414 exam review

A client is admitted to the hospital and is found to have the following arterial blood gas results: pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. What is the priority nursing intervention?

The client is in respiratory acidosis. The client has a PO2 of 60 and the client is hypoxic and needs oxygen. The potassium level may be high with respiratory acidosis and cardiac monitoring may be indicated but it is not the priority. The client is not in metabolic acidosis (DKA) therefore there is not a known need for insulin. The client may need bicarbonate but it is not the priority.

The client is admitted for left heart failure. Which signs and symptoms correlate with this medical condition? A. Orthopnea B. Hepatomegaly C. Crackles in bilateral bases D. Restlessness E. Peripheral edema

A. Orthopnea C. Crackles in bilateral bases D. Restlessness Response Feedback: Signs and symptoms of left heart failure include pulmonary symptoms such as, orthopnea, shortness of breath, crackles, changes in the level of consciousness (restlessness, confusion), and tachycardia. Right heart failure includes peripheral edema, hepatomegaly, splenomegaly, ascites, and JVD.

A client is diagnosed with primary hypertension. When taking the client's history, the healthcare provider anticipates the client will report which of the following? A. "I have not noticed any significant changes in my health." B. "Sometimes I get pain in my lower legs when I take my daily walk." C. "Every once in a while I wake up covered in sweat." D. "I'm starting to get out of breath when I climb a flight of stairs."

A. "I have not noticed any significant changes in my health." Hypertension rarely produces symptoms, except in extreme cases. That's why hypertension is often referred to as a silent disease or silent killer

A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous (IV) fluids followed by an IV bolus of regular insulin. The nurse anticipates that the health care provider will prescribe a continuous infusion of:

Response Feedback: Regular insulin is the only insulin that is administered intravenously. Novolin L insulin cannot be administered intravenously. Novolin N insulin cannot be administered intravenously. Novolin U insulin cannot be administered intravenously.

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply.

Response Feedback: Wearing shoes protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature.

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit?

Response Feedback:A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30) and the HCO 3 - will be low (20 mEq/L). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26. A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis

Which statement by a client with type 2 diabetes indicates to the nurse that additional teaching about the diet is needed?

The client needs further teaching; dietetic fruit is not sugar-free and must be calculated in a diabetic individual's diet. Lettuce is considered a free food in the diet of a diabetic person. It is suggested that the caloric intake of a diabetic person's diet should be 50% carbohydrate, 20% protein, and 30% fat. Saturated fats should be limited to 10% of the fat intake; 90% of fat should be unsaturated fats.

The client is admitted with suspected pneumonia. Vitals signs include: temperature of 101.2, heart rate 112, respirations 24, blood pressure 130/78 and oxygen saturation of 95% on 3L NC. The client has the following rhythm on the heart monitor. Which intervention(s) should the nurse implement? Select all that apply. (SINUS TACH) A. Administer the initial dose of Ceftriaxone IVPB B. Administer the PRN Adenosine C. Promote the use of the incentive spirometer. D. Administer the PRN Acetaminophen. E. Encourage the client to drink fluids.

A. Administer the initial dose of Ceftriaxone IVPB C. Promote the use of the incentive spirometer. D. Administer the PRN Acetaminophen. E. Encourage the client to drink fluids. The client is in sinus tachycardia. The likely cause for the increased heart rate is pneumonia and fever. Administering antibiotics and acetaminophen are appropriate. Increasing fluids will help to prevent dehydration from the increased respiratory rate and the fever; it will also make it easier for the client to expectorate pulmonary secretions. The use of an incentive spirometer is also important for a client with pneumonia. The adenosine is not appropriate for sinus tachycardia with a rate of 112.

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply. A. Heart rate of 110 B. Blood pressure of 90/40 C. Pulmonary congestion D. Hypoactive bowel sounds E. Temperature of 100.1

A. Heart rate of 110 B. Blood pressure of 90/40 Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; a rapid, thready pulse compensates for this shift. Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; the decrease in blood pressure is evidence of hypovolemia. Decreased peristalsis is not the priority. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not the lungs. Fever is not a concern at this time. If the client were to develop an infection as a result of the procedure, a fever will occur several days after the procedure.

Which factors are associated with developing Guillain-Barré Syndrome? Select all that apply. A. Recent upper respiratory infection B. Diabetes C. Epstein-Barr infection D. Client is 4-years-old E. Recent flu vaccination

A. Recent upper respiratory infection C. Epstein-Barr infection E. Recent flu vaccination Risk factors for developing Guillain-Barré Syndrome include: experiencing upper respiratory infection, GI infection (especially from Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination (flu or swine flu)

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? A. Suction the client's oropharynx. B. Administer oxygen via nasal cannula. C. Auscultate for breath sounds. D. Place the client in the orthopneic position.

A. Suction the client's oropharynx. A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway. Oxygen administration will be useless if the airway is not patent. Placing the client in the orthopneic position is unsafe for a client with Guillain-Barré syndrome. The client will be unable to maintain this position. Muscle weakness involves the lower extremities, progressing to the upper extremities and diaphragm.

