Complex Final Exam Questions

The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test? 1. Fast for 8 hours before the test 2. Eat a regular supper and breakfast 3. Continue to take all oral medications as scheduled. 4. Monitor own bowel movement pattern for constipation

1. Fast for 8 hours before the test A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test, depending on the physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the GI tract.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

1. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. Option 2: It may be necessary to suction, so having suction equipment at the bedside is necessary. Option 3: Padded tongue blades are safe to use. Option 4: A toothbrush is appropriate to use.

A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationship

Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? 1. Restrict fluids 2. Encourage ambulation 3. Increase sodium in the diet 4. Give antacids as prescribed

1. Restrict fluids Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space.

A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next? 1. Review the intake and output records for the last two (2) days 2. Change the time of diuretic administration from morning to evening 3. Request a sodium restriction of one (1) g/day from the physician. 4. Order daily weight starting the following morning.

1. Review the intake and output records for the last 2 days Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Option B: Diuretics should be given in the morning whenever possible to avoid nocturia. Option C: Strict sodium restrictions are reserved for clients with severe symptoms.

A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position? 1. Semi-Fowlers 2. Supine 3. Reverse Trendelenburg 4. High Fowler's

1. Semi-Fowlers To prevent aspiration of stomach contents, the nurse should place the client in semi-Fowler's position. High Fowler's position isn't necessary and may not be tolerated as well as semi-Fowler's.

A nurse has the order to begin administering warfarin sodium (Coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate

1. Vitamin K The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur.

When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds 2. Providing skin care following bowel movements 3. Evaluating the client's response to antidiarrheal medications 4. Maintaining intake and output records 5. Obtaining the client's weight.

2, 4, and 5

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? 1. Strict bed rest for 24 hours after transfer 2. Bathroom privileges and self-care activities 3. Unsupervised hallway ambulation with distances under 200 feet 4. Ad lib activities because the client is monitored.

2. Bathroom privileges and self-care activities On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances are encouraged, with distances gradually increased (50, 100, 200 feet).

A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with which of the following classes of medication right away? 1. Beta-adrenergic blockers 2. Bronchodilators 3. Inhaled steroids 4. Oral steroids

2. Bronchodilators Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief.

The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in the abdomen. The client spills water on the catheter dressing while bathing. The nurse should immediately: 1. Reinforce the dressing 2. Change the dressing 3. Flush the peritoneal dialysis catheter 4. Scrub the catheter with povidone-iodine

2. Change the dressing Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that is wet is a conduit for bacteria for bacteria to reach the catheter insertion site. The nurse assures that the dressing is kept dry at all times. Option A: Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Option C: Flushing the catheter is not indicated. Option D: Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnecting of peritoneal dialysis.

Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide: 1. Necessary fluids and electrolytes to the body. 2. Complete nutrition by the I.V. route. 3. Tube feedings for nutritional supplementation. 4. Dietary supplementation with liquid protein given between meals.

2. Complete nutrition by the I.V. route. TPN is given I.V. to provide all the nutrients your patient needs. TPN isn't a tube feeding nor is it a liquid dietary supplement.

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse should: 1. Continue the dialysis at a slower rate after checking the lines for air 2. Discontinue dialysis and notify the physician 3. Monitor vital signs every 15 minutes for the next hour 4. Bolus the client with 500 ml of normal saline to break up the air embolism.

2. Discontinue dialysis and notify the physician If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed.

Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect? 1. Infection 2. Disequilibrium syndrome 3. Air embolus 4. Acute hemolysis

2. Disequilibrium syndrome Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.

When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: 1. Help keep him well hydrated 2. Dissolve clots he may have 3. Prevent kidney failure 4. Treat potential cardiac arrhythmias.

2. Dissolve clots he may have Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at risk for skin breakdown; A score ranging from 15 to 18 is considered at mild risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? 1. Increase the rate of dialysis 2. Infuse normal saline solution 3. Administer a 5% dextrose solution 4. Encourage active ROM exercises

2. Infuse normal saline solution Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.

An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding? 1. Notify the doctor immediately. 2. Stop the feeding, and clamp the NG tube. 3. Discard the 220ml, and clamp the NG tube. 4. Give a prescribed GI stimulant such as metoclopramide (Reglan).

2. Stop the feeding, and clamp the NG tube. A gastric residual greater than 2 hours worth of feeding or 100-150ml is considered too high. The feeding should be stopped; NG tube clamped, and then allow time for the stomach to empty before additional feeding is added.

Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? 1. Osmosis and diffusion 2. Passage of fluid toward a solution with a lower solute concentration 3. Allowing the passage of blood cells and protein molecules through it. 4. Passage of solute particles toward a solution with a higher concentration.

1. Osmosis and diffusion Osmosis allows for the removal of fluid from the blood by allowing it to pass through the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an area of lower concentration. Option B: Fluid passes to an area with a higher solute concentration. Option C: The pores of a semipermeable membrane are small, thus preventing the flow of blood cells and protein molecules through it.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which of the following most frequent symptom(s) of duodenal ulcer? 1. Pain that is relieved by food intake 2. Pain that radiated down the right arm 3. N/V 4. Weight loss

1. Pain that is relieved by food intake

A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? 1. Follow a high potassium diet 2. Strictly follow the hemodialysis schedule 3. There will be a few changes in your lifestyle. 4. Use alcohol on the skin and clean it due to integumentary changes.

