Adult Health Final Exam

A nurse prepares a patient for a colonoscopy scheduled for tomorrow. The patient states, "My provider told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How would the nurse respond? "A negative fecal occult blood test does not rule out the possibility of colon cancer." "I will contact your provider so that you can discuss your concerns about the procedure." "The colonoscopy is required due to the high percentage of false negatives with the blood test." "Your provider would not have given you that information prior to the colonoscopy."

A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the patient has colon cancer, a colonoscopy would be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The patient may want to speak with the provider, but the nurse would address the patient's concerns prior to contacting the provider.

A client with systolic dysfuntion has an ejection fraction of 38%. The nurse assesses fro which phsiologic change? Decrease in arterial vasoconstriction Increase in stroke volume Decrease in tissue perfusion Increase in oxygen saturation

Decrease in tissue perfusion

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? ( Select all that apply. ) Diminished acidity of gastric secretions Increased lymphocytes and antibodies Age-related decrease in immune function Decreased cough and gag reflexes Thinning skin that is less protective

Diminished acidity of gastric secretions Age-related decrease in immune function Decreased cough and gag reflexes Thinning skin that is less protective Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.

An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as priority? T4 and thyroid-stimulaitng hormone (TSH) Echocardiography Arterial blood gas Chest X-ray

Echocardiography Echocardiography is the best tool for the diagnosis of heart failure

A hospitalized patient is placed on Contact Precautions. The patient needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? 1. No special precautions are needed when this patient leaves the unit. 2. Notify the physician that the patient cannot leave the room for the CT scan. 3. Plan to travel with the patient to ensure appropriate precautions are used. 4. Ensure that the radiology department is aware of the isolation precautions.

Ensure that the radiology department is aware of the isolation precautions.

The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply) Hematocrit (Hct), 32.8% Proteinuria Serum creatinine, 1.0 mg/dL Serum sodium, 130 mEq/L Serum potassium, 4.0 mEq/L Microalbuminuria

Hematocrit (Hct), 32.8% Proteinuria Serum sodium, 130 mEq/L Microalbuminuria The hematocrit is low (should be 42.6%), indicating a dilution ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

A nurse assesses a patient who has developed epistaxis. Which conditions in the patient's history would the nurse identify as potential contributors to this problem? ( Select all that apply. ) Diabetes mellitus Hypertension Leukemia Cocaine use Migraine Elevated platelets

Hypertension Leukemia Cocaine use Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

What is the most common symptom when a patient is diagnosed with hypertension? Slurred speech Fainting and dizziness Hypertension is often asymptomatic Headache

Hypertension is often asymptomatic Hypertension is often asymptomatic and has become known as the "silent killer" due to the lack of symptoms. Headaches may occur but not always. Hypertension does not cause slurred speech or fainting.

Which behavioral modification instructions will the nurse teach a client with benign porstatic hyperplasia (BPH)? Select all that apply. Take diurectis to increase urine output Limit alcohol intake Avoid caffeine containing beverages Do no consume large amoutns of fluid in a short time Avoid sexual intercourse Avoid taking antihistamine drugs

Limit alcohol intake Avoid caffeine containing beverages Do no consume large amoutns of fluid in a short time Avoid taking antihistamine drugs

A client who previously had a bacillus Calmette-Gu rin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply) a. Nausea b. Weight loss c. Insomnia d. Ankle edema e. Night sweats f. Increased urination

a. Nausea b. Weight loss e. Night sweats

The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

a. Stridor d. Ecchymosis behind the ear Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture

A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction

b. Decrease in tissue perfusion As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client developes activity intolerance.

The nurse is providing a teaching on how to prevent the spread of infections to a group of patients. Which statement demonstrates that the patients understand the nurse's teaching? a. I should take an antibiotic at the first sign of infection b. Hand hygiene is one of the most effective ways I can prevent the spread of infection c. Vaccinations only prevent a disease from becoming severe d. If I eat a nutritious diet, it will be difficult for me to get an infection

b. Hand hygiene is one of the most effective ways I can prevent the spread of infection

Which statement indicates that the client needs additional discharge teaching after gastric bypass surgery? a. I hope my type 2 diabetes is cured and I won't need insulin anymore b. As soon as I get home, I'm going to enjoy a nice bowl of fruit c. If I get nauseated, I know I'm eating too much at one time d. I will be sure to report any back, shoulder, or abdominal pain

b. As soon as I get home, I'm going to enjoy a nice bowl of fruit After gastric bypass surgery, clients are limited to fluids and pureed foods for about 6 weeks.