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is: A. "All family members, including your child, need to wash their hands after using the bathroom." B. "You will need to clean the bathroom from top to bottom every time a family member uses it." C. "I suggest that you buy a commode exclusively for your child's use." D. "Your child may use the bathroom, but you need to use disposable toilet covers."

A. "All family members, including your child, need to wash their hands after using the bathroom." Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. It is not feasible to clean "from top to bottom" each time the bathroom is used. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Handwashing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

A nurse cares for a client suspected of having acute respiratory distress syndrome (ARDS). Which assessment data supports the suspected diagnosis? Select all that apply.

ARDS is a condition of diffuse alveolar injury that prevents diffusion of oxygen into the bloodstream. ARDS is an acute syndrome with rapid onset. Pulmonary edema and decreased surfactant production increase the thickness of the alveolar capillary space, increasing the distance oxygen must travel to reach the blood. This results in hypoxemia and respiratory acidosis, not metabolic alkalosis. Crackles on auscultation can occur secondary to pulmonary edema, caused by interstitial fluid accumulation secondary to capillary leak syndrome that occurs with ARDS. Confusion can occur after the onset of hypercapnia and impaired ventilation. Tachypnea is often a symptom of ARDS, along with increased work of breathing and nasal flaring or use of accessory muscles.

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? A. Meperidine B. Aspirin C. Lidocaine D. Alprazolam

B. Aspirin Early administration of aspirin in the setting of acute myocardial infarction (MI) has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstructing blood flow. Prompt administration of an antiplatelet agent, such as aspirin, significantly reduces damage and can be lifesaving, the earlier the better, hence the reason why it is part of emergency management treatment. Lidocaine is an antidysrhythmic and is used for ventricular dysrhthmias. Meperdine is an opioid but morphine is the preferred opioid for an MI because of the decrease in preload, afterload, and the reduced oxygen demands on the heart. Alprazolam is an anxiolytic that is used for its calming effect, but it will not relieve the pain of an MI.

An 85-year-old client with a history of congestive heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sim's position, receiving oxygen at 2 L/min via nasal cannula. Which action would the nurse do first? A. Obtain the apical pulse and blood pressure B. Raise the client to high-Fowler position. C. Monitor the pulse oximeter to ascertain the oxygen level D. Call the primary health care provider immediately

B. Raise the client to high-Fowler position. Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary health care provider immediately would not be useful without having a full set of vital signs, which should include the oxygen saturation, which the health care provider would expect the nurse to provide.

A client with Guillain-Barré Syndrome has a feeding tube for nutrition. What priority actions should the nurse perform prior to starting the tube feeding? Select all that apply. A. Don sterile gloves. B. Check the client's gastric residual. C. Check tube placement. D. Raise the head of the bed to 30 degrees. E. Assess the client's bowel sounds.

B. Check the client's gastric residual. C. Check tube placement. D. Raise the head of the bed to 30 degrees. E. Assess the client's bowel sounds. Some patients who experience GBS will need a feeding tube because they are no longer able to swallow safely due to paralysis of the cranial nerves that help with swallowing. GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeding the nurse should always assess for bowel sounds, check gastric residual, placement of the tube. Elevation of the head of the bed helps to decrease the risk of aspiration.

The family member of a client with newly diagnosed Guillain-Barre's syndrome comes out to the nurse's station and informs the nurse the client states he is having difficulty breathing. What is the first action the nurse should do? A. Notify the health care provider. B. Inform the family member the nurse will be in to assess the client. C. Assure the family member this is a normal response for this disease. D. Call a code, as the client will need endotracheal intubation.

B. Inform the family member the nurse will be in to assess the client. The initial response for the nurse is to assess the client to ensure a patent airway. Guillain-Barre's syndrome will exhibit ascending paralysis and can impede respiratory function. The health care provider will be notified after the nurse has assessed the client. This is not a normal response to this disease so it is not correct to assure the family member of this. The nurse will not call a code until she has assessed the client.

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? A. Placing the client in the high-Fowler position immediately after the procedure. B. Maintaining the client in the supine position for several hours. C. Keeping the client in the Trendelenburg position for at least 2 hours. D. Encouraging the client to ambulate every hour for at least 6 hours.

B. Maintaining the client in the supine position for several hours. Staying flat may help to prevent spinal fluid leakage and postprocedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours.

A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory report, which of the following results will the healthcare provider anticipate? A. Neutrophilia B. Thrombocytopenia C. Leukocytosis D. Polycythemia

B. Thrombocytopenia The spleen acts as a reservoir for platelets. When the spleen is enlarged, as with splenomegaly, up to 90 percent of a person's thrombocytes can be sequestered within the enlarged spleen.

A school health nurse is teaching a health class to 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease? A. "The disease is passed from person to person by casual contact." B. "You're more likely to get it in crowded living conditions." C. "You can catch it while you're getting a tattoo." D. "People working at restaurants can give it to you if they don't wash their hands."

C. "You can catch it while you're getting a tattoo." The hepatitis C virus (HCV) is a bloodborne pathogen; it can be acquired during the application of a tattoo with equipment that is contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a bloodborne pathogen. HCV is not transmitted by casual contact; it is a bloodborne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.

