Adult Final

The RN and LPN/LVN work together in a public health clinic. Which client's care does the RN assign to the LPN/LVN? A 19-year-old with genital herpes who is experiencing a painful outbreak A 22-year-old who has been treated repeatedly in the past 3 months for gonorrhea A 24-year-old with many questions about the human papilloma virus (HPV) vaccine A 28-year-old with a history of chlamydia who has been unable to get pregnant

A 19-year-old with genital herpes who is experiencing a painful outbreak The client with genital herpes who is experiencing a painful outbreak has routine health care needs that are within the scope of practice of the LPN/LVN. The client who has been treated repeatedly in the past 3 months for gonorrhea and the client with a history of chlamydia who has been unable to get pregnant need more thorough assessment and teaching that should be done by the RN. The client with many questions about the HPV vaccine needs more thorough education about his or her questions that should be answered by the RN.

The nurse is teaching a group of young men about sexually transmitted diseases. What does the nurse tell them to look for in the primary stage of syphilis? A painless chancre A rash in the genital area Scrotal swelling Weeping discharge from the urethra

A painless chancre The appearance of an ulcer called a chancre is the first sign of primary syphilis. Generalized rash is a common manifestation of the secondary stage of syphilis. Scrotal swelling is not a symptom of syphilis. Weeping discharge from the urethra is a symptom of gonorrhea.

When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? Tobacco use Ethnicity Gender Increased age

Tobacco use Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change. Ethnicity, gender, and increasing age are associated with lung cancer, but they are not modifiable risks.

The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? Administer antibiotics as prescribed. Transfuse ordered packed red blood cells. Teach pursed-lip breathing. Encourage increased fluid intake.

Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules; this increases sites at which oxygen can attach and improves gas exchange. Antibiotics treat infection; they do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? "A tanning bed will supply the ultraviolet light I need." "Medicine can prevent the growth of new skin cells." "I can never be cured." "Stress can cause my flare-ups."

"A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients; this statement indicates that the client requires further teaching. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? "Condoms should be used when lesions are present on the penis." "Always position the condom with a space at the tip of an erect penis." "Make sure it fits loosely to allow for penile erection." "Use adequate lubrication, such as petroleum jelly."

"Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom. Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only.

In teaching a client about skin cancer prevention, which instruction does the nurse include? "Avoid sun exposure between 11 a.m. and 3 p.m." "Examine your skin quarterly for possible cancerous or precancerous lesions." "Wear transparent clothing to protect your skin from the sun." "If you feel you must tan, use a tanning bed."

"Avoid sun exposure between 11 a.m. and 3 p.m." The sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. Opaque clothing should be worn to protect the skin from the sun. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." "Because your tongue may be blocking your throat, and you wake up because you are choking." "It isn't really that often. It just feels that way."

"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. After the client returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is re-obstructed. Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the client to awaken and breathe. Technically the client is not choking. Telling the client he or she isn't really awakening that often minimizes the client's concern and is not accurate. The client may be awakening every 5 minutes as the cycle repeats.

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? "I don't need to use my oxygen all the time." "I don't need to get a flu shot." "I need to eat more protein." "It is normal to feel more tired than I used to."

"I don't need to get a flu shot." An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered, since pneumonia is one of the most common complications of COPD. The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, and may not need it all the time. Increased work of breathing in a client with COPD raises calorie and protein needs, which can lead to protein-calorie malnutrition. Clients with COPD often have chronic fatigue.

A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? "This will not make any difference in the viral load." "Blood concentrations will be decreased, which will lead to increased viral replication." "If only one dose of medication is missed, this will not make a difference." "This will cause an increase in opportunistic infections."

"Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). When this concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. Therefore, it is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting. Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.

The nurse is counseling a client and the client's sexual partner on safe sex practices. Which of the couple's comments indicates a need for clarification? "Condoms are for vaginal and anal sexual encounters, not for oral sex." "If the guy won't wear a condom, the female condom is just as effective." "We heard that latex condoms were better than natural membrane condoms." "We only use condoms once, and then throw them away."

"Condoms are for vaginal and anal sexual encounters, not for oral sex." A condom should be used for every sexual encounter, including oral, vaginal, and anal. Female condoms (polyurethane sheaths in the vagina) are effective for preventing the transmission of sexually transmitted diseases, including HIV. Latex or polyurethane condoms should be used rather than natural membrane condoms. A condom should never be used more than once.

A client has gynecologic cancer. Which client statement demonstrates a correct understanding of her treatment options? "Chemotherapy will be used to shrink my cancer before I have my operation." "External beam radiation therapy (EBRT) may be used after my cancer surgery." "Brachytherapy is given on an outpatient basis for 4 to 6 weeks before surgery." "The purpose of brachytherapy will be to dissolve the cancer."

"External beam radiation therapy (EBRT) may be used after my cancer surgery." EBRT may be used to treat any stage of gynecologic cancer in combination with surgery. Chemotherapy is used as palliative treatment for advanced and recurrent disease when it has spread to other parts of the body. External treatment, not brachytherapy, is given on an ambulatory care basis after surgery, if needed. The purpose of brachytherapy is to assist in preventing disease recurrence.

A 52-year-old client relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? "Don't worry, most lumps are discovered by women during breast self-examination." "Does anyone in your family have breast cancer?" "Finding a cancer in the early stages increases the chance for cure." "Have you noticed a lump or thickening in your breast?"

"Finding a cancer in the early stages increases the chance for cure." Providing truthful information addresses the client's concerns. Mammography can detect lumps smaller than those discovered by palpation. Asking about family history or symptoms is not therapeutic because it does not address the client's fear of cancer.

The nurse is teaching post-mastectomy exercises to a client. Which statement made by the client indicates that teaching has been effective? "For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." "In rope turning, I'll hold the rope with my arms flexed." "In rope turning, I'll start by making large circles." "With hand wall climbing, I'll walk my hands up the wall and back down until they are at waist level."

"For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." To perform the pulley exercise properly, the client should drape a 6-foot-long rope over a sturdy structure. In rope turning, the client holds the end of the rope and steps back from the door until the arm is almost straight out in front. The client starts with small circles and gradually increases to larger circles as the client becomes more flexible. With hand wall climbing, the client walks the hands up the wall and then back down until they are at shoulder level.

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? "Give ibuprofen 800 mg every 8 hours as needed for pain." "Encourage bedrest, with the head of the bed elevated 45 to 60 degrees." "Provide humidified air." "Suction at the bedside."

"Give ibuprofen 800 mg every 8 hours as needed for pain." Ibuprofen is contraindicated in a client with a nosebleed because nonsteroidal anti-inflammatory drugs inhibit clotting. At least initially, bedrest is suggested because significant amounts of blood may have been lost owing to a posterior nosebleed; elevation of the head of the bed is recommended for client comfort and to facilitate drainage of secretions. Humidified air and humidified oxygen, if oxygen is ordered, are recommended because dryness of the nasal mucosa is a cause of epistaxis (nosebleed). Any client who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."

"I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? "Have you had sex with men or women or both?" "I hope you use condoms to protect your partners." "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental.

The nurse is assessing a client during a routine gynecologic examination. Which comment by the nurse shows the least respect for the client's personal values and beliefs? "Have you participated in homosexual relationships?" "How many sexual partners do you currently have?" "How often do you have intercourse?" "What type of protection do you use when you have sex?"

"Have you participated in homosexual relationships?" Asking the client if she participates in homosexual relationships is not an appropriate assessment question; if the client wishes to disclose her sexual orientation, she will do so without prompting from the nurse. Asking the client how many sexual partners she has is an appropriate assessment question because it gets at certain risk factors for sexually transmitted diseases (STDs) and other sexually related problems. Monogamous clients generally have fewer risk factors. The client's level of sexual activity is also appropriate for the nurse to question because it relates to the number of possible risk factors that the client may have. Asking the client what type of protection she uses is appropriate because it is related to the client's becoming pregnant or to the client's exposure to an STD.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."

"I am here to receive the yearly pneumonia shot again." Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

Which statement by a client with a laryngectomy indicates a need for further discharge teaching? "I must avoid swimming." "I can clean the stoma with soap and water." "I can project mucus when I laugh or cough." "I can't put anything over my stoma to cover it."

"I can't put anything over my stoma to cover it." Loose clothing or a covering such as a scarf can be used to cover the stoma if the client desires. To avoid aspiration, the client with a laryngectomy should not swim. Mild soap and water is the proper way to clean the stoma; however, a shield should be used in the shower so a large amount of water does not enter it. The client may project mucus when he laughs or coughs; reinforce with the client and the family that this is normal and is to be expected.

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother? "Wash your hands frequently." "Your child may return to school, but must be isolated from the rest of the class." "Keep the site covered with a bandage." "Keep your child out of school until the infection has cleared."

"Keep the site covered with a bandage." Keeping the site covered prevents spread of the infection. Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I don't like latex balloons."

"I had a heart attack 4 months ago" Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons).

The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? "I may need to restrict my activities for several months." "The dressing should stay in place unless it gets wet." "The incision needs to be cleaned every 4 hours with hydrogen peroxide." "The wound will completely heal in about 2 months."

"I may need to restrict my activities for several months." To protect the integrity of the wound, activities may need to be restricted. The wound will need to be open to air for healing. Using hydrogen peroxide can cause wound irritation, unless specifically ordered. The length of time it takes for a wound to heal varies; a wound can take up to 2 years to heal.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? "Asthma drugs help everybody breathe better." "I must carry my emergency inhaler only when activity is anticipated." "I must have my emergency inhaler with me at all times." "Preventive drugs can stop an attack."

"I must have my emergency inhaler with me at all times." Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol [Proventil]). Asthma medications are specific to the disease and should never be shared or used by anyone other than the person for whom they are prescribed. An emergency inhaler should be carried when activity is anticipated, as well as at other times. Preventive drugs are those that are taken every day to help prevent an attack from occurring. They are not able to stop an attack once it begins.

The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult client indicates understanding of the nurse's instructions? "Cigarette smoking always causes lung cancer." "Taking multivitamins will prevent me from developing cancer." "If I have only one shot of whiskey a day, I probably will not develop cancer." "I need to report the pain going down my legs to my health care provider."

"I need to report the pain going down my legs to my health care provider." Pain in the back of the legs could indicate prostate cancer in an older man. Cigarette smoking is implicated in causing lung cancer and other types of cancer, but it does not always cause cancer. Investigation is ongoing about the efficacy of vitamins A and C in cancer prevention. Limiting alcohol to one drink per day is only one preventive measure.

The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? "When I injected heroin, I was exposed to HIV." "I don't understand how the antiretroviral drugs work." "I remember to take my antiretroviral drugs almost every day." "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

"I remember to take my antiretroviral drugs almost every day." Because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains, it is important that clients take these drugs consistently. The nurse should immediately assess the reasons why the client does not take the medications daily and then should implement a plan to improve adherence. The nurse should assess whether the client is still injecting drugs and should make certain the client understands the risks for infection with another strain of HIV or other bloodborne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I should avoid eating hamburgers." "I must cut out bacon and canned foods." "I shouldn't put the salt shaker on the table anymore." "I should avoid lunchmeats but may cook my own turkey."

"I should avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? "I know that I need to avoid warm climates." "I must cover up the affected areas to prevent spread to my family." "I should practice good handwashing technique." "Psoriasis can be cured with steroids."

"I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection. Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? "I may lose my hair during this treatment." "I must be positioned in the same way during each treatment." "I will have a radioactive device in my body for a short time." "I will be placed in a semiprivate room for company."

"I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? "I hope I can learn esophageal speech." "I will have to take special care not to aspirate while eating." "I won't be able to breathe through my nose anymore." "It is hard to believe that I will never hear my own voice again."

"I will have to take special care not to aspirate while eating." Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus. The client will not be able to breathe through the nose. The client will be able to vocalize after working with a speech/language pathologist if he or she chooses; however, the voice will sound different than the client is used to. Esophageal or mechanical speech will permit the client to speak, but the voice will not sound like his or her own.

The nurse is educating a group of young men about testicular self-examination (TSE). Which statement by a member of the group indicates teaching has been effective? "I will examine my testicles right before taking a shower." "I should squeeze each testicle in my hand to feel any lumps." "I should only report any large lumps to my health care provider." "I will look and feel for any lumps or changes to my testes."

"I will look and feel for any lumps or changes to my testes." With early detection by monthly TSE and treatment, testicular cancer can be successfully cured. In TSE, the client should look and feel for any lumps or changes to the testes. Any lumps that are detected should be immediately reported. A TSE should be performed immediately following a shower. The client should gently roll each testicle between the thumb and forefinger. All lumps should be reported to the provider, no matter the size.

The nurse is performing discharge teaching for a client who is recovering from a total abdominal hysterectomy (TAH). Which client statement indicates a need for clarification? "I cannot jog for 2 to 6 weeks." "I must take my temperature twice a day for the first days after surgery." "I will need to find a new form of birth control." "I will no longer have menstrual periods."

"I will need to find a new form of birth control." The client who has had a TAH can no longer become pregnant; therefore, birth control is no longer necessary. The client must avoid jogging, aerobic exercise, participating in sports, or any strenuous activity for 2 to 6 weeks. The client must take her temperature twice a day for the first days after surgery as a precaution to monitor for infection. The client will no longer have a period, although she may have some vaginal discharge for a few days after going home.

The nurse is teaching a group of young women about screening for chlamydia. Which client statement shows a correct understanding of these practices? "As a sexually active 19-year-old, I should be screened every 2 years." "At age 30, I still need yearly testing, even if I am monogamous." "If I am a 40-year-old woman with a 'new' partner, I should be screened again." "Self-collected urine specimen testing is not a reliable method for screening."

"If I am a 40-year-old woman with a 'new' partner, I should be screened again." Women older than 25 years with new or multiple partners should be screened annually for chlamydia. All sexually active women 25 years old or younger should be screened annually for chlamydia. The 30-year-old woman who is monogamous does not need to be screened; only women older than 25 years with new or multiple partners should be screened annually. The urine self-collection method has been found to be more acceptable and highly sensitive and specific, and has resulted in increased identification of asymptomatic clients with chlamydia.

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? "I don't have to wait between the two puffs if I use a spacer." "If the spacer makes a whistling sound, I am breathing in too rapidly." "I should rinse my mouth and then swallow the water to get all of the medicine." "I should shake the inhaler only if I want to see whether it is empty."

"If the spacer makes a whistling sound, I am breathing in too rapidly." Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client must wait 1 minute between puffs. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid, to prevent the development of an oral fungal infection. An empty inhaler will float on its side in water; a full inhaler will sink. Shaking an inhaler helps ensure that the same dose is delivered in each puff.

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery by his family? "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" "Is there somewhere private in the home where we can go and talk?" "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." "It is your duty to protect your family members from getting AIDS."

"Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

A client is being treated for endometriosis with medroxyprogesterone (Depo-Provera). Which client statement indicates a correct understanding of this drug therapy? "A daily pill will help by preventing the formation of new blood vessels." "It is an injection that I will receive monthly." "Side effects may include a decrease in my bone density." "Treatment may cause me to develop certain food cravings."

"It is an injection that I will receive monthly." Depo-Provera is an injectable form of progestin. It is given every 2 weeks to once a month, depending on the severity of the client's symptoms. Endostatins block the formation of new blood vessels and are used to decrease ectopic endometrial growth. Gonadotropin-releasing hormone agonists, not menstrual cycle control agents, may cause a decrease in bone density. Food cravings are not known to be a side effect of Depo-Provera.

The nurse is teaching care principles to a client who plans uterus-sparing surgery to remove uterine fibroids. Which client statement needs clarification? "I will be able to return to my usual activities in about 2 weeks." "It is important to avoid having sexual intercourse for 3 weeks after surgery." "Probably I will be able to go home on the day of the surgery." "Fewer complications occur with this procedure than with hysterectomies."