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. S: This client had a vaginal hysterectomy 2 days ago b. B: This client has allergies to morphine and codeine c. A: I would like you to order a different pain medication d. R: Dr. Smith doesn't like non-steroidal anti-inflammatory meds

b. B: This client has allergies to morphine and codeine SBAR stands for Situation, Background, Assessment, and Recommendation

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. Are you getting adequate rest and sleep each day? b. It is normal to be fatigued even for years afterwards c. This is not normal and I'll let the provider know d. Try adding more vitamins B and C to your diet

b. It is normal to be fatigued even for years afterwards

A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority? a. Social worker to see if the patient can afford the medications b. Visiting nurses to arrange directly observed therapy on dismissal c. Psychiatric nurse liaison to assess reasons for noncompliance d. Infection control nurse to arrange testing for drug resistance

b. Visiting nurses to arrange directly observed therapy on dismissal

The family of a neutropenic client reports that the client "has a new bruise". What action by the nurse is a priority. a. Ask the client about pain b. Assess the client for fever c. Look at today's platelet count d. Delegate taking a set of vital signs

c. Look at today's platelet count

When assessing for squamous cell cancer, a home health nurse is particularly concerned about a suspicious lesion on the: a. Leg of a 60-year-old Asian female b. Neck of a 73-year-old Hispanic female c. Lower lip of a 70-year-old African-American male d. Back of a 90-year-old Caucasian male

c. Lower lip of a 70-year-old African-American male

A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do? a. Join a support group for people with COPD b. Ask the client's physician for an antianxiety agent c. Verbalize his or her thoughts and feelings d. Participate in community activities

c. Verbalize his or her thoughts and feelings

Which assessment parameter does the nurse monitor in a client with chronic kidney disease to determine fluid and sodium retention status? a. Capillary refill b. Intake and output c. Muscle strength d. Weight and blood pressure

d. Weight and blood pressure Weight and blood pressure rise with excess fluid and sodium.

Which statement indicates accountability by the scrub nurse during a surgical procedure? a. The client should have epidural anesthesia rather than general anesthesia b. The client's endotracheal tube is secured and all monitors are in place c. I will have retention sutures ready for the surgeon d. A surgical sponge is missing so I will do a re-count

d. A surgical sponge is missing so I will do a re-count

A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for which factor? a. Nasal drainage b. Bleeding c. Pain d. Airway patency

d. Airway patency

A patient in the orthopedic clinic has a self-reported history of osteoarthritis. The patient reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Inspect the patient's feet and hands for podagra and tophi on fingers and toes b. Prepare to teach the patient about acetaminophen (Tylenol) regimen c. Reassure the patient that the problems will fade as the weather changes again d. Assess the patient for the presence of subcutaneous nodules or Baker's cysts

d. Assess the patient for the presence of subcutaneous nodules or Baker's cysts

A nurse assess a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first? a. Reassure the client that the voice change is temporary b. Document the finding and assess the client hourly c. Place the client in high-fowler's position and apply oxygen d. Contact the provider and prepare for intubation

d. Contact the provider and prepare for intubation

A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which laboratory value requires the most immediate intervention by the nurse? a. White blood cell count (WBC), 3800/mm3 b. Hemoglobin (Hg), 10.6 g/dL c. Blood urea nitrogen (BUN), 16 mg/dL d. Creatinine, 3.2 mg/dL

d. Creatinine, 3.2 mg/dL Creatinine is very high, this indicates renal disease

The nurse is providing discharge instructions for a client who will be going home following myringotomy surgery. Which assessment by the client indicates that additional teaching is needed? a. When I have a bowel movement, I'll avoid straining b. I will postpone my flight home for one month c. I will wait 3 weeks before I resume my aerobics workouts d. When I blow my nose I will occlude one nostril at a time

d. When I blow my nose I will occlude one nostril at a time When blowing your nose, blow gently, without blocking either nostril, with your mouth open. The other statements are correct.

The nurse is teaching a client who has myelodysplastic syndrome. Which instruction does the nurse include in this client's teaching? a. Rise slowly when getting out of bed b. Drink at least 3 liters of liquids per day c. Wear gloves and socks outdoors in cool weather d. use a soft-bristled toothbrush

d. use a soft-bristled toothbrush Myelodysplastic syndrome is a group of disorders that includes anemia, neutropenia, and thrombocytopenia. Because of lower platelets, the client is at risk for bleeding.

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority? Breathing Bleeding Cardiac rhythm Airway

Airway Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

A nurse is assessing a patient who has suffered a nasal fracture. Which assessment would the nurse perform first? Facial pain Vital signs Bone displacement Airway patency

Airway patency A patent airway is the priority. The nurse first would make sure that the airway is patent and then would determine whether the patient is in pain and whether bone displacement or blood loss has occurred.

What is the nurse's best interpretation when a client is admitted with flank pain, and the urine report indicates turbidity, foul odor, rust color, presence of white and red blood cells as well as bacteria, and microscopic crystals? Staghorn calculus with infection Urolithiasis and infection Pyuria and cystitis Dysuria and urinary retention

Urolithiasis and infection

The RN has assigned a client with severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? Provide passive range of motion (ROM) to all weight-bearing joints. Place a pillow between the client's knees when in the side-lying position. Use a lift sheet to reposition the client. Position the client upright to promote lung expansion.

