ATI quiz questions Exam 2

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the providers prescription? A. A client who has epistaxis B. A client who has amyotrophic lateral sclerosis C. A client who has pneumonia D. A client who has emphysema

A. A client who has epistaxis The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding. The nurse should identify that a client who has amyotrophic lateral sclerosis can receive nasopharyngeal suctioning. The nurse should identify that a client who has pneumonia can receive nasopharyngeal suctioning. The nurse should identify that a client who has emphysema can receive nasopharyngeal suctioning.

A nurse is caring for four clients. Which of the following clients is at greater risk for pulmonary embolism? A. A client who is 48 hr postoperative following a total hip arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications. A client who is postoperative following an open surgical appendectomy is at a low risk for developing a pulmonary embolism. The greatest risk to this client is peritonitis. There is another client who is at greater risk for developing a pulmonary embolism. A client who is postoperative following an open reduction external fixation of the right radius is at a low risk for pulmonary embolism. The greatest risk to this client is neurovascular compromise. There is another client who is at greater risk for developing a pulmonary embolism. A client who is 4 hr postoperative following a laparoscopic cholecystectomy is at a low risk for pulmonary embolism. Some clients develop pain from carbon dioxide retention in the abdomen following a laparoscopic cholecystectomy. There is another client who is at greater risk for developing a pulmonary embolism.

A nurse is developing a plan of care for a client who has active TB. Which of the following isolation precautions should the nurse include in the plan? A. Airborne B. Neutropenic C. Contact D. Droplet

A. Airborne The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask. The nurse should initiate protective environment precautions for clients who need protection from outside infections, such as clients who are receiving bone marrow transplants. The nurse should initiate contact precautions for clients who have infections that are transmitted by direct contact, such as scabies and methicillin-resistant Staphylococcus aureus (MRSA). The nurse should initiate droplet precautions for clients who have infections that are transmitted by large droplets in the air and by being within 3 feet of a client, such as influenza. Staff and visitors should wear a surgical mask when within 3 feet of the client, and the nurse should assign dedicated equipment to the client.

A nurse in an ED is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen. B. Increase the rate of IV fluids. C. Administer pain medication. D. Initiate cardiac monitoring.

A. Apply supplemental oxygen. (ABCs) When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen. The nurse should increase the rate of the IV fluids to increase cardiac output. The nurse should administer pain medication to decrease discomfort and anxiety. The nurse should initiate cardiac monitoring because the client is at risk for dysrhythmias and right ventricular failure. However, another action is the nurse's priority.

A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema

A. Blood-tinged sputum The nurse should expect blood-tinged sputum secondary to bleeding from the tumor. The nurse should expect an increase, rather than a decrease, in tactile fremitus because of tumor tissue or fluid replacing airspaces. The nurse should expect a dullness or flat sound, rather than resonance, upon percussion because of the presence of masses in the lungs. The nurse should expect cyanosis of the lips and fingertips. However, peripheral edema is not an expected finding for a client who has lung cancer.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should ID that which of the following assessments is the priority? A. Presence of gag reflex B. Pain level rating using a 0 to 10 scale C. Hydration status D. Appearance of the IV insertion site

A. Presence of gag reflex The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex. The client is at risk for increased pain because of the introduction of the scope into the trachea. A client who is postoperative following a bronchoscopy has been NPO for 4 to 8 hr, which increases the client's risk for dehydration. The nurse should assess the client's hydration status. IV medication given for moderate sedation places the client at risk for phlebitis. Although the nurse should assess for redness, warmth, and drainage at the IV insertion site, another assessment is the priority.

A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (Select all that apply.) A. Wear goggles and a mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. C. Instruct the client to take deep breaths during the procedure. D. Position the client laterally on the affected side before the procedure. E. Apply pressure to the site after the procedure.

A. Wear goggles and a mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. E. Apply pressure to the site after the procedure. Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.

A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse report to the provider? An asymmetrical papule that is pigmented A patch of silvery-white scales with a red epidermal base A collection of irregular, dry papules that are black An elevated red lesion that arises from a scar

An asymmetrical papule that is pigmented The nurse should identify an asymmetrical papule that is pigmented as an indication of a malignant melanoma. The nurse should report the client's skin change to the provider.

A nurse is providing teaching to a client who has Hodgkin's Lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include?

Avoid direct sun exposure to the skin The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation. The nurse should instruct the client to pat, rather than rub, the skin dry to avoid damage to the skin. The nurse should instruct the client not to remove the ink or dye markings because they identify the location of the site that is being radiated. The nurse should instruct the client to cleanse their skin with mild soap and water because the client's skin is fragile due to the external radiation. The client should avoid antibacterial soaps because they can irritate the skin.