The client with hypertension is being discharged on captopril and spironolactone. What priority discharge teaching should the nurse include? A. Take these medications with food. B. Be sure to avoid eating grapefruit or drinking grapefruit juice. C. Be sure to avoid salt substitutes that contain potassium chloride. D. Be sure to include foods high in potassium.

C. Be sure to avoid salt substitutes that contain potassium chloride Response Feedback: Ace inhibitors and spironolactone may cause hyperkalemia and salt substitutes that are made with potassium chloride could increase this risk. The client should not increase their intake of potassium foods for the same reason. Captopril is best taken on an empty stomach and grapefruit does not affect either medication

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which findings warrant the postponement of the procedure? Select all that apply. A. Ecchymosis and purpura B. Platelet count of 160,000/mm3 C. Marked ascites D. Hepatic cirrhosis E. Hemoglobin less than 9 g/dL

C. Marked ascites E. Hemoglobin less than 9 g/dL Answers: A. Ecchymosis and purpura To do a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL should not have a liver biopsy because the client cannot take the risk of the puncture of a hepatic blood vessel. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy, because it is done to detect the presence of hepatic cirrhosis. Although a platelet count of 160,000/mm3 is within the low range of the expected platelet count for an adult, a liver biopsy is not contraindicated. A count of less than 50,000/mm3 is critical and requires postponement of the test. Ecchymosis and purpura are signs of bruising and If the client has numerous bruises it may indicate deficient thrombocytes or prolonged clotting; both are contraindications for a percutaneous liver biopsy

A nurse is caring for a client with ascites who is to receive intravenous (IV) albumin. The nurse expects that the albumin replacement will decrease the: A. Venous stasis and blood urea nitrogen level B. Ascites and blood ammonia levels C. Peripheral edema and hematocrit level D. Capillary perfusion and blood pressure

C. Peripheral edema and hematocrit level Serum albumin is administered to maintain serum levels and normal oncotic (osmotic) pressure; it does this by pulling fluid from the interstitial spaces into the intravascular compartment. Serum albumin does affect blood ammonia levels; fluid accumulated in the abdominal cavity is removed via a paracentesis. The administration of albumin results in a shift of fluid from the interstitial to the intravascular compartment, which probably will increase the blood pressure. Albumin administration does not affect venous stasis or the blood urea nitrogen

A client with myasthenia gravis improves and is discharged from the hospital. Discharge medications include pyridostigmine (Mestinon) 10 mg orally every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should: A. "Drink milk with each dose of Mestinon." B. "Take the Mestinon on an empty stomach." C. "Set my alarm clock to take my medication." D. "Count my pulse before taking the drug."

C. "Set my alarm clock to take my medication." Pyridostigmine must be taken on time; missed or late doses can result in severe respiratory and neuromuscular consequences or even death. The response "Count my pulse before taking the drug" is unnecessary. The response "Drink milk with each dose of Mestinon" is unnecessary because the drug is not a gastric irritant. The response "Take the Mestinon on an empty stomach" is unnecessary because food does not impair the absorption of the drug.

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding indicates a need for more frequent monitoring? A. Localized seizures B. Skin desquamation C. Ascending weakness D. Hyperactive reflexes

C. Ascending weakness The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Localized seizures are not a characteristic of Guillain-Barré syndrome. Skin desquamation is not a characteristic of Guillain-Barré syndrome. Deep tendon reflexes are absent with Guillain-Barré syndrome.

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis? A. CBC B. Magnetic resonance imaging (MRI) C. Edrophonium chloride D. Lumbar puncture

C. Edrophonium chloride The Tensilon test is used in the client with myasthenia gravis to distinguish between a myasthenic crisis and a cholinergic crisis. In this test, edrophonium chloride (Tensilon), a short-acting anticholinesterase agent, is administered via the intravenous route. Symptoms of flaccid paralysis improve if the cause is myasthenic crisis and worsen if the cause is cholinergic crisis. To avoid respiratory arrest, in the event the symptoms are the result of a cholinergic crisis, the anticholinergic medication atropine must be readily available at the bedside. CBC, lumbar puncture, and MRI tests will offer no insight for differentiating myasthenic and cholinergic crises.

What feeding instruction should a nurse give the mother of a 2-month-old infant with the diagnosis of heart failure? A. Use double-strength formula. B. Avoid using a preemie nipple. C. Feed slowly while allowing time for adequate periods of rest. D. Refrain from feeding until crying from hunger begins.

C. Feed slowly while allowing time for adequate periods of rest. Because of limited exercise tolerance and fatigue, infants with heart failure become too tired to feed; allowing rest and feeding slowly limits the fatigue associated with feeding. Although the infant may be given a formula with a higher caloric value (30 kcal/oz rather than 20 kcal/oz), double-strength formula is too high an osmotic load for the infant. A soft nipple used for preterm infants or a regular nipple with an enlarged opening is preferred to conserve the energy required for sucking. Crying consumes energy and is exhausting. The infant should be fed when exhibiting signs of hunger, such as sucking on a fist.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: A. Monitor the hourly urinary output B. Obtain the vital signs C. Assess the pain further D. Stop the transfusion

D. Stop the transfusion Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.

The nurse cares for a client with atrial fibrillation and a heart rate of 123 beats/min. How does the heart rate affect cardiac output for this client? A. Oxygen demand decreases. B. Ventricular filling time increases C. Stroke volume increases. D. Ventricular filling time decreases.