Use a lift sheet to reposition the client. Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

A preoperative nurse is assessing a patient prior to surgery. Which information would be most important for the nurse to relay to the surgical team? No previous experience with surgery History of lactose intolerance Allergy to bee and wasp stings Use of multiple herbs and supplements

Use of multiple herbs and supplements Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the patient during surgery. Lactose intolerance should also not affect the patient during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over patient safety.

A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? a. Atropine (Atropine) b. Digoxin (Lanoxin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor)

a. Atropine (Atropine) Atropine is a cholinercig antagonist that inhibits parasympathetically-induced hyperpolarization fo the sinoatrial node. This inhibition results in a increased heart rate.

A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response? "Excess sodium causes injury to the arteries, reducing blood flow and eventually causing obstruction." "A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow." "Injury to the arteries causes them to spasm, reducing blood flow to the extremities." "Excess fats in your diet are stored in the lining of your arteries, causing them to constrict."

"A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow." Most researchers believe that a combination of platelet and lipid accumulation following intimal injury is responsible for the process of atherosclerosis.

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this client's care? "Assess the client's ability to eat and swallow before each meal." "Schedule appointments early in the morning to ensure rest in the afternoon." "Assist the client with frequent and meticulous oral care." "Allow the client to be as independent as possible with activities."

"Allow the client to be as independent as possible with activities." Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing

The patient is being treated for angina. He asks the nurse if anginais the same thing as having a heart attack. What is the best response by the nurse? (Select all that apply) "Actually, it depends on what type of angina you mean, there are several types." They are basically the same, but with angina, partof your heart dies." "Angina is caused by insufficient oxygen to the myocardium." "Severe emotional distress and panic can accompany angina." "A heart attack, or myocardia infarction, means part of your heart has died."

"Angina is caused by insufficient oxygen to the myocardium." "Severe emotional distress and panic can accompany angina." "A heart attack, or myocardia infarction, means part of your heart has died."

A nurse cares for a patient with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? "Do you have a strong support system?" "What do you understand about your disease?" "Do you experience shortness of breath with basic activities?" "What medications are you prescribed to take each day?"

"Do you experience shortness of breath with basic activities?" Patients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the patient if shortness of breath is interfering with basic activities. Although the nurse would know about the patient's support systems, current knowledge, and medications, these questions do not address the patient's appearance.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? "His masklike face makes it difficult to communicate, so I will use a white board." "This disease is associated with anxiety causing increased perspiration." "He may have trouble chewing, so I will offer bite-sized portions." "He should not socialize outside of the house due to uncontrollable drooling."

"He may have trouble chewing, so I will offer bite-sized portions." Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible.

A patient has thrombocytopenia. What patient statement indicates that the patient understands self-management of this condition? "I chew hard candy for my dry mouth." "white cotton socks are best when I walk." "I usually put ice on bumps or bruises." "I brush and use dental floss every day."

"I usually put ice on bumps or bruises." The patient should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The patient should wear well-fitting shoes when ambulating.

The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions? "I will mostly use salt substitutes for flavoring." "I'm going to miss my evening glass of wine." "I can have regular coffee only in the morning." "I will give my canned soups to the food pantry."

"I will give my canned soups to the food pantry." Canned and processed foods can contain high levels of sodium and should be avoided. Salt substitutes contain potassium and should not be used freely, especially if the client has kidney impairment. The client is advised to refrain from cooking with salt or adding salt to food at the table and is instructed to limit (not eliminate all) alcohol intake.

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? "I must avoid drinking caffeinated beverages." "I shall try to lose about 10% of my body weight." "I will limit my total intake of fluids." "I must avoid drinking alcoholic beverages."

"I will limit my total intake of fluids." Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

A nurse cares for a patient with colon cancer who has a new colostomy. The patient states, "I think it would be helpful to talk with someone who has had a similar experience." How would the nurse respond? "I will make a referral to the United Ostomy Associations of America." "I have a good friend with a colostomy who would be willing to talk with you." "The enterostomal therapist will be able to answer all of your questions." "You'll find that most people with colostomies don't want to talk about them."

"I will make a referral to the United Ostomy Associations of America." Nurses need to become familiar with community-based resources to better assist patients. The local chapter of the United Ostomy Associations of America has resources for patients and their families, including Ostomates (specially trained visitors who also have ostomies).

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? "I will tell my doctor about my prescription and over-the-counter medications." "If I am nauseated, I will not take my epilepsy medication." "I will wear my medical alert bracelet at all times." "While taking my epilepsy medications, I will not drink any alcoholic beverages."

"If I am nauseated, I will not take my epilepsy medication." The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseated. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications.

A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, "Will the medication my mother is taking improve her dementia?" How would the nurse respond? "It will allow your mother to live independently for several more years." "It is used to improve short-term memory but will not improve problem solving." "It is used to halt the advancement of Alzheimer's disease but will not cure it." "It will not improve her dementia but can help control emotional responses."