A charge nurse is reviewing the care of a client who has a chest tub connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B. "I will notify the provider if there is continuous bubbling in the water seal chamber." C. "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." "D. I will notify the provider if there are several small, dark-red blood clots in the tubing."

B. "I will notify the provider if there is continuous bubbling in the water seal chamber." Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider. Fluctuation of drainage in the tubing with inspiration is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client. However, this finding does not require notification of the provider. Drainage of 60 mL in the first hour after surgery is an expected finding for a client who has a chest tube. The nurse should continue to monitor the client, but notification of the provider is not required at this time. Small, dark-red blood clots are an expected finding for a client who is postoperative after chest surgery. The nurse should continue to monitor the client, but notification of the provider is not required at this time.

A nurse is assessing a client who is 4 hr postpoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased oxygen saturation C. Urinary retention D. Increased pain level

B. Decreased oxygen saturation When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction. Bleeding at the surgical site requires intervention by the nurse because hemorrhage is a complication of the procedure. Urinary retention is a complication following a surgical procedure using general anesthesia and requires assessment by the nurse. An increased pain level is a complication following a surgical procedure and requires intervention by the nurse to promote comfort. However, there is another finding that is the priority for the nurse to report to the provider.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

B. Elevated temperature The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections. Rhonchi on inspiration is an expected finding for clients who have emphysema. Chronic overinflation of the lungs and flattening of the diaphragm lead to the appearance of a barrel-shaped chest, which is an expected finding of emphysema. Diminished breath sounds are an expected finding for clients who have emphysema due to limited chest excursion and air trapping.

A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote affective breathing? A. Lateral position with a pillow at the back and over the chest to support the arm B. High-Fowler's position with the arms supported on the overbed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the head of the bed elevated to 15°

B. High-Fowler's position with the arms supported on the overbed table The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table. A lateral position promotes alignment of the back and can be a good position for sleeping. However, this position does not promote maximum chest expansion to facilitate breathing. The semi-Fowler's position, which has the head and trunk elevated to a 30° to 45° angle, does not promote maximum chest expansion to facilitate breathing. Supine position allows the diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise chest expansion. This position does not promote maximum chest expansion to facilitate breathing.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of O2? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

B. Nonrebreather mask The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2. The oxygen flow rate via nasal cannula is 1 to 6 L/min and provides oxygen at a concentration of 24% to 44%. It does not provide the highest level of oxygen for a client who is in respiratory distress. A simple face mask delivers oxygen concentrations between 40% and 60% and has open exhalation ports that allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress. The partial rebreather mask delivers oxygen concentrations of 60% to 75%. The exhalation ports are open, which will allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress.

A nurse is a providers office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with exertion

B. Productive cough with green sputum When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. An increased anterior-posterior chest diameter, or barrel chest, is nonurgent because it is an expected finding for a client who has COPD. Clubbing of the fingers is nonurgent because it is an expected finding for a client who has COPD with chronic low arterial oxygen levels. Pursed-lip breathing is nonurgent because it is an expected finding for a client who has COPD. Clients who have COPD use pursed-lip breathing to improve oxygenation when performing physical activity. Therefore, there is another finding that is the nurse's priority to report.

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A. I will use clean technique when suctioning a client's endotracheal tube." B."I will use a rotating motion when removing the suction catheter." C. "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D. "I will suction a client's endotracheal tube every 2 hours."

B."I will use a rotating motion when removing the suction catheter." The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway. The nurse should use sterile technique when performing endotracheal suctioning to avoid the introduction of pathogens into the sterile respiratory system. The nurse should suction the endotracheal tube prior to suctioning the nonsterile oropharyngeal cavity to prevent cross contamination. The nurse should suction the endotracheal tube only when needed. Routine suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms.

A nurse is teaching a client who is receiving chemo. The client's lab results indicate bone marrow suppression. Which of the following instructions should the nurse include in the teaching? 'Take aspirin for minor aches and pains." "Clean your toothbrush with warm water weekly." "Bathe with an antimicrobial soap twice per day." "Wear clothing that will minimize sun exposure."

Bathe with an antimicrobial soap twice per day The nurse should instruct the client to bathe twice per day with an antimicrobial soap to decrease their exposure to micro-organisms. A client who has bone marrow suppression is at increased risk for infection. The nurse should instruct the client not to take aspirin or other platelet inhibitors because a client who has bone marrow suppression is at increased risk for bleeding. The nurse should instruct the client to clean their toothbrush weekly with liquid bleach or run the toothbrush through the dishwasher to destroy micro-organisms. A client who has bone marrow suppression is at increased risk for infection. Sun exposure does not pose a risk to a client who is receiving chemotherapy. However, the nurse should instruct the client to use skin protection when spending time in the sun. Furthermore, the nurse should instruct the client to wear clothing that does not rub to prevent bruising or bleeding.