D. Ventricular filling time decreases. Response Feedback: Ventricular filling time is the amount of time allowed for the ventricles to fill with blood before pumping the blood to the rest of the body. Occurring during diastole, it decreases when the heart rate increases. Stroke volume is the amount of blood pumped by the left ventricle with each cardiac contraction. Tachycardia would decrease (not increase) stroke volume. Ventricular filling time decreases when the heart rate increases; there is less time for the ventricles to fill completely. Oxygen demand increases, not decreases, as the heart rate increases.

During the morning assessment of a client with cirrhosis, you note the client is disoriented to person and place. In addition, while assessing the upper extremities, the client's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A.Potassium level of 3.7 mmol/L B. Creatinine level of 2.9 mg/dL C. Calcium level of 10.9 mg/dL D.Ammonia level of 68 µ/dL

D. Ammonia level of 68 µ/dL Based on the assessment findings and the fact the client has cirrhosis, the client is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings

A client undergoes cardiac catheterization via the femoral artery. What is the most important nursing action after the procedure? A. Keep the patient NPO B. Check for a pulse deficit C. Elevate the head of the bed D. Assess the groin for bleeding

D. Assess the groin for bleeding Most complications after cardiac catheterization involve the puncture site; included are localized hemorrhage and hematomas, as well as thrombosis of the femoral artery. Although checking for a pulse deficit is important, it is not the priority assessment. The client should remain supine to avoid disturbing the insertion site. It is not necessary for the client to remain NPO after the procedure.

The nurse cares for a client with type 1 diabetes mellitus. The nurse finds the client shaky, light-headed, and weak with a blood sugar of 61 mg/dL. Which intervention is the best choice for this client?

Response Feedback: A half-cup of juice is equivalent to approximately 15 g of carbohydrate which is appropriate for hypoglycemic treatment in a conscious client. A blood glucose level below 70 mg/dL is considered hypoglycemia. Hypoglycemia can be triggered by several factors, including too much diabetes medication, too little food intake, delayed gastric emptying, alcohol ingestion, exercise, and decreased kidney clearance. Clients usually experience symptoms such as diaphoresis, anxiousness, shaking, weakness, intense hunger, and blurred vision. Treatment of hypoglycemia is carbohydrate replacement by eating, drinking, or medication if unable to swallow. Bread contains 15 g of carbohydrate, but the peanut butter added to the bread contains fat, which slows the absorption of glucose into the bloodstream. Juice is a better treatment choice. The client does not need IV or IM intervention because the client is able to eat/drink

A nurse assesses a client who is recovering from a thoracentesis. Which assessment finding is most concerning to the nurse?

Response Feedback: A thoracentesis is the insertion of a needle in the pleural space at the 8th-10th intercostal spaces on the midaxillary line. This procedure removes the accumulation of fluid in the pleural space, such as an effusion, and can be therapeutic and diagnostic. After a thoracentesis, the nurse should be alert for signs of a pneumothorax. This includes diminished breath sounds, retractions, dyspnea, increased respiratory rate, and cyanosis.The recently performed thoracentesis greatly increases the risk for a pneumothorax. Though a respiratory rate of 25 or an expiratory wheeze is not a normal finding, diminished breath sounds on the affected side would indicate a pneumothorax and would take priority.

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them.

Response Feedback: Air should be injected into the air space of the intermediate-acting insulin vial before short-acting insulin is drawn into the syringe; the needle should not touch the insulin. The nurse should inject the amount of air into the short-acting insulin vial equivalent to the volume to be withdrawn to prevent negative pressure that can make withdrawal difficult. The short-acting insulin should be withdrawn first to prevent possible contamination of the vial with the intermediate-acting insulin, which would cause a delay in onset time of the short-acting insulin. The intermediate-acting insulin should be drawn up after the short-acting insulin to prevent contamination of the short-acting insulin.

A nurse plans to teach a 7-year-old child with recently diagnosed type 1 diabetes how to give insulin injections. What should be included in the first lesson? Select all that apply.

Response Feedback: At 7 years of age, a child is curious and ready to learn when a simple explanation is offered. Seven-year-old children are able to manipulate objects and learn from doing. Children learn best when learning is interactive; a return demonstration provides an opportunity for the nurse to evaluate what is learned. The child is too young to be given reading materials to take home; readiness for this is determined at future meetings as the child gets older and reading skills improve. The presence of friends will be too distracting.

The nurse cares for a client with diabetes mellitus. The client's blood glucose level is 563 mg/dl upon admission. Which physical characteristic does the nurse expect to assess?