"It will not improve her dementia but can help control emotional responses." Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client indicates that additional teaching is needed? "The best time to take the enzymes is immediately before I have a meal or a snack." "The capsules can be opened and the powder in my protein shake if needed." "I will wipe my lips carefully after I drink the enzyme preparation." "I will not crush enteric coated capsules."

"The best time to take the enzymes is immediately before I have a meal or a snack." The enzymes should be taken immediately before eating meals or snacks. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. Protein items will be dissolved by the enzymes if they are mixed together.

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? "Your stool will become firmer over the next couple of weeks." "This is abnormal. I will contact your health care provider." "The stool is usually liquid with this type of colostomy." "Eating additional fiber will bulk up your stool and decrease diarrhea."

"The stool is usually liquid with this type of colostomy." The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time

The nurse is teaching a postmenopausal client about the use of calcium to prevent the effects of osteoporosis. The client asks: "Why do I have to take vitamin D with my calcium?" Which of the following is the nurse's best response? "You are most likely to be deficient in vitamin D." "Vitamin D increases intestinal absorption of calcium." "Calcium and vitamine D supplementation is the only way to prevent osteoporosis." "Vitamin D prevents osteoporosis."

"Vitamin D increases intestinal absorption of calcium." A combination of calcium and vitamin D is recommended for the prevention of osteoporosis. Vitamin D alone does not prevent osteoporosis. Whereas some elderly might be deficient in vitamin D, a postmenopausal state does not necessarily cause a deficiency. There are other interventions for the prevention of osteoporosis, including lifestyle modifications i.e smoking cessation.

A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for development of obstructive sleep apnea? A 26-year-old woman who is 8 months pregnant A 42-year-old man with gastroesophageal reflux disease A 55-year-old woman who is 50 lbs (23 kg) overweight A 73-year-old man with type 2 diabetes mellitus

A 55-year-old woman who is 50 lbs (23 kg) overweight The patient at highest risk would be the one who is extremely overweight. None of the other patients have risk factors for sleep apnea.

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence Urine loss with physical exertion b. Urge incontinence Large amount of urine with each occurrence c. Functional incontinence Urine loss results from abnormal detrusor contractions d. Overflow incontinence Constant dribbling of urine e. Reflex incontinence Leakage of urine without lower urinary tract disorder

ANS: A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

ANS: A, B, E

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

ANS: B, E

A postoperative nurse is caring for a patient who receives a neuromuscular blocking agent during surgery. Which assessment by the nurse is most important? Inability to raise head off the bed Weak hand grasp Blood pressure within 20 points of preanesthetic level Abdominal breathing pattern

Abdominal breathing pattern A retained effect of neuromuscular blocking agents includes muscle weakness of the diaphragm which would impair gas exchange. An abdominal breathing pattern is a compensatory breathing pattern for patients with a weak diaphragm. These patients may also not be able to raise their head off the bed and have a weak hand grasp with retained effects of neuromuscular blocking agents. Blood pressure is usually not affected by neuromuscular blocking agents and a blood pressure within 20 points of preanesthetic level is a desired level.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? A 42-year-old male who has worked in a lumber yard for 10 years An 86-year-old male with a 50-pack-year cigarette smoking history A 25-year-old female with a history of sexually transmitted diseases A 55-year-old female who has had numerous episodes of bacterial cystitis

An 86-year-old male with a 50-pack-year cigarette smoking history The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

A patient is in the family practice clinic. Today, the patient weighs 186.4 lbs (84.7 kg). Six months ago, the patient weighed 211.8 lbs (96.2 kg). What action by the nurse is best? Determine if there are food allergies or intolerances. Perform a comprehensive nutritional assessment. Perform a rapid bedside blood glucose test. Ask the patient if the weight loss was intentional.

Ask the patient if the weight loss was intentional. This patient has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

A nurse is concerned that a preoperative patient has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? Ask the patient to describe current feelings. Tell the patient that there is no need to be anxious. Reassure the patient that this surgery is common. Determine if the patient wants a chaplain.

Ask the patient to describe current feelings. The nurse needs to conduct further assessment of the patient's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The patient may want a chaplain, but the nurse needs to do more for the patient. Reassurance can be good, but false hope is not, and simply reassuring the patient may not be helpful. Telling the patient not to be anxious belittles the patient's feelings.

The family of a neutropenic patient reports that the patient "is not acting right." What action by the nurse is the priority? Delegate taking a set of vital signs. Assess the patient for infection. Look at today's laboratory results. Ask the patient about pain.

Assess the patient for infection. Neutropenic patients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic patients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the patient's vital signs instead of delegating them since the patient has had a change in status. Laboratory results may be inconclusive.

A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next? Assess the patient's bowel sounds. Position the patient with knees to chest. Administer intravenous opioid medications. Insert a nasogastric tube for decompression.