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." C. "I should remove the old twill ties after the new ties are in place." D. "I should apply suction while inserting the catheter into my tracheostomy tube."

C. "I should remove the old twill ties after the new ties are in place." As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation. The client should use gauze squares moistened in 0.9% sodium chloride to cleanse around the stoma or, if prescribed, half-strength hydrogen peroxide can be used on the skin to clean crusty areas. Using a cotton-tipped applicator places the client at risk for aspiration of cotton fibers. Also, the client should be careful not to get hydrogen peroxide into the tracheal stoma. Cutting a 4-inch square gauze dressing places the client at risk for aspiration of gauze fibers. The client should apply a commercially-prepared split gauze tracheostomy dressing under the flange of the tracheostomy tube. The client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma.

A nurse is performing a breast exam on a female client who is pregnant. Which of the following findings should the nurse report to the provider? Slight asymmetrical breast size Breast tissue with an orange-peel appearance Nipple inversion of one breast since puberty Elevated Montgomery's glands

Breast tissue with an orange peel appearance The nurse should report an orange-peel appearance of the client's skin because this can indicate a blockage of lymph channels, which is a manifestation of advanced breast cancer. The nurse should not report elevated Montgomery's glands because this is an expected finding for a client who is pregnant. The nurse should report a recent inversion of a client's nipple because it can indicate a malignant tumor; however, the nurse does not need to report a nipple inversion since puberty. Slight asymmetrical breast size The nurse should identify that slight asymmetrical breast size is a common finding. The nurse should report a significant difference in breast size because this can indicate inflammation or a tumor.

A nurse is providing discharge teaching to client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears is an adverse effect of this medication." B. "Have your skin test repeated in 4 months to show a positive result." C. "Expect your urine and other secretions to be orange while taking this medication." D. "Remember to take this medication with a sip of water just before your first bite of each meal."

C. "Expect your urine and other secretions to be orange while taking this medication." The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise. Tinnitus is not an adverse effect of rifampin. However, the nurse should inform the client that rifampin can cause gastrointestinal disturbances. The nurse should inform the client that the purified protein derivative skin test results will continue to show positive, even after the disease is no longer active. The nurse should instruct the client to take rifampin 1 hr before or 2 hr after a meal.

A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A. Blood pressure B. Capillary refill C. Arterial blood gases D. Heart rate

C. Arterial blood gases (ABCs) When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance. The nurse should monitor the client's blood pressure, which provides important information regarding the client's circulatory status. The nurse should monitor the client's capillary refill, which provides information about peripheral circulation. The nurse should monitor the client's heart rate, which provides important information regarding the client's circulatory status. However, another assessment is the priority.

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

C. Artificial airway cuff leak An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound. An excess of secretions in the airway causes the high-pressure alarm to sound. Kinks in the tubing can cause an obstruction, which causes the high-pressure alarm to sound. Biting on the endotracheal tube causes the high-pressure alarm to sound.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal set C. Container of sterile water D. Nonadherent pads

C. Container of sterile water The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax. The nurse should empty the collection chamber in the drainage system or replace it before the drainage reaches the bottom of the tube. Therefore, it is not necessary to have an extra drainage system easily accessible for the client. The nurse should retrieve a suture removal set when the chest tube is removed. However, it is not necessary to have a suture removal set easily accessible for the client. The nurse should provide nonadherent, airtight, sterile petrolatum gauze when the chest tube is removed. However, it is not necessary to have to have nonadherent pads easily accessible for the client. If the chest tube is accidentally removed, the nurse should cover the wound with dry, sterile gauze.

A nurse is caring for a client who is 1 hr postop following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3° C (99.1° F)

C. Persistent cough When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency. Pallor is an important finding because it can indicate blood loss. Insertion site pain is an important finding because untreated pain can result in shallow respirations. A temperature of 37.3° C (99.1° F) is an important finding because it can indicate infection. However, another assessment finding is the nurse's priority.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals. B. Have the client sit up in a chair for 2-hr periods three times per day. C. Provide a diet that is high in calories and protein. D. Combine activities to allow for longer rest periods between activities.

C. Provide a diet that is high in calories and protein. The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates. The nurse should schedule respiratory treatments before meals. The nurse should provide short periods of activity frequently throughout the day. The nurse should schedule activities that are short in duration with adequate rest periods in between to prevent fatigue.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis

C. Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis. The nurse should monitor the client for hypokalemia, which is a potential adverse effect of albuterol. The nurse should monitor the client for a decrease in dyspnea. A decrease in dyspnea is a therapeutic effect of albuterol, not an adverse effect. The nurse should monitor a client who is taking an inhaled glucocorticoid, such as beclomethasone, for candidiasis.