"It is important to avoid having sexual intercourse for 3 weeks after surgery." The client must avoid having sexual intercourse for at least 6 weeks (not 3 weeks) after the surgery. Most clients can return to their usual activities within 2 weeks of having uterus-sparing surgery for fibroids. Most clients do go home on the day of the surgery. Postoperative pain is less and complications fewer with these procedures than with routine hysterectomies.

A client had a total abdominal hysterectomy 2 days ago and is to be discharged on antibiotics. What does the nurse include in her discharge teaching about antibiotics? "After your first day at home, you can stop them if you do not have a fever." "It is important to take them as directed until they are all gone." "Stop the antibiotic if you feel nauseated because it will lose its effectiveness." "You will need to take the drug until your incision heals."

"It is important to take them as directed until they are all gone." The client must finish her entire course of antibiotics. She must take them even after she has diminished signs or symptoms. This is a fundamental principle of antibiotic administration. The client should never be instructed to stop a course of antibiotics. In cases in which clients are unable to take an antibiotic (due to nausea or another problem), an alternative antibiotic will be prescribed. The client's incision should be healed by the time that the antibiotic course is completed, but this is not the parameter that is used for continuation of the therapy.

A client receiving external beam radiation therapy calls the nurse to report rectal urgency, cramping, and passing of mucus and blood. What is the nurse's best response? "This is an emergency. Go directly to the emergency department." "This is normal and will resolve as soon as the treatment stops." "Avoid caffeine and continue drinking plenty of water and other fluids." "Limit spicy or fatty foods, caffeine, and dairy products."

"Limit spicy or fatty foods, caffeine, and dairy products." The client's symptoms indicate that he is experiencing radiation proctitis, a common complication of external beam radiation therapy. The nurse's instructions to limit spicy or fatty foods, caffeine, and dairy products describe what the client should do to alleviate these symptoms. The client's symptoms do not indicate an emergency, but they should be reported to the health care provider. The client's symptoms should resolve 4 to 6 weeks after the treatment stops. Avoiding caffeine and drinking water and other fluids describe what the client should do if he is experiencing radiation cystitis, which he is not.

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her? "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." "He can only drink milk and eat ice cream until the wires come off." "He must brush his teeth every 2 hours." "Make sure he always has wire cutters with him."

"Make sure he always has wire cutters with him." It is extremely important that the client always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the client to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established. Antiemetics such as promethazine, ondansetron (Zofran), and prochlorperazine (Compazine) are prescribed by a health care provider on an as-needed basis only for nausea. Good nutrition, ensuring adequate protein intake for healing, must be maintained. A specific dental liquid diet will be reviewed with the client and significant others before surgery. Dental hygiene will be maintained with an irrigation device such as a Waterpik or SoniCare, not with a brush.

A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? "I am allergic to iodine." "My urinary stream is very weak." "My legs are numb and weak." "I am incontinent when I cough."

"My legs are numb and weak." Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. Prostate cancer may frequently metastasize to the bone, specifically the spine. Allergy to iodine should be reported when contrast media will be used, but dye is not used in radiation therapy. A weak urinary stream and incontinence are common clinical manifestations of prostate cancer. Incontinence associated with coughing is typical of stress incontinence and is not a complication of cancer.

The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? "My mother and grandmother had breast cancer, so I am at risk." "I get a mammogram every 2 years since I turned 30." "A clinical breast examination is performed every month since I turned 40." "A computed tomography (CT) scan will be done every year after I turn 50."

"My mother and grandmother had breast cancer, so I am at risk." A strong family history of breast cancer indicates a risk for breast cancer. Annual rather than biannual screening may be indicated for a strong family history. An annual mammogram is performed after age 40 or in younger clients with a strong family history. The client may perform a self-breast examination monthly; a clinical examination by a health care provider is indicated annually. Annual CT breast scans after age 50 are not a current recommendation.

The nurse is teaching a female client about managing her sexually transmitted disease with antibiotics. Which client statement indicates that teaching has been effective? "I can resume having sex 24 hours after my first dose of antibiotics." "I will need to take an antacid 2 hours after taking the antibiotic." "My oral contraceptive may not be effective while I take antibiotics." "This antibiotic must be taken with food."

"My oral contraceptive may not be effective while I take antibiotics." If the client is taking oral contraceptives, the client should discuss with the health care provider whether the antibiotics will decrease their effectiveness, as is often the case. Sexual intercourse should be avoided until after antibiotic therapy is completed. If the client's partner is being treated, sex can resume after the partner also completes his or her treatment. Antacids containing calcium, magnesium, or aluminum (Tums, Maalox, or Mylanta) should not be taken with antibiotics because they may decrease their effectiveness. Antibiotics should be taken on an empty stomach unless the provider instructs the client to take them with food.

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs are sterile."

"My scrubs are sterile." Scrub attire is provided by the hospital and is clean, not sterile. All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile; they may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

"Pain medication will take away my pain" Pain medication will minimize pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.

The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which statement by the client indicates a need for further teaching? "Hormonal therapy is only used to prevent the growth of cancer. It won't get rid of it." "I might have chemotherapy before surgery." "If I get radiation, I am not radioactive to others." "Radiation will remove the cancer, so I might not need surgery."

"Radiation will remove the cancer, so I might not need surgery." Typically, radiation therapy follows surgery to kill residual tumor cells. Radiation therapy plays a critical role in the therapeutic regimen and is an effective treatment for almost all sites where breast cancer can metastasize. The purpose of radiation therapy is to reduce the risk for local recurrence of breast cancer. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Chemotherapy drugs destroy breast cancer cells that may be present anywhere in the body; they are typically administered after surgery for breast cancer, although neoadjuvant chemotherapy may be given to reduce the size of a tumor before surgery. The client receiving radiation therapy is radioactive only if the radiation source is dwelling inside the breast tissue.

A client with newly diagnosed pelvic inflammatory disease (PID) is being started on antibiotics as an outpatient. What does the nurse tell the client about her home treatment regimen? "A rise in your temperature is expected for the first several days." "If you engage in sexual activity, be certain to use a latex condom." "Rest in a semi-upright position to help with the infection and pain." "Return to the clinic in 7 to 10 days for a checkup."

"Rest in a semi-upright position to help with the infection and pain." The client should be instructed to maintain rest in a semi-Fowler's position to promote gravity drainage of the infection. This may also help relieve the pain involved with PID. Clients must be taught to report an increase in temperature to their health care provider. Nurses should instruct women treated as outpatients to avoid sexual intercourse. The client must be seen by the provider within 72 hours of starting the antibiotics and then 1 and 2 weeks from the time of the initial diagnosis.

A client with prostate cancer asks why he must have surgery instead of radiation, even if his cancer is the least-invasive type. What is the nurse's best response? "It is because your cancer growth is large." "Surgery is the most common intervention to cure the disease." "Surgery slows the spread of cancer." "The surgery is to promote urination."

"Surgery is the most common intervention to cure the disease." Because some localized prostate cancers are resistant to radiation, surgery is the most common intervention for a cure. The size of the tumor is not likely to be why the client is having surgery. A bilateral orchiectomy (removal of both testicles) is palliative surgery that slows the spread of cancer by removing the main source of testosterone. A transurethral resection of the prostate is done to promote urination for clients with advanced disease; it is not used as a curative treatment.

A client who had an anterior colporrhaphy is being discharged. What does the nurse tell the client before her discharge? "Avoid lifting more than 25 pounds." "Do not have sexual intercourse for at least 2 weeks." "Return to the clinic in 6 weeks for suture removal." "Take a hot bath or use a moist heating pad for discomfort."

"Take a hot bath or use a moist heating pad for discomfort." For discomfort, the client should be instructed to use heat—either a moist heating pad or warm compresses applied to the abdomen. A hot bath may also be helpful. The client must avoid lifting anything heavier than 5 pounds and avoid sexual intercourse for 6 weeks. Sutures do not need to be removed because they may be absorbable or they may fall out (slough off) as healing occurs.

Which information must the organ transplant nurse emphasize before a client is discharged? "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." "You are at increased risk for cancer when you reach 60 years of age." "Immunosuppressant medications will decrease your risk for developing cancers." "After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population."

"Taking immunosuppressant medications increases your risk for cancer and the need for screenings." Use of immunosuppressant medications to prevent organ rejection increases the risk for cancer. Advanced age is a risk factor for all people, not just for organ transplant recipients. Immunosuppressant medications must be taken for the life of the organ; the risk for developing cancer remains.

A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which response by the nurse is best? "Tell me what you mean when you say you don't know how this could have happened to you." "Do you have a family history that might make you more likely to develop breast cancer?" "Would you like me to help you find more information about how breast cancer develops?" "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it."

"Tell me what you mean when you say you don't know how this could have happened to you." The client's statement that he or she does not know how this could have happened may indicate shock and denial or a request for more information. To provide appropriate care, further assessment is needed about the client's psychosocial status. The first action by the nurse in this situation is to obtain more data by asking open-ended questions. The nurse needs to further assess the client's emotional status before asking about family history of cancer or obtaining information for the client.

The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation."

"The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. NX means that no regional lymph nodes can be assessed. A glioma is a benign tumor of the brain, but the client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.

A 42-year-old woman with an intramural leiomyoma (myomas or fibroids) has been taking estrogen replacement therapy for menopausal symptoms. What does the nurse tell her about estrogen replacement therapy and how it relates to her fibroids? "Estrogen will help shrink your fibroids." "Increasing the amount of estrogen you are taking will be necessary." "The fibroids may continue to grow." "Your estrogen dosage will not change."

"The fibroids may continue to grow." The fibroids may continue to grow because of the estrogen stimulation. Therefore, the client should be instructed to see her provider to monitor their growth. The client's estrogen dose will most likely need to be decreased at some point or eliminated.

The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? "Handwashing is the best way to prevent transmission." "I should avoid kissing and shaking hands." "It is best to cough and sneeze into my upper sleeve." "The intranasal vaccine can be given to everybody in the family."

"The intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for healthy clients ages 2 to 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A new recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? "I told family members they need to wash their hands when they enter and leave the room." "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." "Yes, I understand the reasons why I have to wear gloves when I bathe the client." "The client's spouse told me she got HIV from a blood transfusion."

"The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

The nurse is teaching a group of young boys and girls about getting vaccinated for human papilloma virus (HPV). Which statement by one of the girls needs to be clarified? "Having the vaccine will help keep me from getting cancer of my cervix." "I will need to have all three injections to be protected from the disease." "It is better to have the vaccination before I start having sexual relations." "The vaccine is for girls; a different one is available for boys."

"The vaccine is for girls; a different one is available for boys." The same vaccine is advised to be given to both girls and women, as well as to boys and men. It protects men from genital warts and from some strains of HPV. The vaccine will help prevent girls and women from developing cancer of the cervix. The HPV vaccine is comprised of three injections administered over a 6-month period. It is advised that young women have the vaccination before they start having sexual relations. It is typically given between ages 9 and 10 and 25 and 26.

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "These stockings will prevent blood clots." "These stockings help promote blood flow."

"These stockings will prevent blood clots" Antiembolism stockings alone will not prevent deep vein thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). Antiembolism stockings may be used during and after surgery to promote venous return.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "This may be caused by a genetic trait." "Just imagine how bad it would be if you weren't in good shape."

"This may be caused by a genetic trait." Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The nurse is teaching a 19-year-old female with genital warts about her condition. Which client statement requires further education from the nurse? "There is no known treatment that will cure genital warts." "The warts may actually disappear or resolve without any treatment at all." "Genital warts may reappear at the same site." "Wart remover treatment from the drugstore will help me get rid of them."

"Wart remover treatment from the drugstore will help me get rid of them." The nurse must teach clients that over-the-counter wart treatments should not be used on genital tissue. There is no treatment that cures genital warts at the present time. The desired outcomes of management are to remove the warts and treat the symptoms. Warts may disappear or resolve on their own without treatment. They may occur once or recur at the original site.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? "I need to know my HIV status, so I must get tested before caring for any clients." "Putting on a gown and gloves will cover up the itchy sores on my elbows." "Washing my hands and putting on a gown and gloves is what I must do before starting care." "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

"Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes. Knowing HIV status is important for preventing transmission of HIV, but is not a Standard Precaution. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

The client says, "I hate this stupid COPD." What is the best response by the nurse? "Then you need to stop smoking." "What is bothering you?" "Why do you feel this way?" "You will get used to it."

"What is bothering you?" Encourage the client, and the family, to express their feelings about limitations on their lifestyle and about disease progression. This is not the time to lecture the client regarding his smoking habits; the client is expressing a need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. The client's feelings should never be minimized.

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? "Are you Mr. Smith?" "Good morning, Mr. Smith." "What is your name, and where were you born?" "What surgery are you having today?"

"What is your name, and where were you born?" The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification; however, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? "With this treatment, I probably cannot spread this virus to others." "This treatment does not kill the virus." "This medication prevents the virus from replicating in my body." "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

"With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids. HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

The nurse is teaching a client with gonorrhea. What does the nurse tell the client about the disease? "Close follow-up is required because treatment failure is common." "Do not engage in sexual activity until your blood tests are negative." "You are contagious even if you have no outward symptoms." "You are only infectious while the lesions are draining."

"You are contagious even if you have no outward symptoms." Gonorrhea can be asymptomatic in both men and women, but women have asymptomatic, or "silent," infections more often than men. Treatment failure is rare when gonorrhea is treated according to Centers for Disease Control and Prevention recommendations. Clients should avoid sexual activity until antibiotic therapy is completed and they no longer have physical symptoms. Lesions are not associated with gonorrhea.

A 32-year-old client has a laparoscopic removal of endometrial adhesions at a same-day surgery center. What does the nurse tell her to expect postprocedure? "Do not expect to get your menstrual period for at least 3 months; this procedure really gets your hormones out of balance." "You may have referred pain in your chest and shoulders due to the carbon dioxide (CO2) used in the procedure." "This procedure will guarantee that you and your partner will be able to get pregnant within the next year." "You will likely have a fever and a strong-smelling vaginal discharge for several days after the procedure."

"You may have referred pain in your chest and shoulders due to the carbon dioxide (CO2) used in the procedure." Clients often have their abdomen insufflated during these procedures for better visualization. As the CO2 leaves the body, it causes muscular discomfort that is referred and presents as chest and shoulder pain. This procedure should not interrupt the client's menstrual cycle for longer than a month, if at all. If this procedure was done because the couple is having fertility problems, the nurse can never guarantee any sort of outcome, especially pregnancy. Fever and vaginal discharge would be abnormal findings following the procedure.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You are not contagious unless you stop taking your medication." "You will not be contagious to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."

"You will not be contagious to the people you have been living with." The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

A 52-year-old client has been diagnosed with endometrial (uterine) cancer. She says to the nurse, "I was told that my cancer is stage II. What does that mean?" How does the nurse respond? "It means that your cancer remains confined to your uterus." "The spread of your cancer is beyond your pelvic area." "Vaginal and lymph nodes are areas of involvement with your cancer." "Your cancer has spread from your uterus to your cervix."

"Your cancer has spread from your uterus to your cervix." Stage II means that the cancer now also involves the client's uterine cervix. Cancer that remains confined to the endometrium (innermost lining) of the uterus is classified as stage I. The spread of cancer that is beyond the pelvic area is classified as stage IV cancer. Vaginal and lymph node areas of involvement indicate that the cancer is classified as stage III.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. A temperature of 100.4° F and pain upon coughing following bladder surgery are normal on the first postsurgical day. The client awaiting discharge teaching is not a priority.

A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr

A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl A 47-year-old obese man with diabetes A 48-year-old woman who smokes A 98-year-old healthy man

A 47-year-old obese man with diabetes Diabetes and obesity significantly contribute to slow wound healing. The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing.

