ARCHER - PRACTICE QUESTION #4

serum creatinine

A creatinine test is a measure of how well your kidneys are performing their job of filtering waste from your blood. Creatinine is a chemical compound left over from energy-producing processes in your muscles. Healthy kidneys filter creatinine out of the blood. Creatinine exits your body as a waste product in urine. A higher than normal creatinine level may be due to: Blocked urinary tract. Kidney problems, such as kidney damage or failure, infection, or reduced blood flow. Loss of body fluid (dehydration) Low creatinine levels mean something is affecting creatine production in the body. This will often result from a person having low muscle mass or body weight. However, low creatinine levels may also indicate a person has chronic kidney disease, reduced kidney function, or malnutrition.

Serum albumin

A normal albumin range is 3.4 to 5.4 g/dL. If you have a lower albumin level, you may have malnutrition. It can also mean that you have liver disease, kidney disease, or an inflammatory disease. High levels may be a sign of dehydration. Albumin is a protein made by your liver.

The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing. B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer. C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours. D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.

Choice A is correct. A subtotal thyroidectomy requires the nurse to monitor the client for complications such as laryngeal edema. This may be manifested as a hoarse voice, difficulty swallowing, and stridor. The primary healthcare provider (PHCP) may prescribe post-operative steroids to prevent this complication. The nurse needs to follow up with this client to assess the client's airway patency. Additional Info Common complications following thyroidectomy surgery are as follows: ✓ Hypocalcemia: accidental injury or removal of the parathyroid gland can reduce the circulating blood calcium levels. Acute hypocalcemia may present with the Chvostek Sign (tapping on the cheek causes facial twitching), Trousseau's Sign (applying pressure on the arm causes carpopedal spasms), muscle cramps, paresthesia, peri-oral numbness, tetany, seizures, and cardiac arrhythmias. If untreated, it can be life-threatening. To prevent this complication, every thyroidectomy patient is started on 3 grams of elemental calcium per day as soon as they can begin an oral diet. ✓ Recurrent laryngeal nerve (RLN) injury: hoarseness of voice from RLN injury is common due to the damage of RLN intra-operatively. ✓ Following a thyroidectomy, the nurse should have readily available airway equipment and calcium gluconate.

The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove? A. Macaroni and cheddar cheese B. Watermelon slices C. Caffeine free cola D. Baked chicken

Choice A is correct. Pheochromocytoma is caused by a tumor on top of the adrenal medulla, causing a surge in catecholamines to be released, thus causing the client to experience headaches, hypertension, hyperglycemia, tremor, and unintentional weight loss. A client with pheochromocytoma is advised to modify their diet so that it does not increase blood pressure. Cheddar cheese contains tyramine and should not be included in the client's diet. Other dietary modifications include limitations of caffeinated beverages, which may also raise blood pressure. This item should be removed from the client's meal tray. Additional Info ✓ Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla, causing a discharge of catecholamines ✓ This causes a surge in catecholamine discharge resulting in headaches, palpitations, weight loss, marked hypertension, and hyperglycemia ✓ Treatment includes antihypertensives (α-Adrenergic blocking agents are started 7 to 10 days before β-adrenergic blocking agents) and removal of the tumor via adrenalectomy ✓ Diagnosis is confirmed with a 24-hour urine collection looking for elevations in creatinine, total catecholamines, vanillylmandelic acid, and metanephrines ✓ The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure

A nurse is caring for a client receiving nitroglycerin. It is essential to monitor the client's A. Temperature B. Respirations C. Urinary output D. Blood pressure

Choice D is correct. Nitroglycerin is used in the treatment of angina, pulmonary edema, and hypertensive emergencies. Nitroglycerin decreases both preload and afterload, which may result in hypotension. Thus the client's blood pressure needs to be monitored closely. Choices A, B, and C are incorrect. The effects of nitroglycerin do not impact these options.

The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Positive pressure ventilation B. Pericardiocentesis C. Echocardiography D. 0.9% saline bolus

Choice A is correct. Positive pressure ventilation (PPV) would be detrimental to a client experiencing cardiac tamponade. This order requires follow-up. PPV increases intrathoracic pressure, which decreases venous return to the heart. This reduction of venous return impairs ventricular filling and reduces cardiac output. This would be detrimental in a cardiac tamponade where the cardiac output is already impaired. Choices B, C, and D are incorrect. A pericardiocentesis is a primary treatment for cardiac tamponade. Echocardiography is the primary way of identifying cardiac tamponade. This non-invasive approach determines the severity of the tamponade and any other cardiac structure impairment. 0.9% saline bolus may be used to temper the hypotension caused by this condition. This is not an absolute treatment but is useful in mitigating hypotension. ✓ Cardiac tamponade is compression of the myocardium by fluid that has accumulated in the pericardium. ✓ This fluid accumulating causes compression of the atria and the ventricles, prevents them from filling adequately and reduces cardiac output. ✓ Various infectious and noninfectious reasons may cause cardiac tamponade. ✓ Classic manifestations of cardiac tamponade include tachycardia, hypotension, jugular venous distention, distant muffled heart sounds, and pulsus paradoxus.

The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron B. Methimazole C. Omeprazole D. Methylphenidate

Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental. Choices B, C, and D are incorrect. Methimazole is an antithyroid medication used for hyperthyroidism. This is not indicated following hypophysectomy. Omeprazole is a PPI and indicated in the treatment of peptic ulcer disease. Methylphenidate is a psychostimulant indicated in the treatment of ADHD.

The nurse has provided medication instruction to a client who has been prescribed metformin. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? A. "This medication may cause me to have bloating or loose stools." B. "I will need to take my blood glucose prior to taking this medication." C. "If I eat fewer carbohydrates in a day, I should skip a dose." D. "The goal of this medication is to increase my hemoglobin A1C."