Assess the patient's bowel sounds. A change in the nature and timing of abdominal pain in a patient with a bowel obstruction can signal peritonitis or perforation. The nurse would immediately check for rebound tenderness and the absence of bowel sounds. The nurse would not medicate the patient until the provider has been notified of the change in his or her condition. The nurse may help the patient to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

A patient has a platelet count of 9000/mm.. The nurse finds the patient confused and mumbling. What action takes priority? Delegating taking a set of vital signs Placing the patient on bedrest Calling the Rapid Response Team Instituting bleeding precautions

Calling the Rapid Response Team

The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) Client is a white woman with a body mass index (BMI) of 19.4. Client drinks at least four cans of diet cola every day. Client fractured her wrist badly in a fall last year. Client does tai chi exercises for 45 minutes every morning. Client has taken estrogen (Premarin) 0.625 mg daily since menopause. Client has smoked two packs of cigarettes a day for 40 years.

Client is a white woman with a body mass index (BMI) of 19.4. Client drinks at least four cans of diet cola every day. Client fractured her wrist badly in a fall last year. Client has smoked two packs of cigarettes a day for 40 years. Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the client's bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise help reduce the risk of osteoporosis

The circulating nurse and preoperative nurse are reviewing the chart of a patient scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? No prior anesthesia exposure NPO status for the last 8 hours Consent for MIS procedure only Allergies noted and allergy band on

Consent for MIS procedure only All MIS procedures have the potential for becoming open procedures depending on findings and complications. The patient's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is the standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is the standard procedure although individual surgeons may not require being NPO for an entire 8 hours.

A nurse is caring for a patient with a nonhealing arterial lower leg ulcer. What action by the nurse is best? Maintain sterile technique for dressing changes. Give pain medication prior to dressing changes. Prepare the patient for eventual amputation. Consult with the wound care nurse.

Consult with the wound care nurse. A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The patient may need an amputation, but other options need to be tried first.

While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best? Assess for drainage from the site. Cover the insertion site with sterile gauze. Contact the provider and obtain a suture kit. Reinsert the tube using sterile technique.

Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse would not leave the patient to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site would only be assessed after the insertion site is covered. The provider would be called to reinsert the chest tube or prescribe other treatment options.

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment would the nurse complete? Assess religious and spiritual needs while in the hospital. Identify the client's ability to perform self-care activities. Evaluate the client's reaction to a change of environment. Ask the client about relationships with family members.

Evaluate the client's reaction to a change of environment. As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse would be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event.

A patient is scheduled for a below-the-knee amputation. The circulating nurse ensures that the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? Mark the operative site with a waterproof marker. Facilitate marking the site with the patient and surgeon. Tell the surgeon that it is time to mark the surgical site. Have the patient mark the operative site.

Facilitate marking the site with the patient and surgeon. The Joint Commission now recommends that both the patient and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.

A nurse assesses a client who has Parkinson disease. Which manifestations would the nurse recognize as a key feature of this disease? ( Select all that apply. ) Flexed trunk Slow movements Tachycardia Long, extended steps Uncontrolled drooling

Flexed trunk Slow movements Uncontrolled drooling Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider? Torsemide (Demadex)/sodium: 142 mEq/L Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L Spironolactone (Aldactone)/potassium: 5.1 mEq/L Furosemide (Lasix)/potassium: 2.1 mEq/L

Furosemide (Lasix)/potassium: 2.1 mEq/L Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

he nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis? Teaching diet changes to a client with elevated cholesterol levels Suggesting limiting alcohol to an older client with hypolipidemia Encouraging exercise to an obese client who lives a sedentary lifestyle Instructing a diabetic client not to smoke or use any tobacco

Instructing a diabetic client not to smoke or use any tobacco Atherosclerosis can be caused by mechanical and/or chemical injury. People with diabetes often have premature, severe atherosclerosis from elevated low-density lipoprotein (LDL) levels and intimal injury from hyperglycemia. Cigarette smoking or other tobacco use releases toxins into the bloodstream and causes vasoconstriction, further contributing to intimal injury. This would be the priority teaching intervention, although all teaching would be appropriate.

A nurse assesses a patient who is recovering from an ileostomy placement. Which clinical manifestation would alert the nurse to urgently contact the health care provider? Liquid stool Blood-smeared output Ostomy pouch intact Pale and bluish stoma

Pale and bluish stoma The nurse would assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse would expect the patient to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority? Assessing fluid and blood output Ensuring the patient is warm Checking the surgical dressings Participating in hand-off report

Participating in hand-off report Hand-offs are a critical time in patient care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the patient is warm is a lower priority.