A nurse is assessing a client who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Decreased fremitus B. SaO2 95% on room air C. Temperature 38.8° C (101.8° F) D. Bradypnea

C. Temperature 38.8° C (101.8° F) An elevated temperature is an expected finding for a client who has bacterial pneumonia. Increased fremitus is an expected finding for a client who has bacterial pneumonia. An oxygen saturation level of lower than 95% is an expected finding for a client who has bacterial pneumonia. Tachypnea is an expected finding for a client who has bacterial pneumonia.

A nurse is providing teaching to a client who is scheduled for a Pap test. The nurse should inform the client that she is being tested for which of the following? Uterine cancer Cervical cancer Ovarian cysts Fibroids

Cervical Cancer The nurse should inform the client that a Pap test is used to screen for cervical cancer. The nurse should inform the client that a transvaginal ultrasound, along with an endometrial biopsy, is used to screen for uterine cancer. The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for ovarian cysts. The nurse should inform the client that a pelvic examination, along with a transvaginal ultrasound, is used to screen for fibroids.

A nurse is providing teaching to a client who has chronic asthma and a new script for montelukast. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my heart rate every day while taking this medication." B. "I will make sure I have this medication with me at all times." C. "I will need to carefully rinse my mouth after I take this medication." D. "I will take this medication every night even if I don't have symptoms."

D. "I will take this medication every night even if I don't have symptoms." Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening. Clients who take short-acting beta2 agonists should monitor their heart rate because tachycardia is an adverse effect of these medications. However, tachycardia is not an adverse effect of montelukast. Clients who take short-acting beta2 agonists should have their medication with them at all times because these medications are used to relieve bronchoconstriction during an asthma attack. Clients who take inhaled glucocorticoids should rinse their mouths and gargle after use because oral candidiasis is an adverse effect of these medications.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority? A. Provide a quiet environment. B. Encourage use of incentive C. spirometry every 1 to 2 hr. C. Obtain a blood sample for electrolyte study. D. Administer heparin via continuous IV infusion.

D. Administer heparin via continuous IV infusion. (ABCs) When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention. The nurse should provide a client who has a pulmonary embolism with a quiet environment to promote rest and conserve oxygen. The nurse should encourage a client who has a pulmonary embolism to use an incentive spirometer to improve oxygenation and ventilation. The nurse should obtain a blood sample from a client who has a pulmonary embolism to send to the laboratory for coagulation studies, electrolyte levels, and a CBC. However, another intervention is the nurse's priority.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prednisone C. Fluticasone/salmeterol D. Albuterol

D. Albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack. (rescue) The nurse should administer cromolyn sodium, an anti-inflammatory agent, for maintenance therapy of asthma, rather than for treatment during an acute asthma attack. The nurse should administer prednisone following an acute attack to promote anti-inflammatory effects. The nurse should administer fluticasone/salmeterol for maintenance therapy of asthma because it combines a glucocorticoid and a long-acting beta2-adrenergic agonist.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24 mEq/L D. Intercostal retractions

D. Intercostal retractions (bad news bears) The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS. The nurse should identify that decreased bowel sounds is an expected finding for a client who has ARDS. The nurse should identify that an oxygen saturation of 92% is within the expected reference range for a client who has ARDS. The nurse should identify that a CO2 of 24 mEq/L is within the expected reference range for a client who has ARDS.

A nurse in an ED is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? A. Arterial pH 7.50 B. PaCO2 25 mm Hg C. SaO2 92% D. PaO2 58 mm Hg

D. PaO2 58 mm Hg The nurse should expect the client to have lower partial pressures of oxygen. The nurse should expect the client's pH level to decrease because respiratory failure can cause respiratory acidosis. The nurse should expect the client's carbon dioxide level to rise with acute respiratory failure. The nurse should expect the client to have a decrease in oxygen saturation.

A nurse working in an emergency department is caring for a client following an acute chest trauma. Which of the following findings should indicate the the nurse that the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

D. Tracheal deviation to the unaffected side The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side. A client who has a tension pneumothorax will not have collapsed neck veins on the affected side. Distended neck veins are an expected finding. A client who has a tension pneumothorax will not have collapsed neck veins on the unaffected side secondary to a tension pneumothorax. Distended neck veins are an expected finding. The trachea of a client who has a tension pneumothorax does not deviate to the affected side.

A nurse is caring for a client who is postop and has a RR of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

D. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis. A. These ABG values indicate respiratory alkalosis. B. These ABG values indicate metabolic alkalosis. C. These ABG values indicate metabolic acidosis.