Which client does the RN assess first after receiving change-of-shift report? A 45-year-old with a history of hypothyroidism who is scheduled for a hysterectomy and bladder suspension A 48-year-old who is reporting abdominal pain and light vaginal spotting after an endometrial biopsy A 50-year-old who is receiving morphine through a patient-controlled analgesia (PCA) device after a hysterectomy and who rates her pain at a level 3 (0-to-10 scale) A 54-year-old with an anterior and posterior colporrhaphy who has an elevated heart rate and an oral temperature of 101.2° F

A 54-year-old with an anterior and posterior colporrhaphy who has an elevated heart rate and an oral temperature of 101.2° F The client with an anterior and posterior colporrhaphy is showing signs of postoperative infection and warrants frequent assessments that need to be communicated to the surgeon in charge of care. The client with a history of hypothyroidism who is scheduled for a hysterectomy and bladder suspension, the client with abdominal pain and light vaginal spotting after an endometrial biopsy, and the client receiving morphine through a PCA device with a pain level of 3 are not unusual cases, and do not require rapid intervention by the nurse.

Four women phone the gynecology clinic about having new-onset vaginal bleeding. Which call does the RN decide to return first? A 23-year-old using medroxyprogesterone acetate (Depo-Provera) A 34-year-old with a history of multiple leiomyomas A 48-year-old who had an endocervical curettage yesterday A 62-year-old with no previous gynecologic problems

A 62-year-old with no previous gynecologic problems Vaginal bleeding in a postmenopausal woman is abnormal and may be an indication of serious problems such as endometrial cancer. Bleeding in the 23-year-old using medroxyprogesterone acetate (Depo-Provera), the 34-year-old with a history of multiple leiomyomas, and the 48-year-old who had endocervical curettage yesterday is not unusual. The nurse will need to follow up with these clients.

The nurse is reviewing laboratory results on a 34-year-old client who is suspected of having endometrial (uterine) cancer. Which laboratory tests does the nurse expect to see? (Select all that apply.) *Alpha-fetoprotein (AFP) test* *Cancer antigen (CA)-125 test* *Human chorionic gonadotropin (hCG) level* Liver function tests (LFTs) Serum electrolytes *Hereditary nonpolyposis colon cancer (HNPCC) test*

AFP and CA-125 may be elevated when the cancer has spread to the ovaries; they would be checked for this client. The hCG level should be checked to rule out pregnancy in a client of this age as a precaution before treatment is started. Testing for HNPCC is done if a family history is reported because a connection has been noted between HNPCC and endometrial cancer. LFTs and serum electrolytes are not routinely checked in the diagnostic process for endometrial cancer, but might be performed later.

The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? Veins of the legs Lung Heart Abdominal cavity

Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.

The nurse at the public health clinic is assessing a female client with possible gonorrhea. Which client symptom is of greatest concern to the nurse? Abdominal tenderness Anal itching Foul-smelling vaginal discharge Painful urination

Abdominal tenderness Abdominal tenderness indicates that the infection may have ascended into the pelvic structures, increasing the risk for pelvic inflammatory disease or systemic infection. Anal itching, foul-smelling vaginal discharge, and painful urination are typical clinical manifestations for a gonorrheal infection, and would not be of greatest concern at this time.

The nurse is discussing methods of preventing sexually transmitted diseases (STDs). Which approaches does the nurse suggest for sexually active clients? (Select all that apply.) *Abstinence* Cervical cap with spermicidal cream *Latex condoms* *Mutual monogamy* *Polyurethane condoms*

Abstinence, latex condoms, polyurethane condoms, and mutual monogamy all decrease the risk for acquiring an STD. Barrier contraceptive devices such as the cervical cap do not ensure protection from STDs.

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Administer 2 g of cephalothin (Keflin) IV now. Give morphine sulfate 4 to 6 mg IV for pain. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important. Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important; a minimally invasive technique will be less painful than an open technique, but is still painful. Pain management is not the first priority, however. PRBCs may or may not need to be infused to maintain the oxygen-carrying capacity of the blood. Less blood is lost during minimally invasive techniques than during open surgical procedures.

An 18-year-old female is diagnosed with possible toxic shock syndrome and has these vital signs: T 103.2° F (39.6° C), P 124 beats/min, R 36 breaths/min, BP 84/30 mm Hg. Which health care provider request does the nurse implement first? Administer O2 at 6 L/min. Give cefazolin (Ancef) 500 mg IV. Infuse normal saline IV at 500 mL/hr. Obtain blood cultures × 2 sites.

Administer O2 at 6 L/min The highest priority action for clients with shock is to maintain adequate gas exchange, so administration of oxygen should be the nurse's first action. Giving cefazolin (Ancef) 500 mg IV will need to be implemented rapidly for this client because she must be on antibiotics to fight infection and sepsis. Infusing normal saline IV at 500 mL/hr must be implemented rapidly for this client because she needs hydration and treatment for shock. Obtaining blood cultures will need to be implemented rapidly, prior to administration of antibiotics (cefazolin) for the best opportunity to identify the organizm, but her oxygenation is the priority.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? Administering preoperative antibiotics and anxiolytics Assessing the client's nutritional status and need for nutrition supplements Having the client sign the operative consent form Teaching the client about the need for tracheal suctioning after surgery

Administering preoperative antibiotics and anxiolytics Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered after the operative consent has been signed, or the consent will be invalid. The client's nutritional status and need for nutritional supplements should be assessed by the RN or a registered dietitian as part of the multidisciplinary care team. The surgeon is responsible for discussing the laryngectomy procedure, answering any questions, and having the client sign the operative consent form. Client teaching is the responsibility of the RN because it requires complex critical thinking skills.

The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? Adolescent with an erection for "10 or 11 hours" who is reporting severe pain Young adult with a swollen, painful scrotum who has a recent history of mumps infection Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria Older adult with a history of benign prostatic hyperplasia and palpable bladder distention

Adolescent with an erection for "10 or 11 hours" who is reporting severe pain The client who has had an erection for "10 or 11 hours" has symptoms of priapism, which is considered a urologic emergency because the circulation to the penis may be compromised and the client may not be able to void with an erect penis. The client with a swollen, painful scrotum; the client with hematuria; and the client with a history of benign prostatic hyperplasia do not require the nurse's immediate attention since these are not medical emergencies.

With which male client does the nurse conduct prostate screening and education? Young adult with a history of urinary tract infections Client who has sustained an injury to the external genitalia Adult who is older than 50 years Sexually active client

Adult who is older than 50 years A man who is 50 years or older is at higher risk for prostate cancer. A history of urinary tract infections, injury to the external genitalia, and sexual activity are not risk factors for prostate cancer.

A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A diagnosis of diabetes treated with insulin and diet An exercise regimen of jogging 3 miles four times a week A history of cardiac disease Advancing age

Advancing age Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases. Diabetes is not known to cause lung cancer. Regular exercise is not a risk factor for lung cancer, nor does having cardiac disease predispose a person to lung cancer.

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? Albuterol (Proventil) 2 inhalations Fluticasone (Flovent) 2 inhalations Ipratropium (Atrovent) 2 inhalations Salmeterol (Serevent) 2 inhalations

Albuterol (Proventil) 2 inhalations Albuterol is a beta2 agonist that acts rapidly as a bronchodilator. Fluticasone is a corticosteroid; it is used to prevent asthma attacks and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation; it is not as effective as a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time; this client needs a rescue medication.

Which two factors in combination are the greatest risk factors for head and neck cancer? Alcohol and tobacco use Chronic laryngitis and voice abuse Marijuana use and exposure to industrial chemicals Poor oral hygiene and use of chewing tobacco

Alcohol and tobacco use The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer. Chronic laryngitis and voice abuse in combination are not the greatest risk factors; however, each one individually is a risk factor for head and neck cancer. No large, randomized, controlled studies have identified a relationship between marijuana use and head and neck cancer. Exposure to industrial chemicals may increase a person's risk. Poor oral hygiene is a risk factor, as is chewing tobacco; however, no studies have reported that a combination of the two will lead to increased risk. The same cancer-causing agents in smoking tobacco may be present in smokeless (chewing) tobacco.

The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? Alopecia Allergy Fever Chills

Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab). Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.

When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? Recombinant erythropoietin (Procrit) Allopurinol (Zyloprim) Potassium chloride Radioactive iodine-131 (131I)

Allopurinol (Zyloprim TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? Explain that this occurs in some clients and is usually permanent. Inform the client that a small glass of wine may help her relax. Protect the client from infection. Allow the client an opportunity to express her feelings.

Allow the client an opportunity to express her feelings Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.

After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? (Select all that apply.) *Antispasmodic drugs* Emergency surgery Forced fluids Increased intermittent irrigation *Monitoring for anemia*

Although not a common occurrence, bleeding may occur in the postoperative period. Venous bleeding is more common than arterial bleeding. The surgeon may apply traction on the catheter for a few hours to control the venous bleeding. Traction on the catheter is uncomfortable and increases the risk for bladder spasms, so analgesics or antispasmodics are usually prescribed. Hemoglobin and hematocrit should be monitored and trended for indications of anemia. Emergency surgery and increased intermittent irrigation would be indicated for an arterial bleed, which would be a brighter red color. Forced fluids are indicated after the catheter is removed.

The nurse is teaching a local young women's group about health promotion and maintenance measures for prevention of gynecologic cancers. Which preventive factors does the nurse stress? (Select all that apply.) Annual endometrial biopsy Annual human papilloma virus (HPV) vaccination *Annual Papanicolaou (Pap) test and cervical examination* *Safe sex practices* *Well-balanced diet*

Annual Pap tests are recommended starting 3 years after a woman becomes sexually active or at the age of 21, whichever is sooner. Young women should have the test done annually. Using barrier protection, especially if a woman has multiple sexual partners, is recommended. Knowing the history of partners is also a factor in having safe sex. Eating a diet that includes a variety of healthy food choices (fruits, vegetables, low-fat protein, and healthy dairy products) is known to help a woman have a healthy reproductive system. Endometrial biopsies are not routinely performed annually except when risk for the development of the disease is increased. HPV vaccination is given to young girls (and boys) in a series of three injections over a 6-month time frame. It is best administered before they become sexually active.

When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? (Select all that apply.) Physical Assessment Findings / Diagnostic Findings / Medications Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremors Na: 115 K: 4.2 Creatinine: 0.8 ondansetron (Zofran) cyclophosphamide (Cytoxan) *Hyponatremia* *Mental status changes* Azotemia Bradycardia *Weakness*

Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.

A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? (Select all that apply.) *Administer antispasmodic medications.* Encourage the client to urinate around the catheter if pressure is felt. Perform intermittent urinary catheterization every 4 to 6 hours. *Place the client in a supine position with his knees flexed.* *Assist the client to mobilize as soon as permitted.*

Antispasmodic drugs can be administered to decrease the bladder spasms that may occur due to catheter use. Assisting the client to a chair as soon as permitted postoperatively will help to decrease the risk of complications from immobility. An indwelling catheter and continuous bladder irrigation are in place for about 24 hours after TURP. The client should not try to void around the catheter, which causes the bladder muscles to contract and may result in painful spasms. Intermittent urinary catheterization is not necessary. Typically, the catheter is taped to the client's thigh, so he should keep his leg straight.

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) *Assess for fever.* Observe for bleeding. *Administer pegfilgrastim (Neulasta).* *Do not permit fresh flowers or plants in the room.* Do not allow the client's 16-year-old son to visit. *Teach the client to omit raw fruits and vegetables from the diet.*

Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? Arrange for a health care worker to watch the client take the medication. Give the client written instructions about how to take prescribed medications. Have the client repeat medication names and side effects. Instruct the client about the possible consequences of nonadherence.

Arrange for a health care worker to watch the client take the medication. Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Also, the question does not indicate whether the client can read. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless may be more concerned with obtaining shelter and food than with properly taking his or her medication.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? Ask the client whether CPAP has been used consistently at night. Discuss the use of autotitrating positive airway pressure (APAP). Plan to teach the client about treatment with modafinil (Provigil). Suggest that a nasal mask be used instead of a full facemask.

Ask the client whether CPAP has been used consistently at night. The nurse should assess whether the client has actually consistently been using CPAP at night, because clients may have difficulty with the initial adjustment to this therapy. With APAP, the pressures are adjusted continuously depending on the client's needs; this may be more comfortable for the client. Modafinil treats narcolepsy or daytime sleepiness; it does not treat the cause of sleep apnea, but may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the client if he or she is finding the facemask used with CPAP uncomfortable.

A male client is given 1000 mg of oral azithromycin (Zithromax) to treat his chlamydia infection. Two weeks later, he returns to the clinic and says to the nurse, "My symptoms have returned." What does the nurse do first? Asks him whether his partner was also treated for chlamydia Discusses possible complications of untreated sexually transmitted diseases Reminds him to abstain from sexual activity during his treatment Teaches him about the use of doxycycline (Monodox) to treat chlamydia

Asks him whether his partner was also treated for chlamydia Because recurrence of chlamydia is frequently caused by re-infection with a new or untreated partner, the nurse should first assess whether the client's partner was treated. Depending on the data found when the nurse assesses the client further, the nurse may discuss possible complications of untreated sexually transmitted diseases. The nurse also may remind him to abstain from sexual activity during his treatment and may need to teach him about the use of doxycycline (Monodox) to treat chlamydia.

As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do? Calls the surgeon Calls the anesthesiologist Gives the medication as ordered Asks the client to sign the consent form

Asks the client to sign the consent form The nurse may ask the client to sign the consent form, after which the medication can be administered. Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? Assess the airway, breathing, and circulation. Call for the Rapid Response Team. Check the patency of the chest tubes. Listen for breath sounds.

Assess the airway, breathing, and circulation. Assessing the "ABCs" is the priority to determine possible causes of burning in the client's chest. The client's situation does not require the Rapid Response Team to be called. The client's symptoms are not caused by a blockage of chest tubes. Listening for breath sounds would be an appropriate action for the nurse to take to evaluate the client's reported symptoms; however, this would not be the nurse's first action.

What action does the RN delegate to unlicensed assistive personnel (UAP) working on the medical-surgical unit? Inserting a catheter in a client who has a history of uterine prolapse Giving report to a receiving nurse about a client who is being transferred Assisting with a sitz bath for a client with ulcerative vulvitis Providing discharge teaching for a client who is scheduled for brachytherapy

Assisting with a sitz bath for a client with ulcerative vulvitis Assisting with a sitz bath is within the UAP scope of practice and can safely be delegated. Some specially trained UAPs do catheterize clients, but a client with a uterine prolapse poses additional problems and should be managed by a licensed nurse. Giving report to a receiving nurse about a client who is being transferred is an interaction that should be "nurse-to-nurse." Providing discharge teaching for a client who will be having brachytherapy (intracavitary radiation) is a complex nursing action and should be done by an RN.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.

Auscultate the client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? Avoid Cystic Fibrosis Foundation-sponsored events. Avoid the hospital. Stay at home most of the time. Use an antiseptic hand gel.

Avoid Cystic Fibrosis Foundation-sponsored events. A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events. Avoiding the hospital completely is unrealistic, although special infection control procedures may be implemented, such as scheduling the client's office visits on different days or in different areas of the hospital. Social isolation is not needed for clients with CF and may be detrimental to the psychosocial well-being of the client. Hand hygiene is important, although this is not the best response.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? Avoiding or reducing skin exposure to sunlight Avoiding tanning beds Being aware of skin markings and performing skin self-examination Wearing SPF 40 sunscreen

Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). Avoiding tanning beds is significant, but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 ng/dL Chest x-ray report showing right middle lobe consolidation

B-type natriuretic peptide (BNP) of 760 ng/dL BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? Vomiting Back pain Frequent urination Cyanosis of the toes

Back pain Typical sites of breast cancer metastasis include bone (manifested by back pain), lung, liver, and brain. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control, but not vomiting. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease.

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? Barrel chest Cough Dyspnea Reduced gas exchange

Barrel chest Interstitial lung diseases are restrictive, not obstructive, so they do not cause barrel chest, which is the result of air trapping. Both types of pulmonary disease cause cough, dyspnea, and reduced gas exchange.

