEq/L Clients with end-stage renal disease have impaired potassium excretion so the nurse should anticipate a potassium level more than the expected range of 3.5 to 5 mEq/L. Clients with end-stage renal disease usually have a serum pH that is less than 7.35 due to metabolic acidosis. A pH of 7.5 that exceeds the expected range of 7.35 to 7.45 is not anticipated. Clients with end-stage renal disease have decreased erythropoietin which leads to decreased red blood cell production and hematocrit (HCT). A hematocrit of 54% exceeds the expected range which is 42% to 52% for males and 35% to 47% for females. Clients with end-stage renal disease have a decreased ability to eliminate nitrogenous wastes leading to increased creatinine levels. A creatinine level of 1.2 mg/dL is within the expected range of 0.7-1.4 mg/dL and therefore is not anticipated.

What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure? Wear only cotton garments for the procedure. Remove all metal, such as jewelry, glasses, and hair clips. Omit all citrus food for 12 hours before the procedure. Void to completely empty the bladder.

Remove all metal, such as jewelry, glasses, and hair clips.

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse would pay particular attention to monitoring for which of the following high-risk areas for pressure and breakdown? Left heel Back of the head Right heel Scapula

Right heel Rationale: There are specific areas that are under pressure and are at risk for breakdown in the client who has skeletal traction. These include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.

A nurse has given the client instructions regarding crutch safety. The nurse determines that the client needs reinforcement of the instructions if the client states: Not to use someone else's crutches That crutch tips should be inspected periodically for wear and tear The need to have spare crutches and tips available That crutch tips will not slip, even when wet or the floor is wet

That crutch tips will not slip, even when wet or the floor is wet Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

A client is being discharged to home following spinal fusion with insertion of rods. The nurse would suggest a consultation with the continuing care nurse regarding the need for follow-up modification of the home environment if the client states that: There are three steps to get up to the front door The family has rented a commode for use by the client. The bathroom has hand railings in the shower. The bedroom and bath are on the second floor of the home.

The bedroom and bath are on the second floor of the home. Stair climbing may be restricted or limited for several weeks following spinal fusion with instrumentation. The nurse ensures that resources are in place prior to discharge so that the client may sleep and perform all ADLs on a single living level

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client: Keeps the cane 6 inches out to the side of the right foot Holds the cane on the right side Leans on the cane when the right leg swings through Moves the cane when the right leg is moved

The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? The client advances the walker alternately for each with movement of the legs. The client holds the walker using the handgrips. The client leans forward slightly when advancing the walker. The client supports body weight on the hands while advancing the weaker leg.

The client advances the walker alternately for each with movement of the legs. The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.

The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? The cast will give off heat as it dries. The client may bear weight on the cast in 30 minutes. A stockinet will be placed over the leg area to be casted. The cast edges may be trimmed with a cast knife.

The client may bear weight on the cast in 30 minutes. The client needs further teaching about plaster casts if the client plans to bear weight on the cast in 30 minutes. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries.

The patient is a 20-year-old who has suffered a compound fracture of the femur. The nurse would expect the physician to order ____ intramuscularly. morphine gluconate calcium gluconate tetanus toxoid low-molecular-weight heparin

tetanus toxoid Administration of tetanus toxoid is an additional medical measure for compound fracture of the femur.

A nurse has reviewed activity restrictions with a client who is being discharged following insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client states to: Bend carefully to put on socks and shoes. Exercise the leg past the point of 90-degree flexion. Sit in chairs without arms for better mobility Use a raised toilet seat.

Use a raised toilet seat. The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion.

Which action is important for the nurse to implement in a client with an indwelling urinary catheter when irrigating the bladder? 1 Use sterile equipment. 2 Instill the fluid under high pressure. 3 Warm the solution to body temperature. 4 Aspirate immediately to ensure return flow.

Use sterile equipment. The bladder is a sterile body cavity. When introducing a solution/catheter surgical asepsis is required. Excessive pressure can traumatize the lining of the urinary tract. The solution generally is administered at room temperature. Aspirating immediately to ensure return flow is done if the fluid does not return by gravity. The negative pressure exerted during aspiration may cause trauma.

A patient, age 24, has a compartment syndrome after a fracture of his radius and ulna. Nursing assessment will include careful observation for signs and symptoms of Volkmann's contracture. thromboembolism. buccal petechiae. fat embolism.

Volkmann's contracture. Volkmann's contracture is a permanent contracture that can occur as a result of circulatory obstruction secondary to compartment syndrome.

A patient, age 24, is recovering from a fractured tibia. She has been wearing a leg cast for the past month to immobilize the fracture and promote proper alignment. She is being seen at the clinic for follow-up radiographic evaluation of the fracture. The physician tells her that he is hoping for good callus formation to have occurred. When she asks what callus formation is, the nurse tells her it is the formation of a clot over the fracture site. a part of the bone healing process after a fracture when new bone is being formed over the fracture site. when the hematoma becomes organized and a fibrin meshwork is formed. when blood vessels of the bone are compressed.

a part of the bone healing process after a fracture when new bone is being formed over the fracture site. Callus formation occurs when the osteoblasts continue to lay the network for bone build-up and osteoclasts destroy dead bone.

A patient, age 45, has worked as a basket weaver for the past 10 years. She is being seen at the clinic for symptoms of carpal tunnel syndrome. Collection of subjective data might include edema of the fingers. complaints of weight loss and fatigue. radicular pain. complaints of burning pain or tingling in the hands.

complaints of burning pain or tingling in the hands. Collection of subjective data includes the patient's description of discomfort, such as burning pain or tingling in the hands and numbness of thumb, index, and ring fingers.

A 71-year-old patient is manifesting signs and symptoms of gout. When assessing him for signs and symptoms of gout, the nurse should pay particular attention to edema, inflammation and discoloration of the great toe. a history of trauma or occupational injury. dietary intake of foods high in cholesterol. mobility in the hip and knee joints.

edema, inflammation and discoloration of the great toe. Tophi (calculi containing sodium urate deposits that develop in periarticular fibrous tissue, typically in patients with gout) result in inflammation of the joint; it is unclear why this occurs. Typically the big toes are involved, but other joints can also be affected. Particular attention should be paid to foods high in purines.

A patient fell 2 days ago; he has a compound fracture of his left tibia. The physician performed an open reduction with internal fixation (ORIF) to treat the fracture. An important nursing assessment for him would include: ecchymosis and edema at incision site. complaints of activity intolerance. elevated temperature and presence of erythema at incision site. hyperactive bowel sounds.

elevated temperature and presence of erythema at incision site. Collection of objective data includes careful inspection of any wounds. The drainage is assessed for color, amount, and presence of odor. Vital signs are assessed for signs of infection (temperature elevation, tachycardia, and tachypnea).

A patient, age 64, has osteoarthritis of the left hip. He just had a left total hip replacement 2hrs ago. To prevent from developing complications, the nurse should turn the patient frequently from side to side. encourage use of the high Fowler's position. encourage use of an incentive spirometer. administer 10L/min of oxygen through a nasal cannula.

encourage use of an incentive spirometer. The use of incentive spirometers is valuable in assisting the patient to perform adequate respiratory ventilation to prevent pneumonia.