A nurse is caring for a client who has an elevated prostate specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? Palpation of testes Human chorionic gonadotropin level Digital rectal examination Pelvic ultrasound

Digital Rectal Exam The nurse should recognize that a digital rectal examination is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer. The nurse should recognize that human chorionic gonadotropin is used to diagnose testicular cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. The nurse should recognize that palpation of a client's testes is used to screen for testicular cancer, not prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer. The nurse should recognize that a transrectal ultrasound, not a pelvic ultrasound, is used to screen for prostate cancer. An elevated prostate-specific antigen level is a manifestation of prostate cancer.

A nurse is caring for a client who has Non Hodgkin's Lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? Loss of body hair Report of anorexia Mucositis of the oral cavity Erythema at the IV insertion site

Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding. loss of body hair, anorexia and weight loss, and sores in the mouth are expected adverse effects of chemotherapy

A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include? Testicular cancer is more common in males who are older than 65. With early treatment, the survival rate is 50%. Examine the testicles immediately after showering. Schedule an annual ultrasound to screen for testicular cancer.

Examine the testicles immediately after showering. The client should perform a testicular self-examination on a monthly basis by examining the testicles after a bath or shower to allow for easier palpation. Males who are between the ages of 15 to 39 have an increased risk for developing testicular cancer. The survival rate for testicular cancer, when diagnosed and treated early, is nearly 100%. Ultrasounds are not used to screen for testicular cancer. However, if there is a change in testicular size, shape, or texture, the provider might schedule an ultrasound.

A nurse is providing teaching to a group of clients regarding prevention of skin cancer. Which of the following risk factors should the nurse include in the teaching? Light skin pigmentation Psoriasis History of frostbite Immunodeficiency disorder

Light skin pigmentation The nurse should inform the clients that light skin pigmentation is a risk factor for the development of skin cancer.

A nurse is reviewing the lab report for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect? Overgrowth of B-lymphocyte plasma cells Reed-Sternberg cells Epstein-Barr virus Overproduction of blast phase cells

Reed Sternberg cells The nurse should expect to find Reed-Sternberg cells, which are cancer cells specific to a client who has Hodgkin's lymphoma, in the client's lymph nodes. The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte plasma cells. The nurse should recognize that the Epstein-Barr virus is associated with the development of Burkitt's lymphoma and Hodgkin's lymphoma. However, it is not a diagnostic finding after the disease has occurred. The nurse should expect a client who has leukemia to have an overproduction of blast phase cells.

A nurse is caring for a client who has leukemia and a platelet count of 48,000. Which of the following actions should the nurse take? Provide the client with a diet that is low in vitamin K. Place the client on contact precautions. Administer subcutaneous epoetin alfa. Test the client's urine and stool for occult blood.

Test the client's urine and stool for occult blood A client who is thrombocytopenic is at risk for occult bleeding. Therefore, the nurse should test the client's urine and stool for occult blood. The nurse should not provide the client with a diet that is low in vitamin K because this can further decrease coagulation. The nurse should recognize that thrombocytopenia does not require contact precautions. However, the client might require neutropenic precautions and a private room. The nurse should not administer epoetin alfa because it is used to treat anemia and is not effective in increasing platelet production.

A nurse is teaching the parent of a child about administration guidelines for the HPV vaccine. Which of the following information should the nurse include? One dose is administered at birth and another is administered at age 5. The vaccine does not protect males. The vaccine protects against chlamydia. Three doses are administered to adolescents who start the series after age 15.

Three doses are administered to adolescents who start the series after age 15. The nurse should inform the parent that the HPV vaccine is recommended for children beginning at age 11 or 12 years. Children who receive the first dose before age 15 should receive two doses of the HPV vaccine. Adolescents who receive the first dose after age 15 should receive three doses of the HPV vaccine.

A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests? Indirect laryngoscopy Chest x-ray Throat culture Monospot test

Throat culture The nurse should recognize that a throat culture is used to confirm a diagnosis of bacterial pharyngitis by identifying specific micro-organisms present in the pharynx. The nurse should recognize that a monospot test is used to detect mononucleosis, which is a viral infection. The nurse should recognize that a chest x-ray is used to identify disorders such as pneumonia and pleural effusions. The nurse should recognize that an indirect laryngoscopy is used to visually assess pharyngeal structures.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? a. Skin turgor b. Urine output c. Weight d. Mental status

d. Mental status The greatest risk to this client is injury from a fall due to a decline in their mental status. Therefore, assessing the client's mental status is the nurse's priority.

A nurse is reviewing the daily lab results for a female client who has acute leukemia. Which of the following values is an expected finding? WBC count 21,000/mm3 Hgb 14 g/dL Hct 40% Platelets 170,000/mm3

WBC count 21,000 The nurse should expect a client who has acute leukemia to have an elevated WBC count. The nurse should expect a client who has acute leukemia to have a decreased Hgb level. The nurse should expect a client who has acute leukemia to have a decreased Hct level. The nurse should expect a client who has acute leukemia to have a decreased platelet count.