A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? Clean toothbrushes once a week. Bathe daily using an antimicrobial soap. Eat salad at least once a day. Wash dishes in cool water.

Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin. Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

When is the best time for the nurse to begin discharge planning and a community-based plan of care for a client with prostate cancer? Before surgery After surgery 2 days before being discharged The day of discharge

Before surgery Planning should begin as early as possible, on admission and before surgery. After surgery is not the correct time to begin planning. Planning should begin earlier than 2 days before discharge.

A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously. Which assessment finding indicates the need for immediate action by the nurse? Blood pressure of 88/40 mm Hg White blood cell count of 15,000/mm3 Oral temperature of 101° F (38.3° C) Heart rate of 102 beats/min

Blood pressure of 88/40 mm Hg Too-rapid administration of clindamycin can cause shock and cardiac arrest; the client's low blood pressure indicates a need to slow the rate and re-assess the client. An elevated white blood cell count, an elevated temperature, and an elevated heart rate are expected findings in a client with bacteremia.

A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer? Liver Smooth muscle Fatty tissue Brain

Brain The prefix "glio-" is used when cancers of the brain are named. The prefix "hepato-" is included when cancers of the liver are named. The prefix "leiomyo-" is included when cancers of smooth muscle are named. The prefix "lipo-" is included when cancers of fat or adipose tissue are named.

The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply.) Heavy menses Smooth facial skin Hyperkalemia *Breast tenderness* Weight loss *Deep vein thrombosis*

Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Level of consciousness Oxygen saturation Surgical site

Breathing pattern Respiratory assessment is the most important. Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority

When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) *Bruises* Fever *Petechiae* *Epistaxis* Pallor

Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? By nasal cannula at a rate of no more than 1 to 3 L/min By nasal cannula at a rate of no more than 2 to 4 L/min By Venturi mask at a rate of at least 60% By maintaining oxygen saturations greater than 88%

By maintaining oxygen saturations greater than 88% In the past, a client with COPD was thought to be at risk for extreme hypoventilation with oxygen therapy because of a decreased drive to breathe as blood oxygen levels increased. However, recent evidence does not support this; this idea has been responsible for ineffective management of hypoxia in clients with COPD. All hypoxic clients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92%

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? Calmly continues talking Checks the tube for blocks or kinks Immediately calls the health care provider Strips the chest tube

Calmly continues talking Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. Any bubbling that is occurring would stop if a kink or a blockage is present in the chest tube. The chest tube is functioning normally; there is no need to notify the health care provider. "Stripping the chest tube" greatly increases pressure inside the chest and could potentially damage lung tissue; any excessive manipulation should be avoided.

Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? (Select all that apply.) *Change the decorations in the home according to the season.* *Put the bed close to the window.* Write out detailed instructions, and have the client read them over before performing a task. *Ask the client what time he or she prefers to shower or bathe.* *Mark off the days of the calendar, leaving open the current date.*

Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule. Directions should be short and uncomplicated.

Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)

Carvedilol (Coreg) Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

A client with newly diagnosed gynecologic cancer is being discharged home. Which health care team member does the nurse contact to coordinate nursing care at home for this client? Case manager Health care provider Hospice Social services

Case manager If nursing care is needed at home, the hospital nurse or case manager makes referrals to a home health care agency. The health care provider is not the correct team member to coordinate home care. Hospice care is provided for clients who are at the end of their lives; this type of care is not necessary (or indicated) for this client. A referral to a social services agency is needed if the client is unable to meet the financial demands of treatment and long-term follow-up.

The nurse includes which factors in teaching regarding the typical warning signs of cancer? (Select all that apply.) *Persistent constipation* *Scab present for 6 months* Curdlike vaginal discharge *Axillary swelling* Headache

Change in bowel habits, a sore that does not heal, and a lump or thickening in the breast or elsewhere are all potential warning signs of cancer. Curdlike vaginal discharge represents a yeast infection. Headache is not a warning sign, but may be present with multiple problems.

Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? Increasing shortness of breath Diminished bilateral breath sounds Change in mental status Weight gain of 4 pounds in 1 day

Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.

A client has an odorous, purulent wound. How does the nurse best support this client? Changes the dressing frequently Encourages a diet high in protein Suggests whirlpool therapy Places room deodorizers in the room

Changes the dressing frequently Frequent dressing changes help the client feel clean. A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? Check the resident's oxygen saturation. Do a complete neurologic assessment. Give the prescribed PRN lorazepam (Ativan). Notify the resident's primary care provider.

Check the resident's oxygen saturation. A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, notifying the primary care provider may be an appropriate next step.

A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? Actively listen to this client's concerns. Allow the client to wear the hearing aid to surgery. Check to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given. Apologize to the client and explain that it is hospital policy to remove a hearing aid before surgery.

Check to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given. In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction. The OR staff may have a different policy, considering that the hearing aid may get lost. Listening isn't always enough; more intervention is needed. Telling the client that a policy precludes the client's needs is not therapeutic.

Which sexually transmitted diseases are vaginal infections? (Select all that apply.) *Chlamydia* Endometritis Epididymitis *Gonorrhea* Proctitis *Syphilis*

Chlamydia can be transmitted during vaginal, anal, or oral sex. Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Both gonorrhea and chlamydia can also be spread from an infected mother to her baby during vaginal childbirth. Syphilis is a bacterial infection usually spread by sexual contact which starts as a painless sore, typically on the genitals, rectum, or mouth. Syphilis spreads from person to person via skin or mucous membrane contact, such as vaginally. Endometritis is the infection of the innermost lining of the uterus (the endometrium). Epididymitis is an inflammation of the coiled tube (epididymis) at the back of the testicle that stores and carries sperm; pain and swelling are the most common signs and symptoms. Proctitis is an inflammation of the rectum that causes discomfort, bleeding, and, occasionally, a discharge of mucus or pus.

What is the greatest risk factor for lung cancer? Alcohol consumption Asbestos exposure Cigarette smoking Smoking marijuana

Cigarette smoking Cigarette smoking is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease. Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Although asbestos is carcinogenic and some components of marijuana are carcinogenic, neither is the major risk factor for lung cancer.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours Ceftriaxone (Rocephin) 2 g IV every 8 hours Ciprofloxacin (Cipro) 400 mg IV every 12 hours Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day

Ciprofloxacin (Cipro) 400 mg IV every 12 hours Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (Zinamide) is used for treatment of tuberculosis.

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? Surgical technologist with 10 years of experience in the OR at this hospital Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals Holding room RN who has worked in the hospital holding room for longer than 15 years Circulating RN who has been employed in the hospital OR for 7 years

Circulating RN who has been employed in the hospital OR for 7 years The circulating RN has the experience and background to write OR policy and has been employed in this hospital and is aware of hospital policy and procedures. A surgical technologist does not have the background to write policy for nurses. A CRNFA has worked in multiple hospitals but does not have a work history with this specific hospital to be aware of the unit policy. A holding room or preoperative or postoperative care nurse would not be the choice to write OR policy.

Who is the most likely person to administer blood products in an operating suite? Circulating nurse Holding area nurse Scrub nurse Specialty nurse

Circulating nurse Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Holding area nurses manage the client's care before surgery; blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty; they are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? Circulating nurse Holding nurse Anesthesiologist Surgeon

Circulating nurse All OR team members are responsible, but the circulating nurse moves around the room and can see more of what is happening. The holding nurse is not in the operating room. The anesthesiologist is focused on providing sedation to the client. The surgeon is concentrating on the surgery and usually cannot monitor all staff.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? Apply a barrier cream. Assess the area for skin breakdown. Clean the client. Place the client in a side-lying position.

Clean the client. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? Client on warfarin (Coumadin) with epistaxis with profuse bleeding Client with facial burns caused by a mattress fire while sleeping Client with possible facial fractures after a motor vehicle collision (MVC) Client with suspected bilateral vocal cord paralysis and stridor

Client on warfarin (Coumadin) with epistaxis with profuse bleeding The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this client. In addition, laboratory work should be obtained to assess the client's ability to clot, given that the client is on warfarin (Coumadin). A client who has sustained facial burns in an enclosed setting is at high risk for airway involvement and requires observation by an experienced nurse. An experienced nurse should take care of a client with possible facial fractures after an MVC due to the potential for airway compromise from bleeding or swelling. Facial fractures may be accompanied by cervical spine fracture and/or spinal trauma that requires monitoring and evaluation by an RN with experience. Stridor is an indication of respiratory distress; this requires an RN with experience.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? Recent radical mastectomy client requiring chemotherapy administration Modified radical mastectomy client needing discharge teaching Stage III breast cancer client requesting information about radiation and chemotherapy Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy

Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy A nurse working in the ICU would be familiar with postoperative monitoring and care of clients with Jackson-Pratt drains. The recent radical mastectomy client requires chemotherapy, so it is more appropriate to assign her to nurses who are familiar with teaching, monitoring, and providing chemotherapy for clients with breast cancer. The modified radical mastectomy client who requires discharge teaching, and the stage III breast cancer client requiring information about radiation and chemotherapy are more appropriate to assign to nurses who are familiar with breast cancer.

The nurse is assigned to care for four clients. Which client does the nurse assess first? Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperatur The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring; the client is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. Client with emphysema who requires instruction about correct use of oxygen at home. Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day.

Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis. Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population; although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. The client with CF with an elevated temperature and respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first. The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications; this may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal for a hospice client with terminal pulmonary fibrosis; not enough information is provided to determine whether this client is in distress. The client who needs an IV antibiotic could have the medication administered by another RN, or it could be administered in the operating room.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with heart failure who is receiving dobutamine (Dobutrex) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Client with pericarditis who has a paradoxical pulse and distended jugular veins Client with rheumatic fever who has a new systolic murmur

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? Client with bacterial pneumonia and a cough productive of green sputum Client with neutropenia and pneumonia caused by Candida albicans Client with possible pulmonary tuberculosis who currently has hemoptysis Client with right empyema who has a chest tube and a fever of 103.2° F

Client with possible pulmonary tuberculosis who currently has hemoptysis A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? Client with group A beta-hemolytic streptococcal pharyngitis who has stridor Client with pulmonary tuberculosis who is receiving multiple medications Client with sinusitis who has just arrived after having endoscopic sinus surgery Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN

Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? Bathe in cold water. Wear cotton gloves when cooking. Consume a diet high in fiber. Make sure shoes are snug.

Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (Select all that apply.) *Combination drug therapy is effective in preventing transmission.* *Combination drug therapy is the most effective method of treating TB.* Combination drug therapy will decrease the length of required treatment to 2 months. *Multiple drug regimens destroy organisms as quickly as possible.* *The use of multiple drugs reduces the emergence of drug-resistant organisms.*

Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

A client has been diagnosed with breast cancer. Which client-chosen treatment option requires the nurse to discuss with the client the necessity of considering additional therapy? Chemotherapy Complementary and alternative medicine (CAM) Hormonal therapy Neoadjuvant therapy

Complementary and alternative medicine (CAM) No proven benefit has been found with using CAM alone as a cure for breast cancer. The nurse must ensure that the client's choices can be safely integrated with conventional treatment for breast cancer. Chemotherapy is usually used for stage II or higher breast cancer and may or may not be used as a single treatment option. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth; it may or may not be used with other treatment options. A large tumor is sometimes treated with chemotherapy, called neoadjuvant therapy, to shrink the tumor before it is surgically removed; an advantage of this therapy is that cancers can be removed by lumpectomy rather than mastectomy.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Calls the family to lift the client's spirits Considers further assessment for depression Sedates the client to decrease myocardial oxygen demand Tells the client that things will get better

Considers further assessment for depression This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? (Select all that apply.) Limit sodium intake. *Avoid beef and processed meats.* *Increase consumption of whole grains.* *Eat "colorful fruits and vegetables," including greens.* Avoid gas-producing vegetables such as cabbage.

Consuming bran and whole grains and avoiding red meat and processed foods such as lunchmeats can reduce cancer risk. Consuming foods high in vitamin A, including apricots, carrots, and leafy green and yellow vegetables, can also reduce cancer risk. Reducing sodium is helpful in the treatment of hypertension and heart and kidney failure; no evidence suggests that lowering of sodium intake decreases the incidence of cancer. Eating cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage may actually reduce cancer risk.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form.

Contact the surgeon The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? Completing the antibiotic medication regimen Taking pain medications every 4 to 6 hours Contacting the provider if the throat feels more swollen Using warm saline gargles and irrigations

Contacting the provider if the throat feels more swollen Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. It is important to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but none of these is the most important thing to teach the client.

The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? Continuous oozing of bright-red blood Decreased level of consciousness Effective pain management Heart rate and blood pressure trending up over several hours

Continuous oozing of bright-red blood Bright-red blood indicates a rupture in the carotid artery and requires immediate attention. A ventilated postoperative client will be sedated, so a decreased level of consciousness is to be anticipated. Effective pain management should be evaluated during assessment of vital signs and that information relayed to the nurse. Changes in vital signs, including trends, need to be reported to the nurse responsible for the client's care. Increasing heart rate and blood pressure can be an indication that the client is not adequately sedated or is in pain or anxious, for example.

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

Cover the wound with a sterile, warm, moist dressing. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL Fasting glucose, 80 mg/dL Potassium, 3.9 mEq/L Sodium, 140 mEq/L

Creatinine 1.9mg/dL A creatinine of 1.9 mg/dL is outside the normal range and may indicate renal problems. A fasting glucose of 80 mg/dL, a potassium level of 3.9 mEq/L, and sodium level of 140 mEq/L are normal laboratory values.

An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for? Cricothyroidotomy Endotracheal intubation Nasal bi-level positive airway pressure (BiPAP) Tracheotomy

Cricothyroidotomy Cricothyroidotomy is an emergency procedure performed by emergency medical personnel to hold an airway open until a tracheotomy may be performed. Endotracheal intubation is not likely in a client with severe head and neck injuries. Nasal BiPAP depends on a patent upper airway. Tracheotomy is a surgical procedure, not a field procedure.

The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? Easy bruising Dyspnea Night sweats Chest wound

Dyspnea Dyspnea is a sign of lung cancer, as are cough, hoarseness, shortness of breath, bloody sputum, arm or chest pain, and dysphagia. Easy bruising is a nonspecific finding. Night sweats is a symptom of the lymphomas. A chest wound is not specific to lung cancer.

The nurse is evaluating a client's response to antibiotic treatment for pelvic inflammatory disease (PID). Which finding indicates that the treatment is effective? Decreased pelvic tenderness Decreased vaginal discharge Increased appetite Increased libido

Decreased pelvic tenderness Pain management of PID begins with treatment of the infection. Antibiotic therapy relieves pain by decreasing the inflammation caused by infection. Vaginal discharge may be increased at first as the infection drains. Increased appetite and increased libido may be secondary findings, but are not indicative of effective treatment.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) *Chest discomfort or pain* *Tachycardia* Expectorating thick, yellow sputum Sleeping on back without a pillow *Fatigue*

Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? Attempt to remove the obstruction. Call the Rapid Response Team to intubate immediately. Call the Rapid Response Team to perform an emergency cricothyroidotomy. Determine the cause of the obstruction.

Determine the cause of the obstruction. The first step the nurse should take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action. The obstruction cannot be removed until its origin has been determined. Although notifying the Rapid Response Team is important and the client may require intubation, this is not the first action. An emergency cricothyroidotomy is not the first step to take in relieving an upper airway obstruction. This is an invasive procedure that requires specialized training and equipment that is not readily available at the bedside.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? Asks the client if he is squeamish Demonstrates how to change the dressing Determines whether the client can reach the affected area Provides all of the necessary dressing materials

Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess; if the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home. The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which actions would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.

Develop the discharge teaching plan in conjunction with the client Education and preparation for discharge are within the scope of practice of the RN. Reinforcing the need to cough and deep-breathe, and monitoring the client are within the scope of the LPN/LVN nurse. LPN/LVNs can also administer pain medications.