Choice A is correct. The most common side-effect associated with Metformin is gastrointestinal upset. This side-effect typically occurs at the start of the therapy and subsides over time. To minimize these effects, the client should take this medication with meals, or they may be prescribed the extended-release form. Choices B, C, and D are incorrect. Metformin does not cause hypoglycemia, and the client is not required to take their blood glucose before a dose. Other classes of anti-diabetic drugs such as sulfonylureas and insulin cause hypoglycemia. A blood glucose check is recommended before taking bolus doses of insulin. Because Metformin does not cause symptomatic hypoglycemia, clients should not skip the drug based on their carbohydrate intake. The goal of Metformin is to decrease the

The nurse cares for a client who sustained a stroke impacting the occipital lobe. Which of the following assessment findings would support this diagnosis? A. homonymous hemianopia B. impaired proprioception C. expressive aphasia D. impulsivity

Choice A is correct. Visual disturbances are expected for a client with a stroke impacting the occipital lobe of the brain. The occipital lobe is the primary optical center of the brain. Homonymous hemianopia is a complete left or right visual field defect. The client may need to be taught to scan the room, and the nurse should place objects in the unaffected visual field. Choice B is incorrect. Proprioception is for the client to have an awareness of their body position. Testing a client's proprioception is done via the Romberg test. If the client should have impairments with proprioception, this highly suggests an insult to the parietal lobe, which primarily processes sensory input, proprioception, and taste. Choice C is incorrect. Expressive aphasia and impulsivity can be explained as an insult to the frontal lobe, which is the brain's executive center. Broca's area can be found in the frontal lobe and, if damaged, may cause the client to have expressive aphasia. Choice D is incorrect. Impulsivity is also a feature of a stroke that primarily affects the frontal lobe, as this lobe controls cognition, judgment, affective response to situations, and reasonable deduction.

Which of the following vaccines contains a live virus? A. IPV B. DTaP C. Varicella D. Hepatitis B

Choice A is incorrect. IPV is an inactivated polio vaccine. Choice B is incorrect. DTaP contains inactivated forms of the toxin produced by the bacteria that cause the three diseases Diphtheria, Tetanus, and Pertussis. Choice D is incorrect. Hepatitis B vaccine is a genetically engineered (human-made in the laboratory) piece of the virus. It does not contain a live virus.

The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A. Homan's sign B. Cullen's sign C. Hyperactive bowel sounds D. Kernig's sign

Choice B is correct. Cullen's sign refers to the bluish periumbilical discoloration/ecchymosis that is common in acute pancreatitis. The discoloration occurs due to blood-stained exudates seeping from the pancreas. Choice A is incorrect. A positive Homan's sign (pain in the calf with foot dorsiflexion) would indicate the presence of a DVT, not pancreatitis. Choice C is incorrect. A patient with acute pancreatitis would present with hypoactive (decreased) bowel sounds, not hyperactive. Choice D is incorrect. A positive Kernig's sign indicates possible subarachnoid hemorrhage or meningitis. It would not support the patient's acute pancreatitis diagnosis.

The nurse is caring for a client with an acute spinal cord injury. Which client finding would require immediate follow-up? A. absent bowel sounds B. blood pressure 134/82 mm Hg C. pulse 92/minute D. hyperreflexia

Explanation Choice A is correct. Absent bowel sounds, gastric distention, bradycardia, hypotension, and flaccid paralysis are concerning findings for spinal shock. When caring for a client following a spinal cord injury, spinal shock is one of the many complications which may occur within 48 hours following the injury. Choices B, C, and D are incorrect. This clinical data is not consistent with spinal shock. If spinal shock is suspected, the client will develop hypotension and bradycardia. This shock would depress reflexes, not cause hyperreflexia.

The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question? A. Iron sucrose B. Enoxaparin C. Sucralfate D. Hydroxyurea

Choice B is correct. Enoxaparin is a low-molecular-weight heparin (LMWH). Bleeding is the major risk associated with the use of enoxaparin. The client has anemia and active occult gastrointestinal bleeding. Enoxaparin is contraindicated in clients with any active clinically significant bleeding, including gastrointestinal bleeding. Clients with occult blood in their stool should avoid any type of anticoagulant therapy until the cause of the bleeding is identified and addressed. Choice A is incorrect. The client likely has iron deficiency anemia from occult gastrointestinal bleeding. Iron sucrose is a form of iron administeredintravenously to clients with iron deficiency. The client will benefit from iron sucrose. For reference, ferrous sulfate is the most common form of iron supplement administered orally. While there is controversy about whether oral ingestion of iron supplements causes false-positive fecal occult blood tests (FOBT), intravenous iron certainly does not cause false-positive FOBT. Choice C is incorrect. Sucralfate is a gastric mucosa protectant used to treat and prevent the recurrence of duodenal ulcers. Sucralfate does not have the tendency to cause or make gastrointestinal bleeding worse, so the nurse wouldn't need to ask any questions about it. Choice D is incorrect. Hydroxyurea is indicated for the treatment of certain cancers and sickle cell anemia. Based on the information provided, the nurse would not need to question the order for hydroxyurea.

The nurse is caring for a client with a pulmonary embolism (PE). Which of the following findings require immediatefollow-up? A. Pleuritic chest pain B. Restlessness C. Cough D. Exertional dyspnea

Choice B is correct. Restlessness is an ominous sign suggestive of hypoxia. Hypoxia indicates pulmonary embolism(PE) that is advancing, and the client is becoming unstable. The nurse should immediately follow up on this finding. Choices A, C, and D are incorrect. The client has already been diagnosed with PE. Pleuritic chest pain, cough, and exertional dyspnea are all expected features of PE. Individuals with PE may be asymptomatic, depending on the size of the PE. Restlessness or any other indications of hypoxia in a PE client require immediate follow-up. Learning Objective Recognize that worsening hypoxia in a PE client may be a sign of advancing embolism. Additional Info Pulmonary embolism (PE) risk factors include venous thromboembolism, hypercoagulability, immobility, and smoking. Most PEs arise from an untreated deep vein thrombosis (DVT) that may be lethal if it goes unrecognized. Manifestations of PE include pleuritic chest pain, cough, and dyspnea.

Which of the following statements best describes the cardiovascular system? A. It has a heart with six chambers, strong vessels, and valves. B. It is a double-pump circulating blood out to the lungs and the body. C. It includes concepts of precontractility, postcontractility, and load. D. It functions with a conduction system and starts in the ventricles.