2. Strictly follow the hemodialysis schedule To prevent life-threatening complications, the client must follow the dialysis schedule. Option A: The client should follow a low-potassium diet because potassium levels increase in chronic renal failure. Option C: The client should know hemodialysis is time-consuming and will definitely cause a change in current lifestyle. Option D: Alcohol would further dry the client's skin more than it already is.

Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia? 1. A respiratory rate of 25 to 30 breaths per minute 2. The ability to perform ADL's without dyspnea 3. A maximum loss of 5 to 10 pounds of body weight 4. Chest pain that is minimized by splinting the ribcage.

2. The ability to perform ADL's without dyspnea An expected outcome for a client recovering from pneumonia would be the ability to perform ADL's without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5-10 pounds is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? 1. "Have you ever had this pain before?" 2. "Can you describe the pain to me?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 0-10, with ten (10) being the worst?"

3. "Does the pain get worse when you breathe in?" Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

Polystyrene sulfonate (Kayexalate) is used in renal failure to: 1. Correct acidosis 2. Reduce serum phosphate levels 3. Exchange potassium for sodium 4. Prevent constipation from sorbitol use

3. Exchange potassium for sodium In renal failure, patients become hyperkalemic because they can't excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium.

A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? 1. Position changes q4h 2. Nasotracheal suctioning to clear secretions 3. Frequent linen changes 4. Frequent offering of a bedpan.

3. Frequent linen changes Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? 1. Heart disease 2. Allergy to penicillin 3. Hepatitis B 4. Rheumatic fever

3. Hepatitis B Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.

Which of the following factors is believed to be linked to Crohn's disease? 1. Constipation 2. Diet 3. Hereditary 4. Lack of exercise

3. Hereditary

A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications? 1. Heart failure 2. DVT 3. Hypokalemia 4. Hypocalcemia

3. Hypokalemia

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Hypernatremia

3. Hypokalemia Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia.

Which of the following definitions best describes gastritis? 1. Erosion of the gastric mucosa 2. Inflammation of a diverticulum 3. Inflammation of the gastric mucosa 4. Reflux of stomach acid into the esophagus

3. Inflammation of the gastric mucosa Gastritis is an inflammation of the gastric mucosa that may be acute (often resulting from exposure to local irritants) or chronic (associated with autoimmune infections or atrophic disorders of the stomach). Erosion of the mucosa results in ulceration. Inflammation of a diverticulum is called diverticulitis; reflux of stomach acid is known as gastroesophageal disease.

The nurse is reviewing a medication history of a client with BPH. Which medication should be recognized as likely to aggravate BPH? 1. Metformin (Glucophage) 2. Buspirone (BuSpar) 3. Inhaled ipratropium (Atrovent) 4. Ophthalmic timolol (Timoptic)

3. Inhaled ipratropium (Atrovent) Atrovent is a bronchodilator, and its anticholinergic effects can aggravate urinary retention. Options A and B: Glucophage and BuSpar do not affect the urinary system. Option D: Timolol does not have a systemic effect.

A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicated a need for further teaching? 1. Removes the cap and shakes the inhaler well before use. 2. Presses the canister down with finger as he breathes in. 3. Inhales the mist and quickly exhales. 4. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed.

3. Inhales the mist and quickly exhales. The client should be instructed to hold his or her breath at least 10 to 15 seconds before exhaling the mist.

Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder? 1. Circumoral cyanosis 2. Increased forced expiratory volume 3. Inspiratory and expiratory wheezing 4. Normal breath sounds

3. Inspiratory and expiratory wheezing Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be "tight" sounding or markedly decreased; they won't be normal.

Which of the following factors can cause blood pressure to drop to normal levels? 1. Kidneys' excretion of sodium only 2. Kidneys' retention of sodium and water 3. Kidneys' excretion of sodium and water 4. Kidneys' retention of sodium and excretion of water

3. Kidneys' excretion of sodium and water The kidneys respond to a rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic pressure by regulating blood volume

The nurse would question an order for which type of antacid in patients with chronic renal failure? 1. Aluminum-containing antacids 2. Calcium-containing antacids 3. Magnesium-containing antacids 4. All of the above.

3. Magnesium-containing antacids Magnesium-containing antacids can cause hypermagnesemia in patients with chronic renal failure. Aluminum-containing antacids may be used as a phosphate binder in patients with chronic renal failure. Calcium-containing antacids are also appropriate because these patients may be hypocalcemic.