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds over the client's ideal body weight

Diet-controlled diabetes mellitus Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.) Hypokalemia *Sinus bradycardia* *Fatigue* Serum digoxin level of 1.5 *Anorexia*

Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? Decreased sensation in the lower extremities Diminished peripheral pulses in the lower extremities Pale, cool extremities Reddened areas over bony prominences

Diminished peripheral pulses in the lower extremities Diminished peripheral pulses in the lower extremities indicate diminished blood flow. Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.

The nurse admits a client to the clinic who is reporting severe itching of the arms and legs caused by exposure to poison ivy. The nurse anticipates that the health care provider will prescribe which medication? Anthralin (Drithocreme) Benzyl benzoate (Ascabiol) Calcipotriene (Dovonex) Diphenhydramine (Benadryl)

Diphenhydramine (Benadryl) Treatment for inflammations such as poison ivy is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine are helpful. Anthralin is indicated for treatment of psoriasis. Benzyl benzoate is a scabicide indicated for treatment of scabies. Calcipotriene is a synthetic form of vitamin D that is used to treat psoriasis.

Which factor relates most directly to a diagnosis of primary immune deficiency? History of viral infection Full-term infant surfactant deficiency Contact with anthrax toxin Corticosteroid therapy

Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

The nurse is teaching a client how to prevent vaginal inflammation and itching. What information does the nurse include? Avoid loose, flapping clothing; pants should fit well. Cleanse the inner labia daily with soap and water. Do not have unprotected sex with multiple partners. Monthly douching should help reduce symptoms.

Do not have unprotected sex with multiple partners. Unprotected sex with multiple partners can lead to vaginal infection. Tight clothing, such as pantyhose or tight jeans, should be avoided because it can cause chafing. Tight clothing can also cause the vaginal area to get hot and sweaty, which can lead to infection. During a bath or shower, the inner labial mucosa should be cleansed with only water, not soap; soap is an irritant to the sensitive skin in those areas. The use of douches or feminine hygiene sprays is not recommended because they disturb the balance of both pH and bacteria and can aggravate irritation.

The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? Avoid asbestos. Wear sunscreen. Get the human papilloma virus (HPV) vaccine. Do not smoke cigarettes.

Do not smoke cigarettes. All of these actions are part of cancer prevention; however, tobacco is the single most important source of preventable carcinogenesis. Asbestos may be found in older homes and buildings. Most schools have been through an asbestos abatement program so should not pose a risk. It would be important to share with teens who may be involved in the construction industry during the summer to be aware of asbestos risks. Although asbestos may present a risk for lung cancer, it is not a likely exposure for teens. Lifetime exposure to the sun and the use of tanning beds will increase the risk for cancer, but not as much as tobacco use. The HPV vaccine will decrease the risk for cervical cancer, but will not have as much of an impact on cancer prevention as avoiding tobacco.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? Administer levofloxacin (Levaquin) 500 mg IV. Draw aerobic and anaerobic blood cultures. Give lorazepam (Ativan) as needed for agitation. Refer to social worker for alcohol counseling.

Draw aerobic and anaerobic blood cultures. Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this client is febrile and agitated, and a referral is not the immediate concern.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

Draw blood for glucose, electrolyte, and complete blood count values. If blood work is abnormal, the surgery may be rescheduled. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.

The nurse is assessing a male client who has been diagnosed with Chlamydia trachomatis. What clinical manifestation does the nurse expect to see? Dysuria Painless maculopapular rash in the perineal area Pustules on the glans of the penis Testicular edema

Dysuria Dysuria is a clinical manifestation of C. trachomatis. Painless maculopapular rash in the perineal area and testicular edema are not clinical manifestations of C. trachomatis. Pustules on the glans of the penis are a clinical manifestation of herpes simplex type 2.

A client with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the client about this type of pharmacologic management? (Select all that apply.) *Avoid drugs used to treat erection problems.* *Be careful when changing positions.* *Keep all appointments for follow-up laboratory testing.* Hearing tests will need to be conducted periodically. Take the medication in the afternoon.

Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage, so it is important to keep appointments for follow-up laboratory testing. These drugs do not affect hearing. Alpha-adrenergic blockers should be taken in the evening to decrease the risk of problems related to hypotension.

Which method is the best way to prevent outbreaks of pandemic influenza? Avoiding public gatherings at all times Early recognition and quarantine Vaccinating everyone with pneumonia vaccine Widespread distribution of antiviral drugs

Early recognition and quarantine The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings should be avoided only if a widespread outbreak has occurred in a community. No vaccine is available for pandemic influenza. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

The nurse is instructing a client with breast cancer who will be undergoing chemotherapy about the side effects of doxorubicin (Adriamycin). Which side effect does the nurse instruct the client to report to the health care provider? Diaphoresis Dysphagia Edema Hearing loss

Edema Doxorubicin is an anthracycline, and clients must be instructed to be aware of and to report cardiotoxic effects, including edema, shortness of breath, chronic cough, and excessive fatigue. Diaphoresis (profuse sweating), dysphagia (difficulty swallowing), and hearing loss are not associated side effects of doxorubicin.

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? New onset of fatigue Edema of arms and hands Dry cough Weight gain

Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? Ecchymosis Edema Excessive swallowing Sore throat

Excessive swallowing Excessive swallowing in a client who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention. Because of the very vascular nature of the face, ecchymosis is a normal finding in the client who has undergone a nasoseptoplasty. Edema is a normal reaction to any kind of trauma, including that caused by surgery, so it is not an unexpected finding for this client. A sore throat is a common side effect of endotracheal intubation.

A young adult with testicular cancer is admitted for unilateral orchiectomy and retroperitoneal lymph node dissection. Which nursing action is best for the nurse to delegate to unlicensed assistive personnel (UAP)? Encourage the client to cough and deep-breathe after surgery. Discuss reproductive options with the client and significant other. Teach about the availability of a gel-filled silicone testicular prosthesis. Evaluate the client's understanding of chemotherapy and radiation treatment.

Encourage the client to cough and deep-breathe after surgery. Although teaching about routine postoperative client actions such as coughing and deep-breathing should be done by licensed nurses, reminding clients to perform these activities can be delegated to UAP. Client education and evaluation are more complex skills that should be done by licensed nurses.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? Encourages participation in care of the wound Encourages visitors Says, "I know how you feel" Assures the client that it will be all right

Encourages participation in care of the wound Encouraging participation in wound care gives the client a sense of autonomy. Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) Explain to the client that the colostomy is only temporary. *Encourage the client to participate in changing the ostomy.* Obtain a psychiatric consultation. *Offer to have a person who is coping with a colostomy visit.* *Encourage the client and family members to express their feelings and concerns.*

Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? Tell the client that she will be asleep. Ensure that drapes will minimize perianal exposure. Explain postoperative expectations. Restrict the number of technicians in the procedure.

Ensure that drapes will minimize perianal exposure. Using drapes is the best action to take. Telling the client that she will be asleep or explaining the procedure will not alleviate the client's anxiety. The number of people involved in the procedure is not something the nurse can necessarily control.

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified.

Ensure written consultation of two noninvolved physicians. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? Fluconazole (Diflucan) Trimethoprim/sulfamethoxazole (Bactrim) Rifampin (Rifadin) Acyclovir (Zovirax)

Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

What does the nurse do first when setting up a safe environment for the new client on oxygen? Ensures that staff members wear protective clothing Ensures that no combustion hazards are present in the room Sets the oxygen delivery to maintain no fewer than 16 breaths/min Uses a pulse oximetry unit

Ensures that no combustion hazards are present in the room Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use. Protective clothing is not necessary for a client who requires oxygen therapy other than the use of Standard Precautions. The oxygen delivery setting is usually determined in conjunction with the respiratory therapy care partner. Although the setting is important for safe administration, it is not necessary for a safe environment. Pulse oximetry would be useful for monitoring the client's oxygenation status, but is not necessary for a safe environment.

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? Educate the client about ways to avoid aspiration when swallowing after the surgery. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. Teach the client and significant others about how to suction and do wound care of the stoma.

Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the client will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place. Aspiration is not a risk after a total laryngectomy because no connection is present between the mouth and the respiratory system. It will be several weeks before the client will need to address appropriate clothing; overloading the client with too much information before surgery is unnecessary. Suctioning and wound care is discharge teaching that can be started after the surgery, when the client and significant others are more likely to retain the information owing to decreased preoperative anxiety. The significant others can observe the care and then can begin to take over more of the care while the client is still in the hospital in a supervised environment.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? Ethambutol Isoniazid Pyrazinamide Rifampin

Ethambutol Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? Use the Braden Scale to determine pressure ulcer risk for a newly admitted client. Complete daily sterile dressing changes for a client with a venous leg ulcer. Every 2 hours, re-position a client who has had a stroke and is incontinent. Admit a newly transferred client who had pedicle flap surgery 1 week ago.

Every 2 hours, re-position a client who has had a stroke and is incontinent. The nursing assistant has the education and scope of practice to re-position a client. Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice.

A nursing student is observing in an inner-city clinic that offers free sexually transmitted disease testing. Which situation demonstrates appropriate client confidentiality and privacy? Counseling a client in a shared professional office where no other clients are present Exchanging a multiple sign-in log with individual sign-in forms Leaving a message about negative test results on a home answering machine Saying to a friend, "He was tested in our clinic; don't go out with him."

Exchanging a multiple sign-in log with individual sign-in forms Individual sign-in forms prevent other clients from seeing who else has signed in and is being treated in the clinic. Even though no other clients are in the shared professional office, this setup is not private enough; the client may feel uncomfortable sharing any information with anyone in the room, professional or not. Another professional might feel uncomfortable coming into the office, also. Leaving test results on an answering machine is a violation of client privacy and confidentiality because messages can be heard or picked up by anyone with access to the machine. Talking to a friend about a client is a direct breach of confidentiality.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? Crackles on auscultation Fever Headache Wheezing

Fever Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Crackles in all fields S3 present Oliguria Ejection fraction 30% BNP 560 Sodium 130 mEq/L Diagnosis: heart failure Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first? Enalapril Heparin Furosemide Intake and output (I & O)

Furosemide The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure should have daily weights and I & O monitored, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.

A clinic nurse is providing expedited partner treatment (EPT) to a client who is newly diagnosed with chlamydia. What does the nurse do first? Confirms the diagnosis of the partner through appropriate testing Gives the drug and directions to the client for the partner Makes an appointment at the clinic for the partner Provides condoms for the client and partner to use

Gives the drug and directions to the client for the partner EPT is successful in reducing chlamydia infection rates. Clients are given the drug or a prescription with specific instructions for administration to their partners, without direct evaluation by a health care provider. Although there has been some discussion about the legality of this practice, it is supported by the Centers for Disease Control and Prevention. It is not required for the nurse to confirm the diagnosis of the partner or to make an appointment for the partner. Providing condoms is not a component of EPT.

Which factors are possible transmission routes for human immune deficiency virus (HIV)? (Select all that apply.) *Breast-feeding* *Anal intercourse* Mosquito bites Toileting facilities *Oral sex*

HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions. HIV is not spread by mosquito bites or by other insects. HIV is not transmitted by casual contact, and sharing toilet facilities does not allow transmission of HIV.

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery

Having a small glass of juice at 7:00 a.m. Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling. The nurse should confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse should document this in the client's information as well. The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery.

The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? Hemoglobin of 7.4 and hematocrit of 21.8 Potassium level of 2.9 mEq/L and diarrhea 250,000 platelets/mm3 5000 white blood cells/mm3

Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.

Hold the digoxin, and obtain a prescription for a potassium supplement. Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action? Call the legal department. Call the client's primary health care provider. Honor the DNR order. Resuscitate per OR procedure.

Honor the DNR order. According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination. Calling the legal department or the client's health care provider is not an appropriate response. Resuscitating this client after a DNR has been signed is illegal.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? Hyperbaric oxygen Nutrition therapy Topical growth factors Vacuum-assisted wound closure

Hyperbaric oxygen Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers. Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of methicillin-resistant Staphylococcus aureus infection. The nurse plans to monitor the client for which adverse effect of linezolid? Depression Hyperglycemia Hypertension Incontinence

Hypertension Linezolid constricts blood vessels and may trigger hypertensive crisis. Depression, hyperglycemia, and incontinence are not adverse effects of linezolid.

A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication? IV ketorolac (Toradol) IV midazolam (Versed) IV morphine sulfate (Morphine) Oral acetaminophen (Tylenol)

IV morphine sulfate (Morphine) Morphine or other opioids are the best choice for this client in the immediate postoperative period. They can be given both as a bolus dose and continuously by patient-controlled analgesia. The client's airway and respiratory status must be carefully observed. Although nonsteroidal anti-inflammatory drugs do provide pain relief, at this stage of the client's recovery, Toradol is not the best choice. Midazolam is an antianxiety medication; it has no narcotic properties. Oral acetaminophen is not appropriate in the immediate postoperative period as it will not provide sufficient pain control, and the client still will be unable to take oral medication.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)

Ibuprofen (Motrin) Long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF. A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause HF.

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action? Administer cardiopulmonary resuscitation. Continue as normal. Immediately stop all inhalation anesthetic agents and succinylcholine. Inform the surgeon.

Immediately stop all inhalation anesthetic agents and succinylcholine. This client is exhibiting early symptoms of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed, and MH requires immediate intervention. This client does not require resuscitation. Informing the surgeon is not the priority.

A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first? Give oxygen to keep O2 saturation greater than 93%. Immobilize the neck with a cervical collar. Infuse normal saline by large-bore IV catheter. Obtain computed tomography (CT) scan of head, neck, and chest.

Immobilize the neck with a cervical collar. If the cervical spine has not already been stabilized by emergency medical services, this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied. Innervation of the diaphragm is between cervical spine levels C3 and C5. Oxygen administration is important; however, this is not the nurse's first priority and is considered separate from establishing an airway. Two large-bore (16- or 18-gauge) IV catheter lines should be established, and an isotonic fluid such as normal saline should be infused at a rate determined by the client's condition and vital signs. CT scans are not the top priority and should be based on the client's reported problems and condition.

A client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? Therapeutic highly active antiretroviral therapy (HAART) level Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot Positive Papanicolaou (Pap) test Improved CD4+ T-cell count and reduced viral load

Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication. Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? Hair loss Increased risk for sunburn Loss of appetite Pain at site of treatment

Increased risk for sunburn Skin in the path of radiation is more sensitive to sun damage; therefore, clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free; however, the skin may become sore and prone to breakdown over the course of treatment.

When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? Drug toxicity Polycythemia Infection Dose-limiting side effects

Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .

The nurse is establishing a plan of care for a client with newly diagnosed pelvic inflammatory disease (PID). Which problem does the nurse place as the client's highest priority? Infection Infertility Reduced sexual drive Reduced self-esteem

Infection The primary problem for clients with PID is infection; this is related to invasion of pelvic organs by pathogens. Although important, infertility (or the risk for the development of it), reduced sexual drive, and reduced self-esteem are not the client's most important problems in this scenario.

The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? Infection with hepatitis B virus Consuming a diet high in animal fat Exposure to radon Familial polyposis

Infection with hepatitis B virus Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer. Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer. Familial polyposis is a risk factor for colorectal cancer.

The nurse prepares to administer vancomycin (Vancocin) to a client diagnosed with methicillin-resistant Staphylococcus aureus infection. How does the nurse administer this medication? By bolus IV push Infused over 60 minutes Mix with the primary IV bag

Infused over 60 minutes Vancomycin is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes. Vancomycin should not be given by bolus or by IV push, and it should not be mixed with the primary IV bag. It is administered IV piggyback or through a saline or heparin lock.

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Incorrect Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Insertion of a catheter is within the scope of skills approved for the LPN/LVN. Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.

What pain management does a client who has been admitted to the postanesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics

Intravenous opioid analgesics Intravenous (IV) opioids are given in small doses to provide pain relief, but not to mask an anesthetic reaction. Intramuscular nonopioid analgesics and opioid analgesics are too long-acting. IV nonopioid analgesics usually are not given within the first 48 hours after surgery.