A nurse who manages patient placements prepares to place four patients on a medical-surgical unit. Which patient would be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus (MRSA)? Patient transferred from intensive care with an elevated white blood cell count Patient admitted from a nursing home with furuncles and folliculitis Patient with a rash noticed after participating in sporting events Patient with a leg cut and other trauma from a motorcycle crash

Patient admitted from a nursing home with furuncles and folliculitis

A nurse is caring for four patients receiving enteral tube feedings. Which patient should the nurse see first? Patient with a blood glucose level of 138 mg/dL Patient with a potassium level of 2.6 mEq/L (2.6 mmol/L) Patient with foul-smelling diarrhea Patient with a sodium level of 138 mEq/L (138 mmol/L)

Patient with a potassium level of 2.6 mEq/L (2.6 mmol/L) The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this patient first. The blood glucose reading is high, but not extreme. The sodium is normal. The patient with the diarrhea should be seen last to avoid cross-contamination.

A client has a bone density score of -2.8. What action by the nurse is best? Scheduling another scan in 2 years Planning to teach about bisphosphonates Scheduling another scan in 6 months Asking the client to complete a food diary

Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either

The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply) Calcium level of 8.8 mEq/dl Platelet count of 150,000 Type MA Potassium level of 2.8 mEq/L International normalized ratio (INR) of 4 Prothrombin time (PTT) of 30 seconds Positive pregnancy test

Potassium level of 2.8 mEq/L International normalized ratio (INR) of 4 Positive pregnancy test The other values are normal and would not contradict surgery.

Which laboratory tests does the nurse expect to be ordered to screen for prostate cancerin a client with benign prostatic hyperplasia (BPH)? select all that apply. Urinalysis and urine culture Complete blood count (CBC) Prostate specific antigen (PSA) Blood urea nitrogen (BUN) Serum acid phosphatase Serum creatinine

Prostate specific antigen (PSA) Serum acid phosphatase

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer? Cystoscopy Prostate-specific antigen Culture and sensitivity Complete blood count

Prostate-specific antigen A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended?

What is the priority nursing concern when a client is admitted with a history of kidney stones and presents with severe flank pain, nausea and vomiting, pallor, and diaphoresis? Possible hemorrhage Urinary elimination blockage Impaired tissue perfussion Severe pain

Severe Pain

A nurse is caring for a young male patient with lymphoma who is to begin treatment. What teaching topic is a priority? Sperm banking Genetic testing Infection prevention Treatment options

Sperm banking All teaching topics are important to the patient with lymphoma, but for a young male, sperm banking is of particular concern if the patient is going to have radiation to the lower abdomen or pelvis.

Several nurses have just helped a morbidly obese patient get out of bed. One nurse accesses the patient's record because "I just have to know how much she weighs!" What action by the patient's nurse is most appropriate? Walk away and ignore the other nurse's behavior. State "That is a violation of patient confidentiality. Make an anonymous report to the charge nurse. Tell the nurse "Don't look; I'll tell you her weight.

State "That is a violation of patient confidentiality. Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating patient confidentiality rules. The other responses do not address this concern.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? Review the hemoglobin and hematocrit as ordered. Remind the client not to pull on the catheter Take vital signs and notify the surgeon immediately Release the traction on the three-way catheter.

Take vital signs and notify the surgeon immediately Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurse's review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client's plan of care to assist with elimination? Use intermittent catheterization Stroke the medial aspect of the thigh. Provide digital anal stimulation Use the Valsalva maneuver

Use the Valsalva maneuver In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding.

A rehabilitation nurse prepares to move a patient who has new bilateral leg amputations. Which is the best approach? Consult physical therapy before performing all transfers. Ask several members of the healthcare team to carry the patient. Utilize the facility's mechanical lift to move the patient. Use the bear-hug method to transfer the patient safely.

Utilize the facility's mechanical lift to move the patient. Use mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug method and the use of several members of the team to carry the patient do not eliminate staff injuries. Physical therapy would be consulted but cannot be depended upon for all transfers. Nursing staff must be capable of transferring a patient safely.

A nurse teaches a patient who has a flaccid bladder. Which bladder training technique would the nurse teach? Self-catheterization Stroking the medial aspect of the thigh Frequent toileting Valsalva maneuver

Valsalva maneuver With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voiding, such as with the Valsalva and Credé maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to reestablish voiding continence with an uninhibited bladder.

A nurse assesses a patient recovering from coronary artery bypass graft surgery. Which assessment would the nurse complete to evaluate the patient's activity tolerance? Vital signs before, during, and after activity Body image and self-care abilities Ability to use assistive or adaptive devices Patient's electrocardiography readings

Vital signs before, during, and after activity To see whether a patient is tolerating activity, vital signs are measured before, during, and after the activity. If the patient is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the patient's activity tolerance. Electrocardiography is not used to monitor patients in a rehabilitation setting.