Choice B is correct. The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium. Choice A, C, and D are incorrect. The heart has four chambers, not six. These chambers include two atria (right and left) and two ventricles (right and left). Blood from the entire body returns to the heart's right atrium through the superior and inferior vena cavaes. Blood circulates through the right atrium, then to the right ventricle, gets oxygenated in the lungs, moves on to the left atrium, then the left ventricle, and is pumped back to the systemic circulation via the aorta. The conduction system of the heart begins in the right atrium, not the ventricle. The heart's conduction system includes pacemaker cells (SA node, AV node, Bundle of His, bundle branches, and Purkinje fibers) plus contractile cells. The sinoatrial node (SA node), located in the right atrium, is the pacemaker that sets the heart rate and is the starting point of the conduction system. The effectiveness of the pumping action of the heart is described in concepts of preload, afterload, and contractility. Preload (end-diastolic volume) is the amount of initial stretching of the ventricles before the contraction (systole) begins. Preload is determined by the venous return to the heart and is directly related to ventricular filling. Afterload refers to the resistance/load against which the left ventricle pumps out the blood. Afterload is directly determined by aortic pressure (systemic vascular resistance, SVR). Finally, contractility (inotropy) refers to the innate ability of heart muscle to contract at a given afterload and preload. Preload, afterload, and contractility determine the stroke volume and ejection fraction

The nurse is caring for a client with a suspected pulmonary embolism. After the nurse notifies the rapid response team, the nurse should perform which action? Select all that apply. place the client in a left lateral trendelenburg position obtain vital signs obtain a prescription for warfarin place the client in the high-Fowler's position obtain an order for a chest radiograph (x-ray)

Choice B is correct. The nurse needs to obtain vital signs because a client with a suspected pulmonary embolism may experience hypoxia, tachypnea, and tachycardia. The nurse can intervene by providing supplemental oxygen if the vital signs show hypoxia. Finally, the nurse will need to notify the physician, and having recent vital signs is essential to determine the client's overall stability. Choice D is correct. The client should be placed in a high Fowler's position. This allows full chest expansion, which may optimize the client's oxygen saturation. Choice A is incorrect. For a client with a suspected air embolism, they should be placed in a left lateral Trendelenburg position. This position encourages the air bubble to move out of the right ventricular outflow tract (RVOT) and into the right atrium, where it can be trapped and reabsorbed. If this does not work, the client may need immediate treatment via interventional radiology. 100% oxygen administration will also help reduce the air bubble's size and prevent organ ischemia. This client has a pulmonary embolism and needs to be in a high Fowler's position.

The nurse is caring for assigned clients. The nurse should initially follow-up on the client who A. has a blood glucose of 250 mg/dL (13.875 mmol/L) while being treated with prednisone for pneumonia. B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days. C. has diabetes mellitus (type two) and reports burning and tingling in both feet. D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary

Choice B is correct. This client shows signs of heparin-induced thrombocytopenia (HIT): a 50% decrease in platelets 5-10 days after initiating heparin therapy. This is a thrombotic emergency, and the nurse should assess the client, notify the physician, discontinue the heparin drip, and obtain a prescription for a non-heparin-based anticoagulant. Choice A is incorrect. This client is being treated for pneumonia and is likely on antibiotics and corticosteroids. Both of these medications are known to increase blood glucose levels. This blood glucose result is high, and the client may require a change in the insulin dose, but this would not be an emergency or the nurse's top priority. Choice C is incorrect. The client complaining of tingling and numbness in the toes indicates peripheral neuropathy, a common problem in individuals with diabetes mellitus, specifically if it is poorly controlled. This is not a priority because this complication is not life-threatening. Choice D is incorrect. This client presents symptoms typical of acute post-streptococcal glomerulonephritis (APSGN): hypertension due to fluid retention, decreased urinary output, rust-colored hematuria due to upper urinary tract bleeding, and proteinuria due treduceded filtration. The symptoms that are expected are not the highest priority.

The nurse is auscultating bronchovesicular lung sounds on a client. The nurse understands that these lung sounds are best heard A. right second intercostal space. B. midclavicular line, in the fifth intercostal space. C. posteriorly, between the scapula. D. over the trachea.

Choice C is correct. Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae. Choices A, B, and D are incorrect. The right second intercostal space is where the nurse may auscultate the aortic valve. The midclavicular line in the fifth intercostal space is the apex of the heart where the apical pulse may be obtained, and any adventitious sounds such as S3 or S4 may be auscultated. Auscultating lung sounds over the trachea is where the nurse may listen to bronchial breath sounds. These breath sounds are loud and high-pitched with hollow quality.

The nurse is teaching a client who has Graves' disease about self-management. Which of the following should the nurse include in the teaching plan? A. Stool softeners can be taken daily to prevent constipation. B. Thyroid replacement should be taken first thing in the morning. C. Report any significant weight gain while taking the antithyroid medication. D. Maintain the prescribed fluid restriction to prevent fluid overload.

Choice C is correct. Graves' disease is the most common cause of hyperthyroidism. When a client is taking antithyroid medication, such as methimazole, they should be taught about the warning signs of hypothyroidism (weight gain, constipation, anorexia). This could indicate that the dose needs to be decreased. Choices A, B, and D are incorrect. Constipation is a hallmark finding of hypothyroidism (Choice A). This would not be expected of Graves' disease. Thyroid replacement (Choice B) would be contraindicated for Graves' disease as this would worsen hyperthyroidism. Thyroid replacement should be taken first in the morning by patients with hypothyroidism, not hyperthyroidism. Fluid restrictions are not indicated for Graves' disease (Choice D).

A nurse is educating a client recently diagnosed with hepatitis C. Which of the following should the nurse include in the teaching? A. "Disinfect your bathroom with bleach after each use." B. "It is important that you not prepare food for others." C. "You may not experience any symptoms of hepatitis C." D. "It will be important that we vaccinate individuals in your household."

Choice C is correct. Hepatitis C is often asymptomatic and frequently goes unrecognized until the manifestation of chronic liver disease occurs, making detection and testing difficult. Many clients are asymptomatic and do not have jaundice, although some have malaise, anorexia, fatigue, and nonspecific upper abdominal discomfort. Often, the first findings are signs of cirrhosis (e.g., splenomegaly, spider nevi, palmar erythema) or complications of cirrhosis (e.g., ascites, encephalopathy, etc.). Choice A is incorrect. The bathroom is not a transmission mode; thus, disinfection after each use is unnecessary. Hepatitis C is a blood-borne pathogen and is not spread by casual contact. Hepatitis A spreads primarily by fecal-oral contact and thus may occur in areas of poor hygiene. Choice B is incorrect. Advising the client to refrain from preparing food for others would be inappropriate, as hepatitis C is not a food-borne transmitted illness. Such instruction would be appropriate for a client diagnosed with hepatitis A, which spreads primarily by fecal-oral contact and often occurs in areas of poor hygiene. Choice D is incorrect. Currently, no vaccination is available for hepatitis C. Vaccinations are available for hepatitis A and B.