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites, but is not effective against TB. Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway disease to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is a nonsteroidal anti-inflammatory drug that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to clients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid.

A client is receiving chemotherapy treatment for breast cancer and asks for additional support for managing the associated nausea and vomiting. Which complementary therapy does the nurse suggest? Ginger Journaling Meditation Yoga

It has long been believed that ginger helps alleviate nausea and vomiting. Current studies are being done on the effect of ginger on chemotherapy-induced nausea. Journaling is good for reducing anxiety, stress, and fear. Meditation helps reduce stress, improve mood, improve quality of sleep, and reduce fatigue. Yoga has been shown to improve physical functioning, reduce fatigue, improve sleep, and improve one's overall quality of life.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? It would not be beneficial for this client. It would help decrease the bronchospasm. It would clear up the density in the bases of the client's lungs. It would decrease the client's pain on inspiration.

It would help decrease the bronchospasm. A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath. A bronchodilator would not be able to clear up the density in the bases of the client's lung. The cause of the density is unknown; however, an infection such as pneumonia is likely, which bronchodilators do not treat. Although a bronchodilator would help a client breathe easier, it does not have any analgesic properties.

Which action does the RN delegate to unlicensed assistive personnel (UAP) helping with care for a client with pelvic inflammatory disease? Asking the client if she has concerns about infertility Assessing the client for signs of guilt or depression Checking the abdomen for signs of rebound tenderness Keeping the head of the bed elevated at least to 30 degrees

Keeping the head of the bed elevated at least to 30 degrees Positioning clients is included in the scope of training for UAP and is frequently delegated to them. Client assessment requires more education and scope of practice and should be done by licensed nursing staff.

The nurse is administering benzathine penicillin G (Bicillin C-R) intramuscularly to a client with primary syphilis. The client has never been treated with this particular form of the drug. What precaution does the nurse implement? Applies an ice pack to the injection site to minimize trauma to the client's skin Keeps the client for 30 minutes to monitor for a possible allergic reaction Makes certain the client has a skin test for penicillin allergy prior to the injection Tells the client to refrain from all sexual activities for a minimum of 72 hours

Keeps the client for 30 minutes to monitor for a possible allergic reaction The nurse should keep all clients on-site for at least 30 minutes after they have received this antibiotic so that manifestations of an allergic reaction can be detected and treated. The application of ice to the injection site is not recommended because it would actually slow the absorption of the drug into the muscular tissues. The nurse must be sure that the client who has never had any form of penicillin has a skin test before receiving the injection. The nurse should recommend sexual abstinence until the treatment of both the client and his or her partner(s) is completed.

A client is having a radical prostatectomy. Which preoperative teaching specific to this surgery does the nurse emphasize? Incentive spirometry Kegel exercises Pain control Penile implants

Kegel exercises Kegel perineal exercises may reduce the severity of urinary incontinence after radical prostatectomy. The client is taught to contract and relax the perineal and gluteal muscles in several ways. Incentive spirometry and pain control are important for everyone who undergoes surgery; neither is specific to radical prostatectomy. Penile implants are not important to discuss during preoperative teaching; however, they may be necessary to discuss later.

Which type of cancer has been associated with Down syndrome? Breast cancer Colorectal cancer Malignant melanoma Leukemia

Leukemia Leukemia is associated with Down syndrome and Turner syndrome. Breast cancer is often found clustered in families, not in association with Down syndrome. Colorectal cancer is associated with familial polyposis. Malignant melanoma is associated with familial clustering and sun exposure.

A premenopausal client diagnosed with breast cancer will be receiving hormonal therapy. The nurse anticipates that the health care provider will request which medication for this client? Anastrozole (Arimdex) Fulvestrant (Faslodex) Leuprolide (Lupron) Trastuzumab (Herceptin)

Leuprolide (Lupron) Leuprolide is used in premenopausal women whose main estrogen source is the ovaries and who may benefit from luteinizing hormone-releasing hormone agonists that inhibit estrogen synthesis. Anastrozole is an aromatase inhibitor that is used in postmenopausal women whose main source of estrogen is not the ovaries, but rather body fat. Fulvestrant is a second-line hormonal therapy for postmenopausal women with advanced breast cancer. Trastuzumab is not a hormone and is used for targeted therapy for breast cancer.

The nurse is teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client's teaching plan? Lift hips off the chair at least every hour. Eat a low-fat diet. Massage reddened areas. Complete a pressure map.

Lift hips off the chair at least every hour. Lifting the hips off the chair at least every hour relieves pressure and can prevent pressure ulcers. Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.

A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition? Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) Liquid steroids Opioid antagonists Oral diazepam

Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia. Steroids will not help in pain relief and will delay healing. An opioid antagonist will reverse the effect of the narcotic. Diazepam has no pain-relieving properties.

A 60 year-old client with a long-term smoking history, who is being treated for dysfunctional uterine bleeding (DUB), reports heavy vaginal bleeding, abdominal pain, and anemia. What medication used for hormone manipulation would be preferable for her? Contraceptives (oral or patch) Combination hormone therapy (estrogen and progestin) Corticosteroids Long-acting progestins (e.g., Depo-Provera)

Long-acting progestins (e.g., Depo-Provera) Hormone manipulation is usually the treatment of choice for women with anovulatory DUB. The drugs used depend on the severity of bleeding and age of the client. Progestin-only pills or long-acting progestins (e.g., injectable medroxyprogesterone acetate [Depo-Provera]) are preferable for women older than 35 years who smoke or are at risk for thrombophlebitis. Progestin or combination hormone therapy (estrogen and progestin) may be given when bleeding is heavy and acute. For nonemergent bleeding, contraceptives (oral or patch) provide the progestin (artificial progesterone) needed to stabilize the endometrial lining. Abnormal uterine bleeding may be induced by corticosteroid use.

A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list? Amitriptyline (Elavil) Diazepam (Valium) Ketorolac (Toradol) Lorazepam (Ativan)

Lorazepam (Ativan) Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this client's anxiety. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Ketorolac is a nonsteroidal anti-inflammatory drug and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the client is taking medication for anxiety.

The nurse is teaching a group of clients with endometriosis about complementary and alternative medicine (CAM) therapies that may bring relief to them. What does the nurse suggest? (Select all that apply.) Low-fiber diets *Low-level heat applications* *Massage* Protein supplements *Relaxation techniques* *Yoga*

Low-level heat applications can provide temporary relief from the pain that frequently accompanies endometriosis. Massage, relaxation techniques, and yoga may decrease tissue hypoxia and hypertonicity and relieve ischemia by increasing blood flow (oxygen) to affected areas. Dietary changes are not among the recommended therapies for endometriosis.

Which option for prevention and early detection of breast cancer is the option of choice for a client with a high genetic risk? Breast self-examination (BSE) beginning at 20 years of age Hormone replacement therapy (HRT) combining estrogen and progesterone Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 Prophylactic mastectomy

Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 The American Cancer Society recommends that high-risk women (>20% lifetime risk) have an MRI and mammogram every year beginning at age 30. BSE is an option for everyone, not just those at high genetic risk for breast cancer. Use of HRT containing both estrogen and progestin increases risk; risk diminishes after 5 years of discontinuation. With a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue.

The nurse is planning care for a client who has a sexually transmitted disease (STD). Which interventions address the client's psychosocial needs? (Select all that apply.) *Allowing the client to express fears and anxieties* Approaching the client with a nonjudgmental attitude *Ensuring that the client's sexual partner is aware of the diagnosis* *Referring the client to the appropriate support groups* Reporting the STD to the public health department Sharing experiences about working with clients with STDs

Many clients with STDs have fears and anxieties about having such diseases. They are reluctant to share a very private and personal side of their lives. It is therapeutic for a nurse to encourage clients' expressions about these feelings. Nurses must always be completely nonjudgmental about communicating with clients; it is not appropriate to allow personal feelings and biases to be any part of their approaches. Support groups can be very helpful to clients with STDs; hearing how others with similar circumstances have problem-solved in sensitive (sexually intimate) situations can be reassuring to someone who is faced with a new life crisis. Nurses have a responsibility to encourage clients with STDs to contact their sexual partners, but if the client will not disclose whom they may have received the infection from, or to whom they may have given it, the nurse has no means of "ensuring" contact. Reporting the occurrence to a public health agency is a medical responsibility; it would not be categorized as meeting the client's psychosocial needs. Nurses do not share personal experiences about their contacts with other clients; this is a breach of confidentiality and entirely inappropriate, as well as both illegal and unethical.

Which statement about breast reconstruction surgery is correct? Many women want breast reconstruction using their own tissue immediately after mastectomy. Placement of saline- or gel-filled prostheses is not recommended because of the nature of the surgery. Reconstruction of the nipple-areola complex is the first stage in the reconstruction of the breast. The surgeon should offer the option of breast reconstruction surgery once healing has occurred after a mastectomy.

Many women want breast reconstruction using their own tissue immediately after mastectomy. Many women want autogenous reconstruction after mastectomy. Saline- or gel-filled prostheses are recommended as breast expanders in breast augmentation surgery, not for reconstructive surgery. Reconstruction of the nipple-areola complex is the last stage in breast reconstruction surgery. Breast reconstruction surgery should be discussed before mastectomy takes place.

The nursing instructor reviews instructions with the nursing student on caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? Massages bony prominences Avoids reddened areas Re-positions the client every 1 to 2 hours Uses a moisturizing lotion

Massages bony prominences Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be re-positioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

Which action can the same-day surgery charge nurse delegate to an experienced unlicensed assistive personnel (UAP) who is helping with the care of a client who is having a breast biopsy? Assess anxiety level about the surgery. Monitor vital signs after surgery. Obtain data about breast cancer risk factors. Teach about postoperative routine care.

Monitor vital signs after surgery. Vital sign assessment is included in UAP education and usually is part of the job description for UAP working in a hospital setting. Nursing assessment, obtaining data, and client teaching are not within the scope of practice for UAP and should be done by licensed nursing staff.

The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? Monitor weight Trend red blood cells and hemoglobin and hematocrit Monitor platelets Observe for motor deficits

Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? Albuterol (Proventil) inhaler Guaifenesin (Organidin) Montelukast (Singulair) Omalizumab (Xolair)

Montelukast (Singulair) Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication. Albuterol inhalers are beta2 agonists that are rescue medications used on an as-needed basis only. Guaifenesin is a mucolytic that does not provide any bronchodilation; it may or may not be taken daily. Omalizumab is an immunomodulator that is injected subcutaneously every 2 to 3 weeks; it is not commonly used because a high rate of anaphylaxis is associated with it.

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? Mucolytics decrease secretion production. Mucolytics increase gas exchange in the lower airways. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. Mucolytics thin secretions, making them easier to expectorate.

Mucolytics thin secretions, making them easier to expectorate. The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin, making them easier to expectorate; this is important for a client with chronic bronchitis. Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

Which assessment finding indicates to the nurse that a client is at high risk for a malignant breast lesion? A 1-cm freely mobile rubbery mass discovered by the client Ill-defined painful rubbery lump in the outer breast quadrant Backache and breast fungal infection Nipple discharge and dimpling

Nipple discharge and dimpling Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion. On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses usually discovered by the woman herself; their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter. Although the immediate fear is breast cancer, the risk of its occurring within a fibroadenoma is very small. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition; the lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common.

A client is being discharged after having a total abdominal hysterectomy (TAH). What principle guides the nurse who is providing discharge planning and instructions for her? Clients generally adapt better if they are still in their childbearing years. No special home equipment will be necessary for the client. Psychological reactions should be evident by the time of discharge. The client will be able to return to normal activities upon discharge.

No special home equipment will be necessary for the client. Usually, no special home equipment is needed for the client who has undergone a TAH. Generally, clients adjust better to the surgery if they have completed their childbearing years, among other factors. Psychological reactions can occur months to years after surgery, particularly if sexual functioning and libido are diminished. The client who has undergone a TAH should be taught about the expected physical changes, including any activity restrictions. A 4- to 6-week convalescent period is usually required.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.) *Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance.* *The medications may cause nausea. The client should take them at bedtime.* The client is generally not contagious after 2 to 3 consecutive weeks of treatment. These medications must be taken for 2 years. These medications may cause kidney failure.

Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this. The client is generally not contagious after 2 to 3 weeks of consecutive treatment and improvement in the condition has been observed. The combination regimen for treatment of TB has decreased treatment time from 6 to 12 months to 6 months. TB medications may cause liver failure, not kidney failure.

Which client history places a woman at highest risk for developing endometrial (uterine) cancer? Multiparity, human papilloma virus (HPV), smoking, and African-American ethnicity Nulliparity, endometriosis, diabetes mellitus, first pregnancy at older than 20 years Nulliparity, smoking, uterine polyps, hypertension Oral contraceptive use, smoking, localized pain in the thigh

Nulliparity, smoking, uterine polyps, hypertension Nulliparity, smoking, uterine polyps, and hypertension are all risk factors for endometrial cancer. Multiparity, HPV, smoking, and African-American ethnicity are all risk factors for cervical cancer. Nulliparity, endometriosis, diabetes mellitus, and first pregnancy at older than 20 years are all risk factors for ovarian cancer. Oral contraceptive use, smoking, and localized pain in the thigh are all risk factors for a thrombus.

Which statement about the process of malignant transformation is correct? Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. Insulin and estrogen enhance the division of an initiated cell during the promotion phase. Tumors form when carcinogens invade the gene structure of the cell in the latency phase. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.

Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage. The promotion phase consists of progression when the blood supply changes from diffusion to TAF.Insulin and estrogen increase cell division. If cell division is halted, mutation of genes does not lead to cancer development in the initiation phase. In the initiation phase, carcinogens invade the DNA of the nucleus of a single cell. A 1-cm tumor consists of 1 billion cells. The latency phase occurs between initiation and tumor formation.

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? Obtain a 12-lead electrocardiogram (ECG). Call for a portable chest x-ray. Obtain blood cultures from two sites. Give cefazolin (Kefzol) 500 mg IV.

Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

Which nursing action may be delegated to a nursing assistant working on the medical unit? Determine the usual alcohol intake for a client with cardiomyopathy. Monitor the pain level for a client with acute pericarditis. Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis.

Obtain daily weights for several clients with class IV heart failure Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.

Which client has the highest risk for breast cancer? Older adult woman with high breast density Nullipara older adult woman Obese older adult male with gynecomastia Middle-aged woman with high breast density

Older adult woman with high breast density People at high increased risk for breast cancer include women age 65 years and older with high breast density. Nullipara women are at low increased risk for breast cancer. Men are not at high increased risk for breast cancer, but obesity can cause gynecomastia. Being middle-aged does not indicate a high increased risk for breast cancer.

Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? Morphine Ondansetron (Zofran) Naloxone (Narcan) Diazepam (Valium)

Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Morphine is a narcotic analgesic or opiate; it may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only; lorazepam, another benzodiazepine, may be used for nausea.

What are the common cancers related to tobacco use? (Select all that apply.) Cardiac cancer *Lung cancer* *Cancer of the tongue* Skin cancer *Cancer of the larynx*

Organs exposed to the carcinogens in tobacco (lungs, tongue, larynx) are the most likely to develop cancer. Oral cancer is also a risk with "smokeless" tobacco. The heart does not contain cells that divide; therefore, cardiac cancer is unlikely. Skin cancer generally is related to repeated sun and other ultraviolet exposure, such as that found with tanning beds.

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? Apply elastic stockings to lower extremities. Monitor for excessive blood loss. Pad bony prominences. Secure joints on a board in anatomic positions.

Pad bony prominences Padding bony prominences best minimizes skin breakdown. Elastic stockings assist in increased venous return. Monitoring for blood loss and securing joints do not protect the skin.