Which exercise does the nurse recommend to a client at risk for osteoporosis? Jogging 30 minutes four times weekly Walking 30 minutes three times weekly High-impact aerobics 45 minutes once weekly Bowling for 1 hour twice weekly

Walking 30 minutes three times weekly Weight-bearing, nonjarring exercises have been proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

Which statements are true regarding Standard Precautions? ( Select all that apply. ) Wear gloves when touching patient excretions or secretions. Use personal protective equipment as needed for patient care. Remain 3 feet (1 m) away from any patient who has an infection. Sneeze into your sleeve or into a tissue that you throw away. Always wear a gown when performing hygiene on patients.

Wear gloves when touching patient excretions or secretions. Use personal protective equipment as needed for patient care. Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you will also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet (1 m) away from patients is also not part of Standard Precautions.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurses best response? The hospital requires that all in patients be weighed daily Weight is the best indicaiton that you are gaining or losing fluid You need to lose weight to decrease the incidence of heart failure Daily weights will help us make sure that you're eating properly

Weight is the best indicaiton that you are gaining or losing fluid

A patient with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this patient? Bortezomib (Velcade) Dexamethasone (Decadron) Zoledronic acid (Zometa) Thalidomide (Thalomid)

Zoledronic acid (Zometa) All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

The nurse is caring for client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? a. Body mass index (BMI) is 16.6 b. Stool is positive for occult blood c. Client has had four ulcers in the last 5 years d. Hemoglobin is 13 g/dL and hematocrit is 42%

a. Body mass index (BMI) is 16.6 A BMI of 16.6 indicates that the client is underweight (<18.5 is underweight in adults). This finding is more commonly seen with gastric ulcers than with duodenal ulcers because the pain is made worse with food ingestion.

The nurse is concerned that an older client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complicaiton? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

a. Confusion Impending pulmonary edema is characterized by a change in the mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs.

A nurse cares for a client who has Alzheimer's disease. Which communication techniques would the nurse implement? ( Select all that apply. ) a. Gestures when speaking b. Validate client feelings c. Multiple choices d. Pictures with instructions e. Open-ended questions

a. Gestures when speaking b. Validate client feelings d. Pictures with instructions When communicating with a client who has Alzheimer's disease the nurse would use simple, direct questions that require only yes or no answers, provide instructions with pictures, use simple short sentences and gestures when speaking, validate the client's feelings as needed, and limit choices to decrease frustration or increase confusion.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

a. Have suction equipment at the bedside. d. Keep bed rails up at all times. f. Ensure that the client has IV access.

The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L e. Proteinuria f. Microalbuminuria

The nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis? a. Instructing a diabetic client not to smoke or use any tobacco b. Teaching diet changes to a client with elevated cholesterol levels c. Suggesting limiting alcohol to an older client with hypolipidemia d. Encouraging exercise to an obese client who lives a sedentary lifestyle

a. Instructing a diabetic client not to smoke or use any tobacco

The nurse is caring for a client with chronic gastritis. The client asks the nurse how to prevent another flare-up of gastritis. Which is the nurse's best response? a. Join a support group to help you stop smoking b. Take a multivitamin with iron and folic acid every day c. Make sure to include plenty of fresh vegetables in your diet d. Make sure that you weight stays within normal limits

a. Join a support group to help you stop smoking Smoking and stress contribute to the development of gastritis, so the client should join a support group to help him quit smoking.

The nurse is caring for client who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the client? (Select all that apply) a. Monitor and record accurate intake and output (I & O) b. Remind the client to use the incentive spirometer twice daily c. Change abdominal dressings daily using medical asepsis d. Remind the client daily to use the patient-controlled analgesia (PCA) before pain becomes severe. e. Keep the head of the client's bed elevated whenever possible f. Irrigate the nasogastric tube with normal saline every 8 hours PRN

a. Monitor and record accurate intake and output (I & O) d. Remind the client daily to use the patient-controlled analgesia (PCA) before pain becomes severe. e. Keep the head of the client's bed elevated whenever possible

The patient is being treated for angina. He asks the nurse if angina is the same thing as having a heart attack. What is the best response by the nurse? (Select all that apply) a. Severe emotional distress and panic can accompany angina b. A heart attack, or myocardial infarction, means part of your heart has died c. Actually, it depends on what type angina you mean, There are several types d. They are basically the same, but with angina, part of your heart dies e. Angina is caused by insufficient oxygen to the myocardium

a. Severe emotional distress and panic can accompany angina b. A heart attack, or myocardial infarction, means part of your heart has died e. Angina is caused by insufficient oxygen to the myocardium

The nurse is caring for client who has just arrived in the emergency department reporting epigastric pain. The client says that emesis earlier in the day looked like coffee grounds. What does the nurse prepare to do for the client first? a. Check the client's stool for occult blood b. Insert 18-gauge IV lines with normal saline infusions c. Insert a nasogastric tube and prepare for gastric lavage d. Determine whether the client has a history of ulcers

b. Insert 18-gauge IV lines with normal saline infusions The client is at risk for hemorrhage and severe volume depletion and requires two large-bore IVs Immediately.