The nurse is caring for a client scheduled for an adrenalectomy after being diagnosed with pheochromocytoma. Which preoperative clinical data is essential for the nurse to monitor? A. intake and output B. blood glucose C. vital signs D. hemoglobin and hematocrit

Choice C is correct. Vital signs are the most critical priority in the pre-operative period. A client with pheochromocytoma has a high risk of developing a hypertensive emergency and cardiac dysrhythmias because of the increased catecholamine levels. Antihypertensive medications are commonly prescribed to prevent a hypertensive crisis. Choice A is incorrect. Monitoring intake and output is not as important as vital signs because of the client's high risk of developing a hypertensive crisis. Choice B is incorrect. Pheochromocytoma causes a client's blood glucose to increase because of the increased circulation of catecholamines. However, this is not prioritized over vital signs because of the high risk of a hypertensive crisis.

The nurse is caring for a client with lung cancer who recently had a left lower lobe removal. Which postoperative intervention will be performed as a priority in the care of this client? A. Tracheostomy B. Mediastinal tube C. Incentive spirometer

Choice D is correct. A closed chest drainage system is the priority postoperative intervention for a client who has had a left lower lobe removal. This system is used to manage the drainage of air or fluid from the pleural space, which is crucial in preventing complications such as pneumothorax or pleural effusion. Choice A is incorrect. The client will likely not have a tracheostomy. This surgical procedure involves creating an opening in the trachea through the neck and is typically done in situations where there is a need for long-term or permanent airway access. In the case of a lobe removal, maintaining the natural airway and focusing on lung expansion and prevention of complications are the immediate priorities. Choice B is incorrect. A mediastinal chest tube, is not typically a priority after a left lower lobe removal. These tubes are often used in cardiac surgery or procedures involving the mediastinum. Since a left lower lobe removal primarily involves the lung parenchyma and not the mediastinum, this intervention is not an immediate postoperative priority in this context. Choice C is incorrect. The client may use an incentive spirometer during recovery, but it is not the highest priority immediately after surgery as other interventions directly related to the surgical site take precedence. D. Closed chest drainage system

The nurse is answering phones in the general practice clinic and receives a call from a patient who is experiencing leg pain after starting atorvastatin. Which of the following instructions, when given by the nurse, is the best course of action? A. Continue taking the medication as this is an expected side effect. B. Discontinue the medication and schedule an appointment for the next week. C. Stretch for 20 minutes or take a warm shower. D. Discontinue the medication and visit the clinic as soon as possible.

Choice D is correct. Leg pain and muscle aches occur after taking atorvastatin, which may indicate a severe muscular myopathy known as rhabdomyolysis. The nurse would be most accurate to have this patient discontinue their medication and come to the clinic as soon as possible. Choice A is incorrect. This patient should be seen in the clinic to rule out potentially fatal health problems like rhabdomyolysis. Choice B is incorrect. While this medication should be discontinued, waiting for treatment could delay necessary treatment. Choice C is incorrect. Stretching for 20 minutes or taking a warm shower could delay necessary treatment.

Which imbalance would the nurse monitor for a client with fluid imbalance related to the development of ascites? Select all that apply. Effective extracellular fluid volume deficit Protein deficit Metabolic alkalosis Sodium deficit Plasma-to-interstitial fluid shift Metabolic acidosis

Choices A, B, D, and E are correct. Ascites indicates fluid accumulation in the peritoneal cavity. It is easy to get confused that these clients are in a state of overall fluid volume excess, however, these clients are prone to hypotension due to circulatory volume deficit. The "effective" circulatory volume refers to the portion of the extracellular fluid (ECF) present in the vascular compartment and actively perfuses the tissues. ECF is a sum of plasma volume and interstitial fluid volume. Patients with fluid shifts due to ascites are at risk for "effective" ECF deficit, protein deficit (hypoalbuminemia), sodium deficit, and plasma-interstitial fluid shift. ECF is not just confined to interstitial fluid volume. ECF is subdivided into two compartments - blood plasma and interstitial fluid. While interstitial fluid increases in ascites due to fluid shifts, there is a decrease in the circulatory volume or effective ECF volume. Therefore, the cirrhotic clients with ascites are prone to hypotension. The nurse must recognize that these clients are at risk of hypotension because their "effective" circulatory ECF is actually in deficit. In cases where indicated, albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and transiently improving the blood pressure. Hypoalbuminemia occurs in liver cirrhosis because of the failure of synthetic function of the liver. Low albumin causes low oncotic pressure. This low osmotic pressure along with increased hydrostatic pressure within the vascular compartment ( portal hypertension) in liver cirrhosis leads to fluid moving from vascular compartment to peritoneal cavity ( ascites). Sodium deficit is seen as "dilutional" hyponatremia in liver cirrhosis because more water

The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication? Select all that apply. Multivitamin Aspirin Warfarin Simvastatin Salmeterol

Cystic fibrosis is a multisystem disorder that has no cure. A well-balanced diet rich in calories, protein, and fat is recommended to help prevent (or treat) the malabsorption associated with CF. Foods rich in sodium are also recommended because of the salt loss through the skin. A multivitamin is commonly prescribed to help mitigate the vitamin deficiencies that may develop.

The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up? A. Pulse 112/minute B. Persistent nausea and vomiting C. Respiratory rate 21/minute D. Blood glucose 299 mg/dL

Explanation Choice A is correct. A complication associated with DKA is hypovolemic shock. The client having tachycardia is demonstrating early signs of this type of shock. The treatment modalities of DKA include fluid repletion and insulin administration. Considering the client's tachycardia, the nurse should initially administer the prescribed isotonic fluids to treat the significant fluid volume deficit. Choice B is incorrect. Persistent nausea and vomiting is a manifestation of gastroparesis, which may be found with DKA. The nurse must address this finding by administering prescribed antiemetics (metoclopramide) and isotonic fluids. However, this is not the most immediate concern because the client is demonstrating early manifestations of shock. Choice C is incorrect. Tachypnea is an expected finding of DKA. The tachypnea is an attempt for the client to remedy the acid-based imbalance by having the client blow off the excess CO2. Having the client blow off the excess CO2 can treat the acidosis. The nurse is not concerned about an expected finding. Choice D is incorrect. The client diagnosed DKA with hyperglycemia and ketones, which a urine or blood specimen may detect. Clinical hyperglycemia is a blood glucose is greater than 250 mg/dL. This is not a priority because the client has DKA, manifested by hyperglycemia, an expected finding.