Response Feedback: Diaphoresis is a neurogenic symptom of clients experiencing hypoglycemia. It is not a common symptom of hyperglycemia. Tingling lips is a neurogenic symptom of clients experiencing hypoglycemia. It is not a common symptom of hyperglycemia. Tremors are a neurogenic symptom of clients experiencing hypoglycemia. It is not a common symptom of hyperglycemia.Hyperglycemia results in dehydration including hemoconcentration, hypovolemia, poor tissue perfusion, and hypoxia. Poor skin turgor is demonstrated with dehydration and would be a likely physical characteristic with hyperglycemia.

A nurse cares for a client whose endotracheal tube is being removed after successful weaning off mechanical ventilation. Which immediate post-extubation action(s) does the nurse perform? Select all that apply.

Response Feedback: Extubation is the removal of the advanced airway, usually an endotracheal tube (ETT). Depending on the state and individual facility, this procedure may be performed by either a respiratory therapist or an RN. Prior to extubation, the nurse should position the client in the high-Fowler's position to allow for optimal diaphragmatic excursion. Additionally, placing the client on continuous pulse oximetry ensures adequate monitoring of the client's oxygen level. Once extubated, 100% oxygen is administered by mask and the nurse frequently assesses the client's breath sounds. A high-pitch inspiratory sound may indicate stridor, a severely narrowed airway which may occur after extubation. Stridor is a medical emergency and assessing breath sounds frequently helps to identify this life-threatening condition. The client should not be offered oral hydration in the immediate post-extubation period as the client may not have an adequate gag reflex and is at risk for aspiration.

A client is admitted with pneumonia. Which nursing intervention(s) does the nurse start to assist with airway clearance? Select all that apply.

Response Feedback: Incentive spirometry helps maximize alveolar inflation and ventilation, promoting airway clearance. Frequently position changes allows maximum expansion on alternate sides of the chest, allowing for optimal airway clearance. Deep breathing encourages oxygenation before controlled coughing, which allows for airway clearance. Adequate hydration helps the client expectorate mucus by thinning out pulmonary secretions. Placing the client in semi-Fowler's position allows for maximum chest expansion, maximizes the client's ability to clear the airway.

A nurse notes a client's respiratory rate is 24 breaths/min. on 3 L/min. of oxygen. The client reports shortness of breath. Which action does the nurse perform first?

Response Feedback: Just as the assessment is the first step of the nursing process, assessment is the nursing priority when caring for a client with respiratory distress.The client's oxygen flow rate may need to be increased, but this is performed after the comprehensive respiratory assessment and after obtaining the client's vital signs. Though it may be appropriate to administer the prescribed bronchodilator, the nurse must first assess the client to determine the priority of care. The health care provider may need to be notified of the client's condition, but this is performed after the nurse performs a comprehensive respiratory assessment.

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing?

Response Feedback: Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education?

Response Feedback: Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, Metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply.

Response Feedback: Neurologic responses occur when there is an insufficient supply of glucose to the brain, thus causing clinical manifestations such as headache and confusion. Profuse sweating is a classic sign of hypoglycemia. This is triggered by lack of glucose to the nerve cells. Thirst (polydipsia) is a classic symptom of hyperglycemia. Increased urination (polyuria) is a classic sign of hyperglycemia

A 13-year-old-child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur?

Response Feedback: Novolin N is an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration. It was administered at 7 am, so between 1 and 3 pm is when the nurse should anticipate that a hypoglycemic reaction will occur. During the evening or night is when a reaction from a long-acting insulin is expected. Long-acting insulin has a small peak 10 to 16 hours after administration. Noon is when a reaction from a short-acting insulin is expected. Short-acting insulin peaks in 2 to 4 hours after administration. Within 30 minutes of administration is when a reaction from a rapid-acting insulin is expected. Rapid-acting insulin peaks 30 to 60 minutes after administration.

A nurse is performing an assessment on a client with type 2 diabetes. The nurse notes bilateral pedal capillary refill of 3-5 seconds. Which factor does the nurse recognize as contributing to this finding?

Response Feedback: Over time, diabetes causes microvascular damage, which results in decreased blood flow in the extremities. This causes changes including decreased capillary refill time and may lead to ulceration of tissues in the extremities in patients with uncontrolled diabetes. Elevated blood glucose levels do not cause increased viscosity of blood. Though cold extremities may decrease the rate of capillary refill, the patient is diabetic, which the nurse should recognize is more likely the cause of the decreased capillary refill. Diabetic neuropathy is related to diabetes that has been uncontrolled for a prolonged period of time, but it is a nerve-related damage, not vascular, and is unrelated to capillary refill time.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client?

Response Feedback: Physiologic stress increases gluconeogenesis, requiring continued pharmacologic therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic may precipitate hyperglycemia.

A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What acid-base imbalance is the client at risk for?