Which assessment finding causes the nurse to suspect that a client may have testicular cancer? Hematuria Penile discharge Painless testicular lump Sudden increase in libido

Painless testicular lump A painless lump or swelling in the testicles is the most common manifestation of testicular cancer. Hematuria is not a symptom of testicular cancer, but could be indicative of other conditions such as bladder cancer. Penile discharge is not a symptom of testicular cancer, but could be indicative of another condition. A sudden increase in libido is not a symptom of testicular cancer.

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative

Palliative Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? Temperature of 96.6° F Reports of joint pain Pink and dry oral mucosa Palpable lump in the client's axilla

Palpable lump in the client's axilla Clients taking immunosuppressive drugs to prevent rejection are at increased risk for the development of cancer; any lump should be reported to the physician. Fever should be reported to the physician, but this client's temperature is normal. It is not necessary to report joint pain to the transplant team; it is not a sign of rejection and is not a complication of transplant. A pink and dry oral mucosa may be a sign of dehydration, but it is not necessary to report this to the transplant team.

The nurse is caring for a client with erectile dysfunction who has not had success with other treatment modalities. The nurse anticipates that the health care provider will recommend which treatment for this client? Penile implants Penile injections Transurethral suppository Vacuum constriction device

Penile implants Penile implants (prostheses), which require surgery, are used when other modalities fail. Devices include semi-rigid, flexible, or hydraulic inflatable and multi-component or one-piece instruments. Penile injections are tried before using the option of last resort. Transurethral suppository is tried before using the option of last resort. A vacuum constriction device is easy to use, and is often the first option that is tried.

The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? (Select all that apply.) *"I am 78 years old, and I was treated and cured of syphilis many years ago."* "In 1986, I received a transfusion of platelets." *"Seven years ago, I was released from a penitentiary."* "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." *"At 68, I am going to get married for the fourth time."*

People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV. HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

A client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? Ensure that all lesions are reviewed by a dermatologist or a surgeon. Avoid sun exposure. Perform a total skin self-examination monthly. Perform a total skin self-examination monthly with a partner.

Perform a total skin self-examination monthly with a partner. Performing a monthly total skin self-examination with another person is the best secondary preventive measure. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. It is difficult for a person to assess all of the skin surfaces of his or her body by him- or herself, even with the use of mirrors. It is better to involve a partner with the assessment.

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? Helps the surgeon change the gown Picks the gauze up with a pair of sterile gloves Picks the gauze up without touching the surgeon Sprays an antimicrobial on the surgeon's gown

Picks the gauze up without touching the surgeon The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted. A sterile gauze touching a sterile gown does not require a gown change. Sterile gloves are not needed to pick the gauze up. An antimicrobial spray is inappropriate in this situation.

The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? Alphabet board Picture board Translator at the bedside Word board

Picture board A picture board overcomes language barriers and can be used to communicate with clients who do not speak English well if a translator or a translation phone is not readily available. An alphabet board may or may not be useful if the client does not speak English; this is not the best answer, but may be an option depending on what is available at the facility. A translator at the bedside would be beneficial for the nurse to speak with the client, but not for the client to ask questions or communicate concerns to the nurse. Unless the nurse is able to read the language the client speaks, a word board would not be beneficial.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.

Place a respiratory mask on the client. The concern is that this client has TB. A respiratory mask should be placed on the client immediately. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the client know that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? Ensure that ED staff members receive oseltamivir (Tamiflu). Obtain specimens for the H5 polymerase chain reaction test. Place the client in a negative air pressure room. Start an IV line and administer rehydration therapy.

Place the client in a negative air pressure room. If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea, so starting an IV to administer rehydration fluid is important, but is not the first priority.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.

Place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

After gastric surgery, a client arrives in the postanesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? Monitor respiratory rate and airway patency. Irrigate the nasogastric tube with saline. Position the client on the left side. Assess the client's pain level.

Position the client on the left side Positioning the client on the left side can be delegated to an unlicensed care provider. Airway patency requires the care of a nurse in case of emergency management requirements. Irrigating the nasogastric tube with saline is a nursing skill and care by a nurse would be required. Pain assessment is also within the scope of a nurse

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea

Positions the client to alleviate dyspnea Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Post-cough emesis

Post-cough emesis Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing that children with pertussis exhibit. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency Potential for infection transmission related to recurring opportunistic infections High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be the secondary concern because Candida albicans causes the mouth sores. Nutrition will be affected because of Candida albicans; however, it is not a priority.

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? Potential for lack of understanding related to side effects of chemotherapy Potential for injury related to sensory and motor deficits Potential for ineffective coping strategies related to loss of motor control Altered sexual function related to erectile dysfunction

Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? Anemia Decreased wound healing Pressure ulcer development Weight gain

Pressure ulcer development This client is at risk for pressure ulcer if he or she remains bedridden. Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? Keep the mouth moist during treatments Keep the teeth from turning yellow after treatment Prevent radiation scatter when the beam hits metal in the mouth Protect the taste buds on the tongue

Prevent radiation scatter when the beam hits metal in the mouth The gel trays help prevent radiation scatter when the beam hits metal in the mouth. They will not provide additional moisture to the mouth. Gel trays with fluoride are not used to prevent yellowing; fluoride is used to prevent demineralization and to help with uptake of calcium and phosphate ions by the teeth. Gel trays fit over the teeth and do not protect the taste buds on the tongue.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? Homeless people Hospital staff Politicians Prison staff and inmates

Prison staff and inmates High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? Massage the reddened areas. Pad the ulcer. Promote mobility and/or frequent re-positioning. Suggest an egg crate mattress.

Promote mobility and/or frequent re-positioning Frequent re-positioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer. Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

Why is prostate cancer screening often emphasized to the African-American population in the United States? Metastasis of prostate cancer is higher. Prostate cancer occurs at an earlier age. Prostate-specific antigen (PSA) is not sensitive to prostate disease. Clinical presentation is different.

Prostate cancer occurs at an earlier age. In the United States, prostate cancer affects African-American men the most and at an earlier age. There is no difference in prostate cancer metastasis, PSA sensitivity, or clinical presentation of prostate cancer in the African-American population as compared to other populations.

The public health nurse manager is working on a policy designed to decrease the number of recurrences of gonorrhea and chlamydia. Which approach is most effective? Administer a one-dose intramuscular antibiotic therapy whenever possible. Advise clients to return to the clinic if symptoms persist or return. Give clients written information about treatment of these infections. Provide clients with oral antibiotic treatment for their partners.

Provide clients with oral antibiotic treatment for their partners. The most common cause of recurrence of gonorrhea and chlamydia is re-infection by an infected partner. Research indicates that giving clients antibiotics to take to their partners will decrease recurrence rates. Although administering a one-dose intramuscular antibiotic therapy, having clients return to the clinic if symptoms persist or return, and providing written information to clients may help improve the treatment of sexually transmitted diseases, the most common cause of recurrence is re-infection by an infected partner.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? Collaborate with the client to select foods that are high in calories. Provide oral care to the client before meals to enhance appetite. Assess the perianal area every 8 hours for signs of skin breakdown. Discuss the need to avoid foods that are spicy or irritating.

Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice; these actions should be done by licensed staff.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? Ensures that the client is wearing a mask Tells the visitor that the client cannot receive visitors at this time Provides a particulate air respirator to the visitor Provides a mask to the visitor

Provides a mask to the visitor Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator.

When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? Administering a biological response modifier Encouraging oral care with commercial mouthwash Providing oral care with a disposable mouth swab Maintaining NPO until the lesions have resolved

Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.

A client with endometriosis asks the nurse where to find a support group. What resource does the nurse suggest? American Cancer Society American Endometrial Society Endometrial United Association RESOLVE

RESOLVE RESOLVE is an organization for infertile couples, many of whom have endometriosis. The American Cancer Society offers information on local support groups for people and families dealing with cancer. The American Endometrial Society and Endometrial United Association do not exist—the actual organization is called the Endometriosis Association.

Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR

RN who has 5 years of experience in the delivery room The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client. The RN who usually works on the pediatric unit would not be aware of potential complications and routine assessments for this client. The RN who provides education to diabetic clients in a clinic would be able to provide required care for the client's diabetes but not the postoperative aspect of care. The RN who works as a scrub nurse would not have the knowledge and understanding of routine postoperative care that is needed for this client.

Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) *Fatigue* Changes in color of hair *Change in taste* *Changes in skin of the neck* *Difficulty swallowing*

Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.

The potential problem of grief is most relevant to a client after which procedure? Cystoscopy Transurethral microwave therapy Radical prostatectomy Sperm banking

Radical prostatectomy A radical prostatectomy may lead to erectile dysfunction, which could present a potential problem of grief at loss of function. Cystoscopy, a test to view the interior of the bladder, the bladder neck, and the urethra, does not affect sexuality. Transurethral microwave therapy is a minimally invasive procedure involving high temperatures that heat and destroy excess prostate tissue, and does not affect sexuality. The process of sperm banking would not result in a diagnosis of altered self-image; however, the diagnosis leading to the necessity of sperm banking might cause this.

A client who recently had a mastectomy requests a volunteer to visit her home to help with recovery. Which community resource does the nurse recommend? National Breast Cancer Coalition Reach to Recovery Susan G. Komen for the Cure Young Survival Coalition

Reach to Recovery The American Cancer Society's program Reach to Recovery provides volunteers who visit clients in the hospital or at home. They bring personal messages of hope; informational materials on breast cancer recovery; and a soft, temporary breast form. The National Breast Cancer Coalition is an organization dedicated to ending breast cancer through action and advocacy. Susan G. Komen for the Cure is an organization that supports breast cancer research. The Young Survival Coalition is an organization dedicated to educating the medical, research, breast cancer, and legislative communities about breast cancer, as well as serving as a point of contact for young women living with breast cancer. None of these other community resources provide volunteers to visit the home.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? Crusting along the incision line Redness and swelling around the incision Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

Redness and swelling around the incision Redness and swelling around the incision indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? Decrease expected blood loss during surgery Eliminate any risk of infection Ensure that the bowel is sterile Reduce the number of intestinal bacteria

Reduce the number of intestinal bacteria Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.

An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? Storing drugs in dark locations at room temperature Wearing soft clothing Wearing a hat and sunglasses when going outside Reducing all direct and indirect sources of light

Reducing all direct and indirect sources of light Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy; it can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties; drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light; texture is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.

A large-breasted client reports discomfort, backaches, and fungal infections because of her excessive breast size. The nurse provides information to the client about which breast treatment option? Augmentation Compression Reconstruction Reduction mammoplasty

Reduction mammoplasty Breast reduction mammoplasty surgery removes excess breast tissue and repositions the nipple and remaining skin flaps to produce the best cosmetic effect. Breast augmentation surgery enhances the size, shape, or symmetry of breasts. Breast compression is not a treatment. Breast reconstruction surgery is typically performed for women after a mastectomy.

A client who has just been discharged from the hospital after a modified radical mastectomy is referred to a home health agency. Which nursing action is most appropriate to delegate to an experienced home health aide? Assessing the safety of the home environment Developing a plan to decrease lymphedema risk Monitoring pain level and analgesic effectiveness Reinforcing the guidelines for hand and arm care

Reinforcing the guidelines for hand and arm care Reinforcement of previously taught information about hand and arm care should be done by all caregivers. Assessment, developing a care plan, and monitoring pain level and analgesic effectiveness are not within the scope of practice of a home health aide and should be done by licensed nursing staff.

The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? Cure of the cancer Relief of symptoms or improved quality of life Allowing other therapies to be more effective Prolonging the client's survival time

Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? Nothing. This is in the green zone. Provide the rescue drug and reassess. Provide the rescue drug and seek emergency help. Repeat the peak flow test.

Repeat the peak flow test. Since the client is newly diagnosed with asthma, this would be an excellent opportunity for the nurse to observe the client using the peak flowmeter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best. The result of 82% is in the green zone, but this is not the best answer for a newly diagnosed client. Rescue drugs should be used only in the yellow zone, between 50% and 80% of the client's personal best. They should not be used in this situation, and the nurse does not need to seek emergency help until readings are in the red zone, or below 50% of the client's personal best.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

Respiratory rate of 6 breaths/min The most important postoperative assessment is respiratory assessment, and a rate of 6 breaths/min is too low. A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? First Second Third Mixed

Second Second-intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

Which method is a common complementary and alternative therapy for benign prostatic hyperplasia (BPH)? Acupuncture Calcium supplements Serenoa repens Yoga

Serenoa repens Serenoa repens (saw palmetto), a plant extract, is often used by men with early to moderate BPH. They believe that this agent relieves their symptoms and prefer this treatment over prescription drugs or surgery. (It should be noted, however, that studies on the effectiveness of Serenoa repens have not shown that it is effective.) Acupuncture, calcium, and yoga are not common alternative therapies for BPH.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? Calcium Hematocrit Numbers of immature white blood cells (WBCs) Serum albumin

Serum albumin Albumin measures protein, which is necessary for healing; increased serum albumin indicates successful collaboration with the dietitian. Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L Serum potassium level of 2.8 mEq/L Serum creatinine of 1.0 mg/dL Serum magnesium level of 1.9 mEq/L

Serum potassium level of 2.8 mEq/L Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

A client is scheduled for a total hysterectomy with a laparoscopic vaginal approach after a diagnosis of microinvasive cervical cancer. What psychological and/or social changes does the nurse expect this client to experience? Because the surgery does not affect a visible site, altered body image issues will be fewer in number. The client will be actively involved in her own care in the immediate postoperative period. Sexual counseling may be needed, especially if the client has doubts about her ability to feel like a woman and engage in sexual activities. The client should demonstrate reality testing and should experience a grief reaction immediately after her surgery.

Sexual counseling may be needed, especially if the client has doubts about her ability to feel like a woman and engage in sexual activities. Sexual function may be (or feel) different after a hysterectomy. Couples may need counseling about intercourse or alternative sexual activities. The nurse assesses the need for sexual counseling by listening for cues about altered perceptions of body image and anxiety in either of the sexual partners' responses. For many women, hysterectomy can mean the loss of their femininity, so altered body image issues must be expected with the client. Hysterectomy is major surgery, so the client will be convalescing for days to a week or longer; active involvement in her self-care will be delayed until she has moved past the initial surgical procedure recovery period. Reality testing is a later step in the grief and acceptance processes that women who have hysterectomies experience.

The issue that is often foremost in the minds of men who have been diagnosed with prostate cancer and must be addressed by the nurse is the alteration of which factor? Comfort because of surgical pain Mobility after treatment Nutrition because of radiation side effects Sexual function after treatment

Sexual function after treatment Altered sexual function is one of the biggest concerns of men after cancer treatment. Comfort, mobility, and nutrition are important, but are typically not the foremost concern in the minds of men with prostate cancer.

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? Corticosteroids Long-acting beta agonists Nonsteroidal anti-inflammatory drugs (NSAIDs) Short-acting beta agonists

Short-acting beta agonists Short-acting beta agonist medications have a rapid onset and cause bronchodilation; they would be excellent for marathon running because some types of asthma may be exercise-induced. Corticosteroids disrupt production pathways of inflammatory mediators. Maximum effectiveness requires 48 to 72 hours of continued use; therefore, they are not appropriate as a rescue medication. Long-acting beta agonists do cause bronchodilation, but have a slow onset; they are not used as rescue inhalers. NSAIDs stabilize the membranes of mast cells and prevent release of inflammatory mediators. They have a slow onset of action and are used for prevention of symptoms, not as rescue medication.

Which clinical manifestation in the client with facial trauma is the nurse's first priority? Bleeding Decreased visual acuity Pain Stridor

Stridor Stridor is an indication of a partial airway obstruction and requires immediate attention. Although bleeding is important in all trauma clients, it is not the first priority in assessing the "ABCs". The question does not specify where the bleeding is occurring. The type (venous or arterial) and quantity of the bleeding need to be noted. Visual acuity will be assessed in the secondary survey because it is not considered life-threatening. Pain must be addressed to fully evaluate a client and complete a reliable examination; however, it is not the nurse's first priority.