The nurse is caring for a client who has a vaso-occlusive event (VOE) secondary to sickle cell disease (SCD). Which of the following would indicate the client is achieving the treatment goals? A. Decreased self-report of pain. B. Increased white blood cell (WBC) count. C. Decreased energy while ambulating. D. Increased skin tenting in the sternum.

Explanation Choice A is correct. Classic manifestations associated with a vaso-occlusive crisis include diffuse pain and signs of dehydration. Choices B, C, and D are incorrect. Increased WBCs is a classic finding for a client experiencing a VOE. This is caused by the inflammation occurring with this disease process. Fatigue is a common complaint associated with the disease process overall. This is not specific to a VOE which is manifested by hypovolemia and pain. Increased skin tenting in the sternum would be evidence of dehydration and would indicate the client is not meeting the treatment goals, which involves repleting fluids.

The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)? A. Haloperidol B. Levodopa-carbidopa C. Pramipexole D. Ropinirole

Explanation Choice A is correct. Haloperidol is a typical antipsychotic indicated in treating schizophrenia and other psychotic disorders. This medication antagonizes dopamine which is lacking in a client with Parkinson's disease. Thus, this medication would be questioned. Antipsychotics may be used in a client with Parkinson's disease because the progression of the disease often brings about hallucinations and delusions. However, an atypical antipsychotic such as pimavanserin or quetiapine is often utilized because it does not block as much dopamine. Choices B, C, and D are incorrect. All of these medications are indicated for Parkinson's disease. Levodopa is a typical medication used to treat Parkinson's disease and is commonly combined with carbidopa. Ropinirole and Pramipexole are dopamine agonists used to treat Parkinson's disease.

The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe A. morphine sulfate B. adenosine C. diltiazem D. atropine sulfate

Explanation Choice A is correct. Morphine sulfate is the drug of choice for use during tet spells. It helps calm the child down while reducing the infundibular spasm that causes right ventricular outflow obstruction and, therefore, the hypercyanotic tet spell. Choice B is incorrect. Adenosine is an antiarrhythmic drug indicated in the treatment of supraventricular tachycardia. This medication would not have an indication in the treatment for a hypercyanotic episode. Choice C is incorrect. Diltiazem, a calcium channel blocker, would be contraindicated because it would decrease cardiac output, likely worsening the tet spell. Choice D is incorrect. Atropine sulfate is an anticholinergic. It is used for several purposes, such as treating a slow heart rate or decreasing saliva production before surgery, but not for tet spells.

The nurse, assigned to triage in the emergency room, has four people check in at the same time. Which client should receive immediate priority care? A. A 29-year-old female two-day post-cesarean section that complains of a headache and leg swelling. B. A 15-year-old female with LLQ pain for three days. C. A 55-year-old male with dull RUQ pain & history of pancreatitis. D. A 2-year-old female child with pain upon urination.

Explanation Choice A is correct. This client is at risk for pre-eclampsia which is a severe condition that can lead to seizures, stroke, and other complications if not promptly treated. Pregnant women are at risk for preeclampsia anytime through pregnancy as well as 6-10 weeks post-partum. Post-partum pre-eclampsia usually develops in 48 hours post-partum but the risk can extend up to 6 to 10 weeks. Symptoms include headache, blurred vision, proteinuria, swelling in the hands/face, and high blood pressure. If treatment is started, this condition can be controlled. Choice B is incorrect. While LLQ pain for three days is concerning and warrants medical attention, it does not pose an immediate life-threatening situation compared to the potential complications of a post-cesarean section client. Choice C is incorrect. Dull RUQ pain with a history of pancreatitis is concerning but does not constitute an immediate emergency, especially without additional information on the severity of symptoms. Choice D is incorrect. Pain upon urination in a 2-year-old child is concerning and requires medical attention, but it is not an immediate emergency.

The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

Explanation Choice B is correct. A stoma that has retracted will appear concave and bowl-shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is important. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, which could lead to leakage and irritated skin. Choice A is incorrect. A narrow, flattened, or constricted stoma indicates stenosis. Choice C is incorrect. A dry, dusky, or reddish-purple stoma indicates ischemia. Choice D is incorrect. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. It should appear pinkish-red and moist.

A nurse is evaluating an 83-year-old client hospitalized after a fall. The client has not had a bowel movement for five days, and a fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction? A. Rigid, board-like abdomen B. The client has lost the urge to defecate C. Liquid stools D. Complaints of abdominal pain without distention

Explanation Choice C is correct. Clients with fecal impaction often pass watery mucus or fecal material around the impacted mass, mimicking diarrhea (also referred to as overflow diarrhea or paradoxical diarrhea). Abdominal cramping may or may not occur when the client passes this liquid stool. Due to the hardness of the stool present at the site of the client's fecal impaction, the bowel will often begin to leak out watery stool around the hardened stool. These watery stools will leak out of the rectum and present like watery diarrhea. Choice A is incorrect. An acute perforated ulcer is a frequent cause and presents with characteristic "board-like" rigidity of the abdominal wall, not fecal impaction. Choice B is incorrect. A common symptom of clients experiencing fecal impactions is the intense need to have a bowel movement.

The nurse is admitting a client newly diagnosed with acute pancreatitis. The nurse should anticipate a prescription for which medication? A. 3% saline infusion B. fentanyl C. diphenoxylate-atropine D. sucralfate

Explanation Choice B is correct. Acute pancreatitis is a painful condition that causes an individual to experience intense epigastric to periumbilical pain that is accompanied by nausea, vomiting, abdominal distention, tachypnea, tachycardia, and hypoactive bowel sounds. Adequate pain control is key in the management of pancreatitis and can be accomplished through prescribed opioids. Patient-controlled analgesia may be a beneficial option for individuals with acute pancreatitis. Alternatives to fentanyl include hydromorphone or morphine. Choice A is incorrect. 3% saline is not indicated in the management of acute pancreatitis. Part of the emergency medical care for an individual with acute pancreatitis is fluid resuscitation with isotonic fluids (lactated ringers or normal saline). Individuals with acute pancreatitis may develop hypovolemic shock if they are not promptly rehydrated. Choice C is incorrect. Diphenoxylate-atropine is an antidiarrheal medication with no involvement in pancreatitis. This medication could be theoretically harmful because this medication slows peristalsis, which may cause paralytic ileus. Individuals with pancreatitis are at risk for an ileus, which this medication could hasten. Choice D is incorrect. Sucralfate is a gastric-fortifying medication used to coat ulcers in the stomach. Gastric medications such as proton pump inhibitors are used in pancreatitis to suppress the production of gastric acid. However, gastric fortifying medications such as sucralfate do not have a mainstream role in acute pancreatitis because this condition does not directly cause an ulcer. Sucralfate is prescribed for gastric ulcers one hour before meals to make the digestion of the meal tolerable.