Response Feedback: Rapid absorption of acetylsalicylic acid (aspirin) causes the stomach contents to become more acidic, leading to metabolic acidosis. Hyperventilation is the body's attempt to blow off excess hydrogen ions; carbon dioxide is converted to hydrogen ions by way of the carbonic anhydrase reaction. The pH of the stomach contents decreases with aspirin toxicity, becoming more acidic, resulting in metabolic acidosis. Although increased renal excretion of bicarbonate can contribute to metabolic acidosis, this is not the mechanism associated with aspirin toxicity. In metabolic acidosis associated with aspirin toxicity the kidneys attempt to decrease the renal excretion of bicarbonate.

A client is admitted for respiratory distress and suspected pneumonia. Which assessment findings consistent with this diagnosis require continued monitoring?

Response Feedback: Signs and symptoms of pneumonia include fever, productive cough, dyspnea, pleuritic chest pain, increased respiratory rate, and chills. Bronchophony is assessed by having the client say the word ninety-nine in a normal voice while the nurse auscultates the posterior lung fields. Normal bronchophony is present if the nurse is unable to distinguish what the client is saying. Abnormal bronchophony is present if the word the client is saying can be heard clearly when auscultated due to consolidation, such as in the case of pneumonia because air does not transmit sounds as clearly as an area of consolidation. The nurse continually assesses for findings that suggest pneumonia complications. When complications are suspected, the nurse notifies the health care provider immediately. Septic shock is a life-threatening complication, so the nurse does more than document and monitors with this finding. Other complications include lung abscess, pleural effusion, and respiratory failure.

The nurse is caring for a client with diabetes. Which task can be delegated to the unlicensed assistant personnel (UAP)?

Response Feedback: The UAP can obtain a blood glucose value and give this information to the nurse to evaluate the result. The UAP cannot assess, educate or evaluate knowledge, or answer questions on signs and symptoms of hypoglycemia. These are all independent functions of the registered nurse.

A nurse provides oral care for a client who is mechanically ventilated. What is the best rationale for providing this care?

Response Feedback: The most significant risk for pneumonia related to being hospitalized is being on a mechanical ventilator. The mouth is fertile ground for bacterial growth. Bacteria from the mouth can be transferred into the lungs, causing pneumonia. Although evidence is lacking to link oral care to the prevention of ventilator-associated pneumonia (VAP), this continues to be recommended. Although clients on mechanical ventilation may be dependent on the nurse's actions, this is not the best rationale for performing oral hygiene for clients on mechanical ventilation. Additionally, although the client's oral cavity becomes dry while orally intubated, this is not the best rationale for performing oral hygiene.

A client is orally intubated and mechanically ventilated due to respiratory failure. Which item does the nurse ensure is kept next to the client's bed at all times?

Response Feedback: The nurse should always have a manual resuscitation bag next to the client's bed in case of emergency or if the ventilator malfunctions. An extra endotracheal tube, arterial blood gas kit, and tracheostomy kit are not needed at the client's bedside.

A 10-year-old girl with diabetes joins the school's soccer team. Her mother is unsure whether to tell the coach of her child's condition. The mother asks the school nurse for guidance. On what information should the nurse base the response?

Response Feedback: The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode.Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.

A 12-year-old child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply.

Response Feedback: The stress of surgery causes the release of epinephrine and glucocorticoids, which increase the blood glucose level. Most individuals with type 2 diabetes who control their diabetes through diet and exercise require insulin during the recovery period. Although the child with diabetes is at risk for infection, surgical aseptic technique should prevent infection. Ketoacidosis is associated with type 1, not type 2, diabetes. Urine test results are affected by many variables and therefore are not reliable indicators of the blood glucose level.

What should the nurse emphasize when teaching insulin self-administration to a 10-year-old child with recently diagnosed diabetes?

Response Feedback: Thorough handwashing is the best infection-prevention technique and should always precede preparation of an injection. Shaking insulin causes air bubbles, which can interfere with preparation of an accurate dose; the bottle should be rolled gently between the palms. Although injection sites should be rotated, the abdomen, not the extremities, is the preferred site for self-administration of insulin. The injection site should not be rubbed, because this will affect absorption of the insulin and cause a reaction at the site.

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's best response?

Response Feedback:Emptying the fluid from the tubing is necessary to prevent fluid from entering the trachea; some systems have receptacles attached to the tubing to collect fluid; others have to be temporarily disconnected while fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Decreasing the amount of humidity is unsafe; humidity is necessary to preserve moistness of the respiratory tract and to liquefy secretions. The amount of condensation is irrelevant to intake and output.

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position?

Response Feedback:The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.

A client is admitted with heart failure. Which lab value supports this diagnosis? A. An elevated brain natriuretic peptide B. Decreased C-reactive protein C. Elevated troponin I D. Increased creatinine kinase

A. An elevated brain natriuretic peptide Response Feedback: Increased fluid volume causes an increased stretch of the myocardium, causing the cells to release BNP. BNP is a peptide that opposes the actions of the renin-angiotensin system.

A health care provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Double vision B. Drooping of the upper eyelids C. Problems with cognition D. Difficulty swallowing saliva E. Nonintention tremors of the extremities F. Intention tremors of the hands

A. Double vision B. Drooping of the upper eyelids D. Difficulty swallowing saliva Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common? A. Increased risk for respiratory complications B. Involuntary twitching of small muscle groups C. Deficiencies of essential neurotransmitters D. Progressive deterioration until death

A. Increased risk for respiratory complications As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? A. Take the medication according to a specific schedule. B. Perform range-of-motion exercises. C. Eat foods that are pureed D. Take a stool softener daily.