What is the best lead to look at to determine heart rate, rhythm and P wave? a. Lead I b. Lead II c. Lead III d. Lead IV

b. Lead II

A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder? a. Careful compliance with diet and medications will control the patient's symptoms b. Notify the doctor about any symptoms of heart failure such as shortness of breath c. No more than one to two alcoholic drinks daily are permitted d. Elevating the legs above the heart will help relieve angina

b. Notify the doctor about any symptoms of heart failure such as shortness of breath

A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time the following morning. Which of the following are appropriate nursing interventions for the patient? (Select all that apply) a. Encourage oral fluid intake of 2,500 mL per day b. Place the patient on strict I & O. c. Weigh the patient before and after dialysis d. Maintain a fluid restriction of 1,000 mL as prescribed

b. Place the patient on strict I & O. c. Weigh the patient before and after dialysis d. Maintain a fluid restriction of 1,000 mL as prescribed Fluids are restricted in patients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate.

The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? a. Place the client in a knee-chest position b. Prepare the client for emergency surgery c. Insert a nasogastric (NG) tube to low intermittent suction d. Assess the client pain and administer analgesics

b. Prepare the client for emergency surgery Sudden, sharp mid-epigastric pain is indicative of perforation, which is a surgical emergency

A client has nephrotic syndrome. Which finding shows that therapy is effective? a. Serum albumin level, 2.8 g/dL b. Serum albumin level, 4 g/dL c. Urine protein level, 3.7 g/24 hr d. Potassium 4.2 mEq/L

b. Serum albumin level 4 g/dL The main diagnostic findings in nephrotic syndrom are severe proteinuria, low serum albumin, high serum lipids, and fat in the urine. A serum albumin of 4 g/dL is within normal range, showing that therapy is working. An albumin level of 2.8 g/dL is low, and protienuria of 3.7 g/24 hr is high, showing that the disease is not yet controlled. Potassium is not affected.

The nurse is caring for client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

b. Speech alterations Clients with atrial fibrillation are at risk for embolic stroke.

21. A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this clients teaching? a. Use the toilet when you first feel the urge, rather than at specific intervals. b. Try to consciously hold your urine until the scheduled toileting time. c. Initially try to use the toilet at least every half hour for the first 24 hours. d. The toileting interval can be increased once you have been continent for a week.

b. Try to consciously hold your urine until the scheduled toileting time.

Which is the best approach for the nurse to use to obtain a history from a client with sudden hearing loss? a. Question the client's family b. Write out the questions for the client to answer c. Obtain the information from the client's old chart d. Check with the client's primary health care provider

b. Write out the questions for the client to answer

A client with acute kidney failure and on dialysis asks how much fluid will be permitted each day. Which is the nurse's best response? a. This is based on the amount of damage to your kidneys b. You can drink an amount equal to your urine output, plus 700mL. c. It is based on your body weight and changes daily d. You can drink approximately 2 liters of fluid each day

b. You can drink an amount equal to your urine output, plus 700mL. For clients on dialysis, fluid intake is generally calculated to equal the amount of urine excreted plus 500 to 700 mL.

The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention does the nurse prepare to provide for the client? a. Administer a soap suds cleansing enema b. Change the client's diet to clear the liquids only c. Insert a nasogastric (NG) tube to low intermittent suction d. Administer prochlorperazine (Compazine) 10mg IM

c. Insert a nasogastric (NG) tube to low intermittent suction Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance.

A client is receiving continous arteriovenous hemofiltration (CAVH). Which laboratory value does the nurse monitor most closely? a. Hemoglobin b. Glomerular filtration rate c. Sodium d. White blood cells

c. Sodium CAVH is used for clients who have fluid volume overload. It continuously removes large quantities of plasma, water, waste, and electrolytes, such as sodium.

The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should reply, a. It can be used immediately so the catheter can come out anytime b. It will take 2 to 4 weeks to heal before it can be used c. The fistula will be usable in about 4 to 6 weeks d. The fistula was made using graft material so it depends on the manufacturer.

c. The fistula will be usable in about 4 to 6 weeks

A nurse notes the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 seconds. What action does the nurse take? a. Assess serum cardia enzymes b. Administer 1 mg epinephrine IV c. Administer oxygen via nasal cannula d. Document the finding in the client's chart

d. Document the finding in the client's chart The PR interval normally ranges from 0.12 to 0.20 seconds. This is a normal finding, so the nurse simply documents this. No further action is required.

The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse? a. Obtain informed consent from the client b. Continue teaching the client about the surgery c. Revise the teaching plan for the client d. Notify the surgeon and document the finding

d. Notify the surgeon and document the finding

The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse corrolate with this problem? a. Decreased breath sounds b. Foul-smelling urine c. Heart rate of 50 beats/min d. Respiratory rate of 40 breaths/min

d. Respiratory rate of 40 breaths/min A client with uremia will also have metabolic acidosis. With severe MA the client will develop hyperventilation, as the body attempts to compensate for the falling pH.