A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should monitor for and report which of the following findings to the provider immediately? Watery diarrhea Vaginitis Furry tongue Nausea and vomiting

Watery diarrhea The greatest risk to this client is pseudomembranous colitis, which is manifested by watery diarrhea. Therefore, the priority finding is diarrhea. The nurse should report this finding to the provider immediately and discontinue the medication. Vaginitis can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. Furry tongue can indicate the client has developed a superinfection such as Candida albicans, which is an adverse effect of clindamycin. However, another finding is the priority. Nausea and vomiting are adverse effects of clindamycin. However, another finding is the priority.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. 1 large hard-boiled egg b. 1 cup bran cereal c. 1/2 cup almond d. 1 cup cooked spinach

a. 1 large hard-boiled egg One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium. Cereal has 112 mg. Almonds 193 mg and spinach 157 mg.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Administer IV fluids to the client evenly over 24 hr. b. Provide the client with a salt substitute. c. Assess the client for pitting edema. d. Encourage the client to rise slowly when standing up. e. Weigh the client every 8 hr.

a. Administer IV fluids to the client evenly over 24 hr d. Encourage the client to rise slowly when standing up e. Weigh the client every 8 hr Administer IV fluids to the client evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension. Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance. Provide the client with a salt substitute is incorrect. There is no reason to limit the client's sodium intake. A client who has hypernatremia might require dietary sodium restriction. However, this client might require electrolyte replacement, depending on the cause of fluid loss. Assess the client for pitting edema is incorrect. This action is appropriate for a client who has fluid volume overload.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except? a. Confusion b. Peripheral edema c. Facial flushing d. Hyperreflexia

a. Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur. Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased heart rate d. Increased blood pressure

a. Decreased muscle strength The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea. The nurse should expect the client to experience increased gastric motility, including abdominal cramps and diarrhea. Increased heart rate The nurse should expect the client to experience bradycardia. The nurse should expect the client to experience hypotension.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure

a. Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling. Decreased bowel sounds are an expected finding for a client who has hypomagnesemia. Insomnia is an expected finding for a client who has hypomagnesemia. Increased blood pressure is an expected finding for a client who has hypomagnesemia.

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions. b. Administer phosphate. c. Initiate diuretic therapy. d. Prepare the client for hemodialysis.

a. Implement seizure precautions. The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury. Administering phosphate can further decrease the client's calcium level. Diuretic therapy can further decrease the client's calcium level. Hemodialysis is administered to treat hypercalcemia, not hypocalcemia.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a. Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis. The pH level is elevated above 7.45 in both respiratory and metabolic alkalosis. With metabolic acidosis, the pH is less than 7.35 but the PaCO2 is either within or below the expected reference range, and the HCO3- is decreased. The pH level is elevated above 7.5 in both respiratory and metabolic alkalosis.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a. Sodium 128 mEq/L b. Potassium 4.8 mEq/L c. Calcium 9.1 mg/dL d. Magnesium 2.0 mEq/L

a. Sodium 128 mEq/L This level is below the expected reference range of 136 to 145 mEq/L and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort. Potassium finding is within the expected reference range. However, the nurse should continue to monitor for hypokalemia while the client is taking hydrochlorothiazide. Calcium is within the expected reference range. However, the nurse should continue to monitor for hypercalcemia while the client is taking hydrochlorothiazide. Magnesium is within the expected reference range. However, the nurse should continue to monitor for hypomagnesemia while the client is taking hydrochlorothiazide.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L c. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 that is either elevated or within the expected reference range indicates metabolic alkalosis. With metabolic alkalosis, the pH is above 7.45 and HCO3- is elevated, not within the expected reference range. The PaCO2 is either elevated or within the expected reference range. With respiratory alkalosis and metabolic alkalosis, the pH is elevated above 7.45.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr c. Bumetanide 8 mg/day d. 100 mL of dextrose 10% in water with 10 units of insulin

b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride. Sodium polystyrene sulfonate is an electrolyte cation exchange medication that is given to treat hyperkalemia, not hypokalemia. High-ceiling loop diuretics such as bumetanide are given to treat hyperkalemia, not hypokalemia. Dextrose 10% in water with 10 units of insulin is an IV solution given to treat hyperkalemia, not hypokalemia.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. 1/2 cup chopped celery b. 1 cup plain yogurt c. 1 slice whole grain bread d. 1/2 cup cooked tofu

b. 1 cup plain yogurt One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium. One-half cup of chopped celery contains 132 g of potassium. One slice of whole grain bread contains 60 g of potassium. One-half cup of cooked tofu contains 164 g of potassium.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes b. Cardiac rhythm c. Peripheral sensation d. Bowel sounds

b. Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia. The nurse should assess the client's deep-tendon reflexes because this total serum calcium level is below the expected reference range of 9 to 10.5 mg/dL, and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. The nurse should assess the client's peripheral sensation to check for paresthesias because this total serum calcium level is below the expected reference range, and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. The nurse should assess the client's bowel sounds to check for hypermotility because this total serum calcium level is below the expected reference range, and hypocalcemia can cause increased peristalsis. However, there is another assessment the nurse should make first.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050

b. Hematocrit 34% The nurse should identify that a client who has fluid volume excess can have a Hct level that is below the expected reference range of 37% to 47% for females or 42% to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level. The nurse should identify that a client who has dehydration can have a Hgb level that is above the expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess can cause hemodilution and a decreased hemoglobin level. The nurse should identify that a client who has dehydration can have a BUN that is above the expected reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN. The nurse should identify that a client who has dehydration can have a urine specific gravity that is above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in urine specific gravity.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a. Assist with intubation. b. Initiate high-flow oxygen therapy. c. Administer a rapid-acting diuretic. d. Provide cardiac monitoring.

b. Initiate high-flow oxygen therapy. When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%. The nurse should be prepared to assist the provider with intubation and mechanical ventilation if less invasive measures are ineffective. However, there is another action the nurse should take first. The nurse should administer a rapid-acting diuretic IV bolus to the client to relieve pulmonary congestion. However, there is another action the nurse should take first. The nurse should provide cardiac monitoring because premature ventricular contractions and dysrhythmias are manifestations of pulmonary edema. However, there is another action the nurse should take first.

nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a. Hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse

b. Orthostatic hypotension The nurse should plan to monitor the client for orthostatic hypotension, which places them at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia. The nurse should plan to monitor the client for hyporeflexia. Manifestations of hypokalemia include weak hand grip strength and weak deep-tendon reflexes. The nurse should plan to monitor the client for respiratory distress. Weakening of the respiratory muscles and shallow respirations are manifestations of hypokalemia. The nurse should plan to monitor the client for a weak and thready pulse. A weak, thready pulse is a manifestation of hypokalemia.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a. PaO2 b. PaCO2 c. Sodium d. Bicarbonate

b. PaCo2 The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO2 level due to hyperventilation. The nurse should anticipate that a client who has respiratory alkalosis will have a PaO2 level within the expected reference range of 80 to 100 mm Hg The nurse should anticipate that a client who has respiratory alkalosis will have a sodium level within the expected reference range. The nurse should anticipate that a client who has respiratory alkalosis will have a bicarbonate level within the expected reference range. The bicarbonate level is increased in metabolic alkalosis.

A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 142 mEq/L c. Hct 56% d. Urine specific gravity 1.035

b. Serum sodium 142 mEq/L Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 142 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective. A BUN of 26 mg/dL is above the expected reference range of 10 to 20 mg/dL. An elevated BUN is an indication that the client is still dehydrated. This Hct is above the expected reference range of 42 to 52% for males and 37 to 47% for females. An elevated Hct is an indication that the client is still dehydrated. A urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030. An elevated urine specific gravity is an indication that the client is still dehydrated.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?a. "If my stockings feel tight, I'll just roll them down for a while." b. "I'll put on my elastic stockings at the first sign of swelling." c. "When I sit down to watch television, I'll be sure to put my feet up." d. "It's okay to cross my legs as long as it's for less than an hour."

c. "When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase venous return. The client should elevate their feet for at least 20 min several times per day. The client should not roll the stockings down, because the rolled part can become a constricting band around the leg which can impede circulation. The client should don graduated compression stockings upon awakening and remove them at bedtime. Wearing the stockings throughout the day prevents swelling of the extremities and improves circulation. The client should not cross their legs. Doing so can further impair circulation of the lower extremities.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a. Monitor the client's bowel sounds. b. Review the client's daily laboratory results. c. Auscultate the client's lungs. d. Palpate the client's peripheral pulses.

c. Auscultate the client's lungs. An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles. The nurse should monitor the client's bowel sounds for increased or decreased peristalsis due to hypokalemia. However, there is another action the nurse should take first. The nurse should review the client's daily laboratory results, especially the potassium level. However, there is another action the nurse should take first. The nurse should palpate the client's peripheral pulses to assess for cardiovascular changes, such as a thready and weak pulse. However, there is another action the nurse should take first.