A. Take the medication according to a specific schedule A priority of care for a client with myasthenia gravis is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing. Dysphagia usually is not an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dsyphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, range-of-motion exercises prevent joint contractures rather than promote muscle strength. Anticholinergic medications taken for myasthenia gravis cause relaxation of smooth muscle, resulting in diarrhea rather than constipation.

When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Wash the area thoroughly with soap and water. B. Report to the emergency room. C. Place the needle in a biohazard bag for testing. D. Contact employee health so antiretrovirals can be started.

A. Wash the area thoroughly with soap and water The puncture site and skin should be washed thoroughly with soap and water. Then the healthcare provider will follow the next steps in the facility protocol.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. The nurse instructs the client to assess for: A. Weight gain B. Clubbing of the nail beds C. Increased appetite D. Hypertension

A. Weight gain The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? A. "I will be sure to take naps throughout the day." B. "I will take acetaminophen for pain" C. "I will eat small frequent meals." D. "I will avoid alcohol."

B. "I will take acetaminophen for pain" Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Elevated serum albumin levels B. Ascites C. Left arm blood pressure reading of 160/80 D. Esophageal varices E. Splenomegaly

B. Ascites D. Esophageal varices E. Splenomegaly Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, the pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices. The systemic blood pressure is usually low in a patient with portal hypertension- not high. Serum albumin levels decrease with portal hypertension.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? A. Tachycardia B. Hyperkalemia C. Ecchymosis D. Hypoglycemia

B. Hyperkalemia Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? A. Recognize the response is expected. B. Check the client's pedal pulses. C. Take the client's blood pressure. D. Call the health care provider.

B. Check the client's pedal pulses Response Feedback: These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the health care provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.

A client has the rhythm below. What intervention is the priority? V.Fib A. Elective cardioversion B. Immediate defibrillation C. Administer Digoxin IVP D. Administer Adenosine IVP

B. Immediate defibrillation The rhythm is ventricular fibrillation. CPR should be initiated immediately once the client is found to be pulseless. Immediate defibrillation increases the likelihood the client will establish a normal rhythm. Digoxin and Adenosine are not appropriate medications for this dysrhythmia.

A client with a coronary occlusion is experiencing chest pain and distress. The nurse administers oxygen to: A. Increase oxygen tension in the circulating blood. B. Increase oxygen concentration to heart cells. C. Prevent cyanosis. D. Prevent dyspnea.

B. Increase oxygen concentration to heart cells. Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects that which procedure will be considered as a treatment option? A. Immunosuppression therapy B. Plasmapheresis C. Thrombolytic therapy D. Hemodialysis

B. Plasmapheresis A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.

During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with: A. Signs and symptoms that are symmetrical and ascending that start in the upper extremities B. Signs and symptoms that are symmetrical and ascending that start in the lower extremities C. Signs and symptoms that are asymmetrical and ascending that start in the upper extremities D. Signs and symptoms that are unilateral and descending that start in the lower extremities

B. Signs and symptoms that are symmetrical and ascending that start in the lower extremities GBS signs and symptoms will most likely start in the lower extremities (ex: feet), be symmetrical, and will gradually spread upward (ascending) to the head. There are various forms of Guillain-Barré Syndrome. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common type in the U.S. and this is how this syndrome tends to present.

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response? A. Strength improves immediately after meals B. Strength decreases with repeated muscle use C. Weakness decreases after hot baths D. Weakness improves with muscle use

B. Strength decreases with repeated muscle use Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement.

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to avoid the potential danger of inducing ventricular fibrillation during cardioversion? A. Energy level is set at its maximum level. B. Synchronizer switch is in the "on" position. C. Skin electrodes are applied after the T wave. D. Alarm system of the cardiac monitor is functioning simultaneously.

B. Synchronizer switch is in the "on" position. The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 W/sec. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave.

The nurse is caring for a client with heart failure. The client is scheduled to receive lisinopril and carvedilol in the next 30 minutes. The unlicensed assistive personnel reports the following vital signs to the nurse: Temperature of 98.9, heart rate of 52, respiration rate of 18, and blood pressure of 136/72. What is the most appropriate action for the nurse? A. Administer the carvedilol but hold the lisinopril and notify the HCP. B. Administer the lisinopril but hold the carvedilol and notify the HCP. C. Hold both the lisinopril and the carvedilol and notify the HCP. D. Administer the lisinopril and carvedilol as scheduled.

B.Administer the lisinopril but hold the carvedilol and notify the HCP. The nurse should hold the carvedilol with a heart rate of 52 and notify the HCP. Carvedilol is a beta-blocker and may reduce both blood pressure and heart rate. Lisinopril is an ace inhibitor and will not lower the heart rate and would be appropriate to administer.