A cardiac intensive care unit nurse is caring for a client who underwent a coronary artery bypass graft (CABG) 24 hours ago. The nursing care plan indicates a nursing diagnosis of "decreased cardiac output related to alterations in cardiac contractility." Based on the formulated nursing diagnosis, which nursing intervention should be implemented in the nursing care plan? A. Monitor the client's arterial blood gas (ABG) continuously. B. Monitor the client's weight daily and calculate the change. C. Administer prescribed opioids. D. Monitor mediastinal chest tubes for hourly output.

Explanation Choice B is correct. Monitoring the daily weight of the client and noting any changes provides the nurse with a picture of the client's fluid volume status, which is influenced by the client's cardiac output. Weight is the most reliable indicator of fluid gain and loss. Choice A is incorrect. Monitoring the client's arterial blood gas (ABG) is also needed in the care of a post-CABG client to detect hypoxemia or acidosis, which would likely require modifications to the existing ventilation parameters. However, monitoring the client's ABG is not directly related to the nursing diagnosis of decreased cardiac output; instead, it is an intervention used to address impaired gas exchange-related nursing diagnoses.

A nurse in the psychiatric unit is administering fluoxetine together with tranylcypromine. Following the co-administration of these two medications, the nurse should monitor the client for which symptoms potentially signifying an adverse reaction from administering the combination of these two medications? A. Low blood pressure and urinary retention B. Muscle rigidity and hyperthermia C. Shortness of breath and pink, frothy sputum D. Weakness and diaphoresis

Explanation Choice B is correct. Serotonin syndrome is a potentially life-threatening condition resulting from increased central nervous system serotonergic activity. Serotonin syndrome is often characterized by muscle rigidity, hyperthermia, autonomic hyperactivity, and altered mental status. Upon noticing these symptoms, the nurse must report these symptoms to the health care provider (HCP) immediately to initiate medical intervention. Choice A is incorrect. Low blood pressure and urinary retention are not symptoms associated with serotonin syndrome. Choice C is incorrect. Shortness of breath and pink, frothy sputum are symptoms typically related to pulmonary edema, not serotonin syndrome.

This nurse is caring for a client who is receiving prescribed sitagliptin. Which assessment findings indicate the client is experiencing a severe adverse effect? A. Nasal stuffiness B. Abdominal pain C. Headache D. Occasional dry cough

Explanation Choice B is correct. Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. The most common adverse effect associated with this medication is pancreatitis. Pancreatitis is manifested by abdominal pain, nausea, and persistent vomiting. Choices A, C, and D are incorrect. Sitagliptin may cause headaches, nasal stuffiness, and an occasional dry cough. Respiratory congestion is common with this medication, but it is not as severe as a client with pancreatitis, which could die without treatment. Pancreatitis causes significant dehydration, which, if untreated, may lead to hypovolemic shock.

The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed A. intravenous hydromorphone for chronic back pain and is drowsy. B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw. C. intravenous dexamethasone for chronic bronchitis reporting perineal itching. D. nitroglycerin infusion for chest pain and reports a headache.

Explanation Choice B is correct. This client reports follow-up because dystonic movements of the face are a significant adverse reaction to metoclopramide. Metoclopramide is a dopaminergic and carries a risk for extrapyramidal syndrome. The nurse can avoid having the client experience this by administering this medication with prescribed diphenhydramine and diluting metoclopramide when giving it parenterally. Choice A is incorrect. Drowsiness with opioids, like hydromorphone, is expected. It is sedation that is concerning. Drowsiness is a state where the client can quickly awaken, where sedation requires more noxious stimuli for arousal. Sedation is critical to recognize because it occurs right before respiratory depression. Choice C is incorrect. Intravenous dexamethasone for chronic bronchitis carries a risk of perineal itching, which is uncomfortable for the client but not life-threatening. This can be avoided by diluting the medication and infusing the medication slowly. Dexamethasone is a steroid used to treat inflammatory conditions. Choice D is incorrect. Intravenous nitroglycerin is a vasodilating medication where a headache is expected. This client does not require follow-up because this is an expected finding.

The nurse is caring for an undernourished client who recently began receiving total parenteral nutrition (TPN). Which laboratory value would indicate that the client is responding to treatment? A. Fasting blood glucose: 129 mg/dL (7.15 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L] B. White blood cell (WBC) count: 12,000 mm3 (0.012×10⁹/L) [4,000-11,000 cells/µL,3.5-10.5 × 10⁹/L] C. Albumin: 3.6 g/dL [3.5-5 g/dL] D. Urine specific gravity: 1.040 [1.005-1.030]

Explanation Choice C is correct. In cases when the gastrointestinal system must be bypassed, TPN must be used to provide the client with parenteral nutrients. In general, serum albumin is one laboratory value that may be decreased in the presence of undernourishment. The therapeutic range for albumin is 3.5-5 g/dL. Amino acids are essential to TPN, helping increase the client's serum albumin levels. Thus, the client's result of 3.6 g/dL would indicate that the client is responding to treatment. Choice A is incorrect. The base solution of TPN contains a high dextrose concentration. This high dextrose level may cause a client to exhibit signs and symptoms of hyperglycemia and, as such, exhibit elevated blood glucose readings. A therapeutic fasting blood glucose for adults ranges between 70-110 mg/dL. Although the client's fasting blood glucose level of 129 mg/dL is abnormal, this result should not be construed as the client responding to TPN treatment. Choice B is incorrect. TPN is administered via a central vascular access device (usually the subclavian or internal jugular veins). The client's risk for a central line-associated bloodstream infection is elevated due to the use of a central venous access device and the high glucose content of TPN. A normal WBC count for adults is 5,000-10,000 mm3. Not only would an elevated WBC of 12,000 mm3 not be indicative that the client is responding to the administration of TPN, but the elevated WBC would also require the nurse to immediately investigate the cause of the WBC elevation, as this elevation is indicative of infection and/or inflammation.