How does the nurse position a client with postoperative nausea and vomiting? Flat in bed, with the head in alignment with the body Prone, with the head of the bed flat Side-lying, with the head in a neutral position Supine in bed, with the neck flexed

Side-lying, with the head in a neutral position The side-lying position helps reduce this distressing symptom. The flat-in-bed position with the head in alignment is not a neutral position. The prone position with the head of the bed flat is unnatural, as is the supine position with the neck flexed.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Snoring sounds when inhaling Sore throat on swallowing

Snoring sounds when inhaling Snoring sounds when inhaling may indicate respiratory depression. Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? Peak flowmeter readings that are yellow after the third reading Productive cough SpO2 level of 92% after ambulating 50 feet Stable arterial blood gases (ABGs)

SpO2 level of 92% after ambulating 50 feet Maintaining a baseline SpO2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective. A yellow reading means "caution," which indicates narrowing airways. Although a productive cough may be an indication of success, it can also be an indication of infection. ABGs are invasive, costly, and painful and are not the most effective indicator of successful teaching in this situation.

A client with testicular cancer is worried about sterility and the ability to conceive children later. Which resource does the nurse refer the client to before surgery takes place? American Cancer Society American Fertility Society RESOLVE: The National Infertility Association Sperm bank

Sperm bank After radiation therapy or chemotherapy has been started, the client is at increased risk for producing mutagenic sperm, which may not be viable or may result in fetal abnormalities. If the client is interested in having children, he should be encouraged to arrange for semen storage as soon as possible after diagnosis. Sperm collection should be completed before radiation therapy or chemotherapy is started. The client is referred to the American Cancer Society for more generalized information on testicular cancer. The American Fertility Society and RESOLVE: The National Infertility Association are appropriate referrals if permanent sterility occurs and sperm storage has not been feasible.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? Friction rub auscultated at the left lower sternal border Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Thickening of the endocardium

Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? Allow the client to bring up the topic first. Remind the client to avoid sexual intercourse for 2 months after the surgery. Suggest that the client wear a bra or camisole during intercourse. Teach the client that birth control is a priority.

Suggest that the client wear a bra or camisole during intercourse. Clients may prefer to lay a pillow over the surgical site or wear a bra or camisole to prevent contact with the surgical site during intercourse. The client may be embarrassed to discuss the topic of sexuality, so the nurse must be sensitive to possible concerns and approach the subject first. Sexual intercourse can be resumed after surgery whenever the client is comfortable. Sexually active clients receiving chemotherapy or radiotherapy must use birth control because of the therapy's teratogenic effects, but this is not necessary for clients who have had surgery only.

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.

Supplemental pain reduction is needed. The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious.

The nurse is teaching a client how to adapt to physical and psychological changes after surgery for ovarian cancer. What is included in the teaching plan? (Select all that apply.) *Encouraging the use of support groups and counseling* *Encouraging the expression of grief and fears* Offering vaginal dilators *Suggesting alternatives to vaginal intercourse* Suggesting the use of oil-based lubricants

Support groups such as Gilda's Club are advisable for clients with ovarian cancer because the loss of reproductive organs involves a grief reaction. Ovarian cancer particularly carries the connotation of being serious and incurable in the view of many women. Because the client must refrain from having sexual intercourse for 6 weeks after surgery, it is appropriate to discuss alternatives. These could include expressing affection in other ways, such as cuddling or being close with her partner. The use of a vaginal dilator is not indicated. After the woman becomes sexually active, she may have a problem with vaginal dryness as the result of hormonal changes. Water-based, rather than oil-based, lubricants should be suggested.

Hormone treatment for prostate cancer works by which action? Decreases blood flow to the tumor Destroys the tumor Shrinks the tumor Suppresses growth of the tumor

Suppresses growth of the tumor Hormone therapy, particularly antiandrogen drugs, inhibits tumor progression by blocking the uptake of testicular and adrenal androgens at the prostate tumor site. Antiandrogens may be used alone or in combination with luteinizing hormone-releasing hormone agonists for a total androgen blockade (hormone ablation). Hormone treatment for prostate cancer does not decrease blood flow to the tumor, destroy the tumor, or shrink the tumor.

Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma? Aphonia Hemoptysis Hoarseness Tachypnea

Tachypnea Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma; this requires immediate action on the part of the nurse. Aphonia (the inability to produce sound) is a manifestation of laryngeal trauma and may be caused by nerve damage, swelling, cartilage fracture, or other events; it does not require immediate action by the nurse. Hemoptysis (bleeding from the airway) may occur as the result of laryngeal trauma. The quantity needs to be observed; an increase in the amount of bleeding can become an emergency because it affects airway patency. Hoarseness is commonly associated with laryngeal trauma, but does not require immediate attention.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.

Talk to the client The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? Call admissions. Cancel the surgery. Contact the surgeon. Talk to the operating team.

Talk to the operating team The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Calling admissions is not the first step; the stamp is correct. Canceling surgery is not done by the floor nurse. This is an administrative issue, and not one for the surgeon.

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client where the smoking lounge is.

Teach the importance of incentive spirometry Incentive spirometry is good for lung hygiene; it encourages deep breathing. The nurse can suggest quitting or advise about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Directing the client to the smoking lounge is not helpful or therapeutic.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? Encourages proper building ventilation Refers workers to a tobacco cessation program Suggests that workers find another job Teaches workers how to use a mask

Teaches workers how to use a mask Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure. Proper building ventilation often requires work orders, reconstruction, time, and money; this will need to be implemented, but it will not occur quickly. Particulate matter can be emitted from a variety of sources; smoking may be unrelated to the question. Suggesting that workers find another job does not solve the problem of particulate matter in a rapid or safe manner.

Which activity performed by the community health nurse best reflects primary prevention of cancer? Assisting women to obtain free mammograms Teaching a class on cancer prevention Encouraging long-term smokers to get a chest x-ray Encouraging sexually active women to get annual Papanicolaou (Pap) smears

Teaching a class on cancer prevention Primary prevention involves avoiding exposure to known causes of cancer; education assists clients with this strategy. Mammography is part of a secondary level of prevention, defined as screening for early detection. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. A Pap smear is a means of detecting cervical cancer early—secondary prevention.

The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? Testing of stool specimens for occult blood Teaching about the importance of dietary fiber Referring clients for colonoscopy procedures Giving vitamin and mineral supplements

Testing of stool specimens for occult blood Testing of stool specimens for occult blood is done according to a standardized protocol and can be delegated to nursing assistants. Client education is within the scope of practice of the RN, not of the LPN or nursing assistant. Referral for further care is best performed by the RN. Administration of medications is beyond the nursing assistant's scope of practice and should be done by licensed nursing personnel.

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy The 28-year-old client with a fractured femur who is having an open reduction and internal fixation The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed The client with stage I breast cancer is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience. The client who has a ruptured appendix is less stable and at high risk for infection/sepsis; a more experienced nurse is required. The client with a fractured femur is at high risk for clotting, infection, and aspiration owing to the surgery; a more experienced nurse would be better. The client with coronary artery disease is having high-risk surgery with risk for multiple complications and requires an experienced operating room nurse.

A client with prostate cancer asks the nurse for more information and counseling. Which resources does the nurse suggest? (Select all that apply.) *American Cancer Society's Man to Man program* *Us TOO International* American Prostate Cancer Society *National Prostate Cancer Coalition* *Client's church, synagogue, or place of worship*

The American Cancer Society's Man to Man program helps the client and partner cope with prostate cancer by providing one-on-one education, personal visits, education presentations, and the opportunity to engage in open and candid discussions. Us TOO International is a prostate cancer support group that is sponsored by the Prostate Cancer Education and Support Network. The National Prostate Cancer Coalition provides prostate cancer information. The client's church, synagogue, or place of worship is a community support service that may be important for many clients. There is no such organization as the American Prostate Cancer Society.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? It affects only young people. The client has dyspnea. The client is coughing. The client is symptom-free between exacerbations.

The client is symptom-free between exacerbations. The client may be completely symptom-free between exacerbations. Asthma affects people of all ages. Dyspnea is a common symptom of many chronic lung diseases. Coughing occurs in many acute and chronic lung diseases.

Which gynecologic clients does the charge nurse assign to an LPN/LVN? (Select all that apply.) *A 23-year-old who is nauseated after her laparotomy and needs to receive antiemetic drugs* A 34-year-old who had a total hysterectomy for invasive cervical cancer and has a blood pressure (BP) of 88/54 mm Hg *A 42-year-old who had an abdominal hysterectomy whose health care provider wants to remove sutures at her bedside* A 48-year-old who is receiving IV chemotherapy to treat stage II cervical cancer A 52-year-old who just returned to the unit following a total abdominal hysterectomy

The client who is nauseated after laparotomy and needs to receive antiemetic drugs, and the client who had an abdominal hysterectomy and whose health care provider wants to remove sutures, both require care that can be provided by an LPN/LVN. The client with a total hysterectomy and low BP has a deteriorating status (dropping BP) and requires treatment that only an RN can administer. Likewise, the client who is receiving IV chemotherapy requires treatment that only an RN can administer. The client who has just returned from surgery must first be assessed by the RN to determine if she is stable.

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? The client will be treated for 5 to 7 days. The client will require IV antibiotics for 7 to 10 days. The client will complete 6 days of therapy. The client must be afebrile for 24 hours.

The client will be treated for 5 to 7 days. Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg.

The client's weight decreases by 2.5 kg. The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? The dietary worker hands the disposable meal trays to the LPN assigned to the client. The social worker encourages the client to verbalize about stressors at home. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. The health care provider orders vital signs, including temperature, every 8 hours.

The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection. Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk for infection.

Which statement about the early detection of breast masses is correct? Clinical breast examinations should be done yearly starting at age 20. Detection of breast cancer before or after axillary node invasion yields the same survival rate. Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. The goal of screening for breast cancer is early detection.

The goal of screening for breast cancer is early detection. The purpose of screening is early detection of cancer before it spreads. It is recommended that the clinical breast examination be part of a periodic health assessment at least every 3 years for women in their 20s and 30s, and every year for asymptomatic women who are at least 40 years of age. Detection of breast cancer before axillary node invasion increases the chance of survival. The American Cancer Society recommends screening with mammography annually beginning at age 40.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? Take daily tub baths using a mild soap. The infected area should be covered with a clean, dry bandage. Wash the infected areas first, then wash the uninfected areas. Use bath sponges or puffs when bathing.

The infected area should be covered with a clean, dry bandage. The infected area should be covered with a clean, dry bandage to prevent the spread of infection. The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered; washcloths should be used only once before laundering.

The nurse is discussing transvaginal repair for pelvic organ prolapse (POP) using surgical vaginal mesh with a client who plans to have the procedure. What teaching does the nurse include? (Select all that apply.) Incisional care instructions *Manufacturer's labeling and information* *Signs and symptoms of infection* Statements from women who have had successful outcomes *When to contact the surgeon after the procedure*

The manufacturer's labeling and information is included so that the client has an understanding of the product, its qualifications, and the recommendations from the U.S. Food and Drug Administration (FDA). Although rare, infection is one of the possible complications, so women should know the signs and symptoms. Clients who have had this procedure need to know when to seek help from their gynecologist/surgeon, so the nurse should include these criteria. Since 2008, client reports of complications associated with the use of transvaginal mesh has required the FDA to release an initial report and update advising about the safety and effectiveness of the use of this product for POP. Such complications include vaginal mesh erosion, painful sexual intercourse, infection, urinary problems, bleeding, organ perforation, and possibly death. No surgical incision is involved with the procedure. Statements (testimonials) from other women are not appropriate for client education.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when he becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? Chest x-ray Complete blood count (CBC) Tuberculosis (TB) skin test Throat culture

Throat culture A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests

The risk for hypotension Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The nurse is discussing the prevention of sexually transmitted diseases (STDs) with a group of young adults. What information does the nurse include? Female condoms are not effective in preventing the transmission of STDs. Spermicidal agents, when used with condoms, will prevent the transmission of STDs. The risk of STDs increases with the number of sexual partners. Using latex condoms always keeps STDs from spreading and infecting others.

The risk of STDs increases with the number of sexual partners. STD risk factors for sexually active people include multiple sexual partners. Female condoms (polyurethane sheaths in the vagina) are effective for preventing transmission of STDs, including human immunodeficiency virus. The use of spermicide with condoms, either lubricated condoms or vaginal application, has not been proved to be more or less effective against STDs than use without spermicide. Latex condoms do not completely prevent the spread of STDs; they do substantially decrease the risk.

The nurse is instructing a client on how to perform breast self-examination (BSE). Which techniques does the nurse include in teaching the client about BSE? (Select all that apply.) Instruct the client to keep her arm by her side while performing the examination. *Ensure that the setting in which BSE is demonstrated is private and comfortable.* Ask the client to remove her shirt. The bra may be left in place. *Ask the client to demonstrate her own method of BSE.* Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts.

The setting should be private and comfortable to promote an environment conducive to learning and to prevent potential client embarrassment. Before teaching breast palpation, ask the client to demonstrate her own method, so that the nurse can assess the client's understanding of BSE. For better visualization, the arm should be placed over the head. The client should undress completely from the waist up. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts.

The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? The student scrubs the hub of IV tubing before administering an antibiotic. The nurse overhears the student explaining to the client the importance of handwashing. The student teaches the client that symptoms of neutropenia include fatigue and weakness. The nurse observes the student providing oral hygiene and perineal care.

The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.

Why is it important to wear sterile gloves during a dressing change? They protect the client from infection. They protect the nurse from infection. They protect both the client and the nurse from infection. Their use prevents lawsuits.

They protect both the client and the nurse from infection. Standard Precautions and infection control protect both the nurse and the client from infection, not just the client or just the nurse. Preventing lawsuits is not the purpose of wearing sterile gloves.

A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? (Select all that apply.) *Brain* *Bone* *Lymph nodes* Kidneys *Liver*

Typical sites of metastasis of lung cancer include the brain, bone, liver, lymph nodes, and pancreas. Kidneys are not a typical site of lung cancer metastasis.

A new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action? Apply a hot pack over the flap site. Massage the flap site vigorously. Place a tight dressing over the flap. Use a Doppler device to assess flow to the area

Use a Doppler device to assess flow to the area A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed and the surgeon must be notified, because the client may have to be returned to the operating room immediately. Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? Monitoring platelets Administering packed red blood cells Using strict aseptic technique to prevent infection Administering low-dose heparin therapy for clients on bedrest

Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? Administering throat-numbing lozenges Assessing the mouth for inflammation and infection Teaching about skin care while receiving radiation Washing the skin with soap and water

Washing the skin with soap and water Personal hygiene is within the scope of practice of the nursing assistant. Throat-numbing lozenges should not be administered by nursing assistants because they are medication, and administering medication is out of the scope of practice. Assessment is a complex task that must be completed by licensed nursing staff. Educating the client is the responsibility of licensed nursing staff and is an ongoing part of the client's care.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? Keeping the head of the bed elevated 30 to 45 degrees Performing oral care after suctioning the oropharynx Washing hands and donning gloves prior to the procedure Wearing a disposable particulate mask respirator and protective eyewear

Wearing a disposable particulate mask respirator and protective eyewear To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds since the last visit Reports sucking on ice chips all day for dry mouth

Weight loss of 6 pounds since the last visit Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

The nurse working in the same-day-surgery unit has just received report and plans to assess which client first? Adult with a basal cell carcinoma excised who needs discharge teaching about wound care Young adult who has had rhinoplasty and is swallowing frequently Middle-aged adult who reports 7/10 pain after removal of a cyst Older adult ready to be transferred to a long-term-care facility after débridement of a pressure ulcer

Young adult who has had rhinoplasty and is swallowing frequently Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse. Discharge teaching, controlling pain, and client transfers are all important, but are not priorities because each of these clients is stable and not experiencing a postoperative complication that requires immediate attention.