A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate

c. Bounding peripheral pulses The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses. The nurse should recognize that an increased respiratory rate is a manifestation of fluid volume overload. The nurse should recognize that increased gastrointestinal motility is a manifestation of fluid volume overload. The nurse should recognize that an increased urine specific gravity indicates a greater concentration of urine, which occurs with dehydration, not fluid volume overload.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? a. Instruct the client to cough forcefully. b. Assist the client with ambulation. c. Provide calming interventions. d. Discontinue the PCA.

c. Provide calming interventions. The client's respiratory rate is above the expected reference range of 12 to 20/min. The nurse should instruct the client to breathe slowly. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45. Coughing forcefully will not treat the underlying cause of the ABG results. Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time. Discontinuing the PCA will not treat the underlying cause of the ABG results and could exacerbate the client's respiratory distress.

A nurse is reviewing the medical record of a client who had diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a. Urine output of 30 mL/hr b. Blood glucose of 180 mg/dL c. Serum potassium 3.0 mEq/L d. BUN 18 mg/dL

c. Serum potassium 3.0 mEq/L This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider. A blood glucose level of 200 mg/dL or less is an indication that the client's diabetic ketoacidosis is resolving and is within the expect reference range for a casual glucose level. Therefore, the nurse does not need to report this finding to the provider A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur due to dehydration for a client who has diabetic ketoacidosis. The expected reference range for urinary output is between 1,500 to 2,000 mL daily. A urinary output of less than 30 mL/hr, known as oliguria, can indicate dehydration, impaired renal blood flow, or renal failure. However, a urine output of 30 mL/hr does not need to be reported to the provider.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? a. Hepatic failure b. Abdominal pain c. Slow peripheral pulses d. Increase in cardiac output

c. Slow peripheral pulses This phosphorus level is below the expected reference range of 3 to 4.5 mg/dL. The nurse should expect the client to have slow peripheral pulses. The nurse might also find that the client's pulses are difficult to find and easy to block. This phosphorus level is below the expected reference range. The nurse should expect a decrease in cardiac output. Hypophosphatemia causes weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown. It does not cause abdominal pain. The nurse should assess a client who has hypophosphatemia for manifestations of kidney failure, not hepatic failure.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution. b. Repeat the potassium level. c. Withhold the medication. d. Monitor for paresthesia.

c. Withhold the medication. The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider. A potassium level of 5.5 mEq/L indicates the client has hyperkalemia. This places the client at risk for bradycardia, hypotension, and life-threatening cardiac complications. The nurse should administer a hypertonic solution to correct the hyperkalemia and repeat the potassium level to evaluate for effective treatment, but another action is the priority. The nurse should monitor the client for paresthesia because numbness and tingling are indications of hyperkalemia, but another action is the priority.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat more cheese because I can't drink milk." b. "I need to avoid foods with vitamin D because I am allergic to milk." c. "I will stop taking my calcium supplements if they irritate my stomach." d. "I will add broccoli and kale to my diet."

d. "I will add broccoli and kale to my diet." The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products. The nurse should recommend that the client prevent gastric upset by taking the calcium supplements with food. Vitamin D is necessary for calcium absorption and is unlikely to trigger an allergic reaction in a client who has a dairy allergy. Cheese is a dairy product. If the client is allergic to milk, they will also be allergic to cheese.

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching?a. "I should conserve energy by limiting my physical activity." b. "I will wait until my pain is at least six out of ten before I use the PCA." c. "I will limit my daily fluid intake to two to three glasses." d. "I will use the incentive spirometer every hour."

d. "I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should encourage the client to ambulate and change positions frequently to prevent postoperative complications. The nurse should encourage the client to use the PCA when feeling acute pain to prevent the pain from worsening. Dehydration can cause metabolic acidosis. The nurse should encourage the client to take in approximately 2,200 mL of fluid daily. This includes fluid intake of six to eight glasses containing 240 mL each, as well as liquids obtained from eating solid foods. Limiting fluid intake to two to three 8 oz glasses would not meet the client's total daily intake needs.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride b. Dextrose 5% in lactated Ringer's c. 3% sodium chloride d. 0.45% sodium chloride

d. 0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys. Lactated Ringer's contains sodium and other electrolytes and is not indicated for hypernatremia. 3% sodium chloride is a hypertonic solution Dextrose 5% in 0.9% sodium chloride is a hypertonic solution.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? a. Sodium 152 mEq/L b. Chloride 102 mEq/L c. Magnesium 1.8 mEq/L d. Potassium 6.1 mEq/L

d. Potassium 6.1 mEq/L Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves. Although this sodium level is outside the expected reference range, it would not cause a prolonged PR interval and widened QRS complex. However, it can cause cerebral dysfunction. Magnesium and Chloride are within the expected range.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L A pH below 7.35 is an indication of acidosis. An HCO3- below 22 mEq/L is an indication of metabolic acidosis. When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause A pH above 7.45 is an indication of alkalosis.