The nurse is caring for a client with a breast tumor. The client reports trouble breathing, a puffy face/neck, nasal congestion, and a raspy voice. The nurse would suspect which of the following? A. Spinal cord compression B. Non-Hodgkin's Lymphoma (NHL) C. Superior vena cava syndrome D. Shock

Explanation Choice C is correct. This patient's tumor originates in the breast. Breast cancer may spread locally into the chest wall and lymph nodes. Due to its proximity to the superior vena cava (SVC), a locally advanced tumor or metastatic lymph node enlargement in the chest may obstruct blood flow to and from the superior vena cava. Such an obstruction results in venous congestion (puffiness in the face/ neck) and jugular-venous distension. Frequent clinical features of venous congestion in superior vena cava syndrome include blurred vision, hoarse voice, stridor, dyspnea, and nasal congestion. Choices A, B, and D are incorrect. These do not explain the patient's presentation. Spinal cord compression (choice A) may present with motor and sensory deficits, not puffy face and dyspnea. Non-Hodgkin's lymphoma (choice B) may cause SVC obstruction. However, the client has breast cancer, likely responsible for the SVC obstruction, not an occult lymphoma. Shock (choice D) presents with hypotension and impaired perfusion, not a puffy face and stridor.

The nurse is preparing to apply a prescribed nitroglycerin ointment to a client. The nurse should A. apply it only to the client's upper chest. B. rub the ointment into the client's skin until it disappears. C. rotate the application sites. D. cover the ointment with a gauze dressing.

Explanation Choice C is correct. Topical nitroglycerin is used to help prevent/ treat anginal symptoms in coronary artery disease. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. Choice A is incorrect. The nitroglycerin ointment may be applied anywhere on the anatomy as long as it is dry, clean, the skin is intact, and is hairless. It is not limited to just the client's chest. Choice B is incorrect. The ointment should not be rubbed into the client's skin. This would enhance its absorption, exposing the client to the potential for severe hypotension. Choice D is incorrect. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin.

The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client A. trendelenburg's position. B. semi-Fowler's position. C. left lateral position. D. right lateral with the head of the bed lowered.

Explanation Choice C is correct. When administering an enema for fecal impaction, the nurse should place the patient in the left lateral position. This allows the medicine to move naturally throughout the colon. Choice A is incorrect. Trendelenburg's position would not allow the fluid from the enema to flow throughout the colon. Choice B is incorrect. Semi-fowler's position works against gravity when giving an enema. This position is not recommended. Choice D is incorrect. Lowering the head of the bed is not necessary and would not be appropriate during this procedure. The client should be positioned in the left-lateral position, not right.

The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for Incorrect Correct Answer(s): D A. enalapril [22%] B. regular insulin [5%] C. levothyroxine [44%] D. dexamethasone

Explanation Choice D is correct. A thyroid storm is a medical emergency and is a complication of hyperthyroidism. Manifestations of a thyroid storm include fever, tachycardia, hypertension, and cardiac dysrhythmias. Emergent treatments for a thyroid storm include prescribed dexamethasone (corticosteroids inhibit the peripheral conversion of T4 into T3), propranolol (to reduce heart rate and blood pressure), and an antithyroid medication such as propylthiouracil. Choice A is incorrect. Enalapril is an ACE inhibitor and has no role in treating a thyroid storm. While this medication may ameliorate hypertension found with a thyroid storm, it is not the preferred drug because both tachycardia and hypertension are present in this endocrine emergency. Thus, the prescribed propranolol should be used. ACE inhibitors are preferred drugs for heart failure and hypertension. Choice B is incorrect. Regular insulin is not used in the management of a thyroid storm. Regular insulin is one of the two treatments for diabetic ketoacidosis. Choice C is incorrect. Levothyroxine is the treatment for hypothyroidism. Giving this medication would be catastrophic because it would further increase circulating thyroid levels.

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobiais an unreasonable fear of: A. Social interactions B. Clowns C. Crowds D. Cats

Explanation Choice D is correct. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear. Choice A is incorrect. A fear of social interactions is referred to as a social phobia. Social interaction phobias are typically treated with exposure therapy, antidepressants, or beta-blockers. Choice B is incorrect. The fear of clowns, which is referred to as coulrophobia, is typically treated with exposure therapy. Choice C is incorrect. The fear of crowds, which is referred to as enochlophobia, is also typically treated with exposure therapy.

A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions? A. Air travel will not be possible due to airport screening equipment. B. You will need to discard any radios at home that have antennas. C. Computed tomography (CT) scans are not permitted with this device. D. You should use your cellular phone on the opposite side of the generator.

Explanation Choice D is correct. For a client with a pacemaker, it is recommended that they talk on their cellular phone opposite of the pulse generator to prevent electromagnetic interference. Choices A, B, and C are incorrect. Air travel is not prohibited for a client with a pacemaker. They should carry their medical alert card if they are stopped by airport security. Discarding radios and other home appliances is unnecessary as they do not cause any interference. CT scans are permitted for a client with a pacemaker. Diagnostics with an MRI are contraindicated.

The nurse is supervising a student nurse perform an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order? A. Auscultation, inspection, palpation, percussion B. Inspection, palpation, percussion, auscultation C. Palpation, percussion, inspection, auscultation D. Inspection, auscultation, percussion, palpation

Explanation Choice D is correct. Inspection is always performed first. Auscultation of the abdomen must be performed before percussion and palpation to prevent the alteration of bowel sounds. When palpating the abdomen, any area(s) of tenderness should be palpated last to prevent the client from guarding their abdomen. Choices A, B, and C are incorrect. Performing percussion and palpation before auscultation may cause falsely increased bowel sounds by stimulating bowel activity. An inspection does not interfere with the rest of the abdominal exam. Therefore, inspection should be performed first, followed by auscultation, percussion, and palpation.

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

Explanation Choice D is correct. Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect. Choices A, B, and C are incorrect. Risperidone increases prolactin levels and weight. Atypical antipsychotics, unfortunately, carry this consequential effect that may induce metabolic syndrome. Risperidone would assist in providing mood stability - not increased lability. Adversely, risperidone may cause extrapyramidal side effects causing gait disturbances.