A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "Do you also eat when you drink?" B. "What prompts your drinking episodes?" C. "When was your last drink of vodka?" D. "Why do you mix the vodka with orange juice?"

C. "When was your last drink of vodka?" The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important, but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A health care provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? A. Stay on a liquid diet for 24 hours after the procedure. B. Consume a diet low in fat for three days before the procedure. C. Empty the bladder immediately before the procedure. D. Maintain a supine position during the procedure.

C. Empty the bladder immediately before the procedure. The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.

A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the healthcare provider include in this client's plan of care? A. Weigh once a week B. Provide high-protein feedings C. Monitor the blood glucose D. Institute droplet precautions

C. Monitor the blood glucose Interventions for this patient include blood glucose monitoring (because of decreased glycogen synthesis and storage), monitoring PT and INR (because of decreased clotting factors), checking reflexes (because of the neurological effects of increased ammonia), providing diet/feedings that are low in protein (to decrease ammonia levels), and following standard precautions. The client should be weighed every day.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C. Diminished plasma protein level The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to man

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates and a tracheostomy is performed. Nasogastric tube feedings are prescribed. The nurse should manage the tracheostomy cuff by: A. Deflating the cuff after the tube feeding has been completed B. Deflating the cuff before starting each tube feeding C. Inflating the cuff before the feeding and for 30 minutes after each feeding D. Inflating the cuff for one hour before and after each feeding Response Feedback:

C. Inflating the cuff before the feeding and for 30 minutes after each feeding Inflating the tracheostomy cuff before and for 30 minutes after each feeding occludes the tracheal lumen around the tracheostomy tube, preventing aspiration if regurgitation occurs. Deflating the tracheostomy cuff before starting tube feeding will permit aspiration if regurgitation occurs. Although the cuff must be inflated during the tube feeding as well as after to prevent aspiration, it is done just before feeding, not one hour before. Deflating the tracheostomy cuff after the tube feeding has been completed will permit aspiration if regurgitation occurs.

The nurse reviews the health record of a client with coronary artery disease (CAD). When assessing client risk, which elevated lab value is the most likely to cause the progression of CAD? A. High-density lipoproteins B. Microalbuminuria C. Low-density lipoproteins D. Blood glucose

C. Low-density lipoproteins Elevated low-density lipoproteins are the most common lipoprotein abnormality associated with CAD progression. Less-significant markers include triglycerides, C-reactive protein, and homocysteine. Elevated blood glucose is a serious risk factor for CAD and can worsen disease progression, but low-density lipoprotein values are more influential. Studies show that elevated high-density lipoproteins protect against CAD. Elevated microalbumin in urine is commonly used as a marker for renal disease. That marker, along with additional testing, may be useful in estimating risk for CAD.

The physician orders Lactulose 30 mL by mouth per day for a client with cirrhosis. What finding below demonstrates the medication is working effectively? A. Decreased albumin levels B. Absence of fruity breath C. Presence of asterixis D. Improvement in level of consciousness

D. Improvement in level of consciousness A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands). This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status, decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level. Fruity breath is associated with DKA not hepatic encephalopathy.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: A. Determine the client's reasons for drinking. B. Improve the client's nutritional status. C. Increase the client's fluid intake. D. Monitor the client's vital signs

D. Monitor the client's vital signs A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

An electrocardiogram (ECG) is prescribed for a client who reports chest pain. What early finding does the nurse expect on the lead over the infarcted area? A. Flattened T waves B. Absence of P waves C. Inverted p waves D. Elevated ST segment

D. Elevated ST segment Elevated ST segments are an early, typical finding after a myocardial infarct, because of altered contractility of the heart. Flattened or depressed T waves indicate hypokalemia. The absence of P waves occurs in atrial and ventricular fibrillation as well as in junctional rhythm. Inverted p waves occur in junctional rhythms

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? A. Administer oxygen. B. Call the health care provider. C. Perform tracheal suctioning. D. Raise the head of the bed.

D. Raise the head of the bed. Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Oxygen will not assist in the management of dysphagia or the prevention of aspiration. Performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the health care provider to the problem is necessary, but only after client safety is ensured.

What lab results does the nurse expect when clients develop respiratory alkalosis?

In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the Pco2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated Pco2 partially is compensated metabolic alkalosis. A decreased pH, elevated Pco2 is respiratory acidosis. A decreased pH, decreased Pco2 is metabolic acidosis with some compensation.

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?

Response Feedback: Signs of poor oxygenation in the client on a ventilator may include, but are not limited to, cyanosis, PaO2 less than 90, increased restlessness or agitation, skin pale, cool and clammy, and thick tenacious secretions present when suctioned.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). Which instruction does the nurse use when teaching the client about breathing techniques for COPD?

The diaphragm tends to be flat in COPD due to hyperinflation of the lungs from air trapping. Diaphragmatic breathing exercises assist in strengthening breathing ability and improves the contraction of the diaphragm. The nurse should teach the client to exhale slowly through the mouth using pursed lips in order to better splint open the airway and facilitate better ventilation. Rapid, deep breathing is not beneficial for clients with COPD and hyperventilation may be detrimental.