The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below. A. Pulmonary embolism B. Hypovolemic shock C. Disseminated intravascular coagulation (DIC) D. Pulmonary edema

Explanation Choice D is correct. The client's history of congestive heart failure significantly increases the risk for pulmonary edema. The vital signs show respiratory distress (tachypnea, hypoxia, and tachycardia), which supports the complication of pulmonary edema. Choices A, B, and C are incorrect. These conditions are not as likely to occur in an individual with CHF. While CHF places a client at higher risk for venous thromboembolism, it is reasonable for the nurse to first suspect the most common complication, which is pulmonary edema. DIC is quite rare and is highly unlikely. Hypovolemic shock is not plausible because the client with CHF typically has a problem with fluid volume excess, not a deficit.

The nurse is caring for a post-abdominal surgery client four days after surgery. The nurse notes a temperature of 37°C, no complaints of pain at the incision site or elsewhere, a dry and intact wound dressing, and hypoactive bowel sounds in all four quadrants. Based on all the assessment data, what conclusion can the nurse make? A. The client's wound is becoming infected. B. Pain relief measures should be implemented. C. There are no current concerns for the client. D. Additional gastrointestinal assessments should be performed.

Explanation Choice D is correct. The nurse should use all the data gathered to analyze the situation. The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to perform further assessments (i.e., evaluation of last bowel movement, questions regarding dietary intake, abdominal distention, etc.) to determine if there are any impending gastrointestinal problems for the client and if any treatments need to be initiated. Choice A is incorrect. The client's wound dressing is dry and intact. The client is afebrile and denies pain at the incision site. Therefore, based on the assessment data, there is no indication that the client's wound is becoming or is currently infected. Choice B is incorrect. Since the client denies pain and there are no indications of objective signs of pain, there is no need to implement pain relief measures. Choice C is incorrect. A nurse assessing a client four days after the client underwent abdominal surgery should anticipate hearing normoactive bowel sounds in all four quadrants. Therefore, a finding of hypoactive bowel sounds in all four quadrants is an abnormal finding, thus signifying a potential problem/concern for this client.

The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply. Aspirin overdose Pneumothorax Opioid overdose Anxiety Renal disease

Explanation Choices B and C are correct. Respiratory acidosis is caused by the inability to expel carbon dioxide through airway obstruction or decreased ventilation. A pneumothorax causes shallow breathing, which causes the retention of CO2 (an acid). Opioids are central nervous system depressants. When the client is exposed to toxic levels, the effect causes hypoventilation and the retention of CO2. Choices A, D, and E are incorrect. An aspirin overdose stimulates causes metabolic acidosis because excessive ingestion leads to an increase in the hydrogen ion concentration. Renal disease also causes metabolic acidosis because the kidneys are unable to recycle bicarbonate. Anxiety causes a client to increase their ventilations and potentially trigger hyperventilation. Hyperventilation would cause the client to exhale a significant amount of CO2, leaving them in a respiratory alkalotic state.

boarderline personality disorder

Explanation The client's clinical picture is strongly suggestive of borderline personality disorder. BPD has a defense mechanism of splitting where they may view an individual(s) as all good or all bad. This is demonstrated in the client's view of the male gender. The client stated she sought psychiatric care previously and then devalued her previous psychiatrist. Devaluation, splitting, denial, and projection are common defense mechanisms used in this disorder. The client reports two previous parasuicide attempts with the intent to get attention; this is consistent with BPD as they seek attention even by engaging in self-mutilation The client engaging in indiscriminate sex with others is a finding stemming from the impulsivity found in this disorder. It is unlikely that this client has antisocial personality disorder because no evidence of illegal behavior, or lack of empathy, was in the client's history. Narcissism is not likely because individuals with this PD have a self-inflated view of themselves that is not necessarily unstable. Nor is parasuicide common in this disorder. This client is quite social and expressed no disinterest in others; this is not found in schizoid personality disorder. This client must be assessed for suicide. Suicide is a priority assessment for any client, and considering the client's previous attempts, it is even more critical to evaluate the client for any thoughts of self-harm. The other assessments are not a priority because a client suicide assessment is directly linked to the client's safety. No medication is approved to treat personality disorders. Instead, therapy is the cornerstone treatment. For clients with BPD, dialectical behavioral therapy (DBT) is used, which focuses on emotional regulation and mature defense mechanisms.

The nurse is caring for a client with congestive heart failure Using the ISBAR format, click to highlight the text that expresses the nurses' recommendation to the physician. 2030 - Client reported a cough and shortness of breath while resting. The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees. Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air. Lung sounds had crackles in all fields. A rapid response was called because of the unstable vital signs. Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.

Explanation The nurse notifying the physician to obtain orders is a recommendation. The nurse explicitly outlined specific orders necessary for this client's care. The client's situation is best described by his reports of coughing, shortness of breath, and rapid response being called. Vital signs and the breath sounds collected would be classified as the assessment.

The nurse has instructed self-management strategies for a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client would indicate a correct understanding of the teaching? A. "It's much better for me to wear loose-fitting clothes right now." B. "I stopped eating grilled chicken and now eat more ground hamburger." C. "If I wake up with GERD symptoms, I should lower the head of my bed while sleeping." D. "I should take my prescribed omeprazole after meals."

ice A is correct. The client with GERD is advised to avoid tight clothing and wear loose-fitting clothing. This type of clothing may increase pressure in the abdomen, forcing stomach contents into the esophagus. Choice B is incorrect. The client with GERD is encouraged to eat a low-fat, high-fiber diet. Ground hamburger has a high-fat content and may stimulate excess gastric acid production. Dietary modifications for GERD include avoiding excessive caffeine, chocolate, alcohol, peppermint, and fatty foods. Choice C is incorrect. If a client awakens with GERD symptoms, they should raise the head of their bed to reduce the reflux of gastric acid. Sleeping on more pillows is not enough for them as that increases neck flexion. Often, the client's bed will need to be modified so the head of the bed is elevated six to eight inches. Choice D is incorrect. Omeprazole is a proton pump inhibitor. This medication is intended to be taken on an empty stomach in the morning. This medication should not be taken with any other medication to avoid decreasing absorption of those medications.

Cystitis

inflammation of the bladder, usually caused by a bladder infection. It's a common type of urinary tract infection (UTI), particularly in women, and is usually more of a nuisance than a cause for serious concern. Mild cases will often get better by themselves within a few days.