A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? 1. Monitoring vital signs 2. Completing a physical assessment 3. Maintaining cardiac monitoring 4. Maintaining at least one IV access site

3. Maintaining cardiac monitoring Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished by the MI monitoring.

The most important long-term goal for a client with hypertension would be to: 1. Learn how to avoid stress 2. Explore a job change or early retirement 3. Make a commitment to long-term therapy 4. Control high blood pressure

3. Make a commitment to long-term therapy Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance.

Which of the following associated disorders may the client with Crohn's disease exhibit? 1. Ankylosing spondylitis 2. Colon cancer 3. Malabsorption 4. Lactase deficiency

3. Malabsorption

Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient? 1. TPN 2. PPN 3. NG feeding 4. Oral liquid supplements

3. NG feeding Because the GI tract is functioning, feeding methods involve the enteral route which bypasses the mouth but allows for a major portion of the GI tract to be used.

The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? 1. Indeterminate 2. Needs to be redone 3. Negative 4. Positive

3. Negative This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate isn't a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC.

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of an antihypertensive. The nurse should plan to administer this medication: 1. Just before dialysis 2. During dialysis 3. On return from dialysis 4. The day after dialysis

3. On return from dialysis Antihypertensive medications are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.

Medical treatment of coronary artery disease includes which of the following procedures? 1. Cardiac catheterization 2. Coronary artery bypass surgery 3. Oral medication therapy 4. Percutaneous transluminal coronary angioplasty

3. Oral medication therapy Oral medication administration is a noninvasive, medical treatment for coronary artery disease. Option A: Cardiac catheterization isn't a treatment, but a diagnostic tool. Options B and D: Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments.

A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? 1. Antibiotics 2. Bed rest 3. Oxygen 4. Nutritional intake

3. Oxygen

A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? 1. Overflow 2. Reflex 3. Stress 4. Urge

3. Stress Stress incontinence is an involuntary loss of a small amount of urine due to sudden increased intra-abdominal pressure, such as with coughing or sneezing.

Which of the following characteristics is typical of the pain associated with DVT? 1. Dull ache 2. No pain 3. Sudden onset 4. Tingling

3. Sudden onset DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. Option A: A dull ache is more commonly associated with varicose veins. Option C: If the thrombus is large enough, it will cause pain. Option D: A tingling sensation is associated with an alteration in arterial blood flow.

The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence? 1. Abdominal cramping and pain 2. Bradycardia and indigestion 3. Sweating and pallor 4. Double vision and chest pain

3. Sweating and pallor Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? 1. Take the medication with antacids 2. Double the dosage if a drug dose is forgotten 3. Increase intake of dairy products 4. Limit alcohol intake

4. Limit alcohol intake INH and rifampin are hepatotoxic drugs. Clients should be warned to limit intake of alcohol during drug therapy. Both drugs should be taken on an empty stomach. If antacids are needed for GI distress, they should be taken 1 hour before or 2 hours after these drugs are administered. Clients should not double the dosage of these drugs because of their potential toxicity. Clients taking INH should avoid foods that are rich in tyramine, such as cheese and dairy products, or they may develop hypertension.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? 1. Bloody diarrhea 2. Hypotension 3. A hemoglobin of 12 mg/dL 4. Rebound tenderness

4. Rebound tenderness Rebound tenderness may indicate peritonitis. Blood diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician.

A client's ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate? 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis

4. Respiratory acidosis

It's highly recommended that clients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons? 1. All clients are recommended to have these vaccines 2. These vaccines produce bronchodilation and improve oxygenation. 3. These vaccines help reduce the tachypnea these clients experience. 4. Respiratory infections can cause severe hypoxia and possibly death in these clients.

4. Respiratory infections can cause severe hypoxia and possibly death in these clients. It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these clients to need intubation and mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The vaccines have no effect on bronchodilation or respiratory care.

Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He's jaundiced and reports weakness. Which intervention will you include in his care? 1. Regular exercise. 2. A low-protein diet. 3. Allow patient to select his meals. 4. Rest period after small, frequent meals.

4. Rest period after small, frequent meals. Rest periods and small frequent meals are indicated during the acute phase of hepatitis B.

A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? 1. ABG analysis 2. Chest x-ray 3. Blood cultures 4. Sputum culture and sensitivity

4. Sputum culture and sensitivity Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is systemic.

Which of the following symptoms may be exhibited by a client with Crohn's disease? 1. Bloody diarrhea 2. Narrow stools 3. Nausea and vomiting 4. Steatorrhea

4. Steatorrhea Steatorrhea is stool containing fat, and is a finding that is specific to Crohn's disease

Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? 1. There is no skin breakdown. 2. Her appetite improves. 3. She loses more than 10 lbs. 4. Stools are less fatty and decreased in frequency.

4. Stools are less fatty and decreased in frequency. Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance.

Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which information is important for providing care for the patient? 1. The patient shouldn't feel pain during initiation of dialysis 2. The patient feels best immediately after the dialysis treatment 3. Using a stethoscope for auscultating the fistula is contraindicated 4. Taking a blood pressure reading on the affected arm can cause clotting of the fistula

4. Taking a blood pressure reading on the affected arm can cause clotting of the fistula Pressure on the fistula or the extremity can decrease blood flow and precipitate clotting, so avoid taking blood pressure on the affected arm.

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. Seating the client with arm bared, supported, and at heart level. 2. Measuring the blood pressure after the client has been seated quietly for 5 minutes. 3. Using a cuff with a rubber bladder that encircles at least 80% of the limb. 4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion

4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. Option B: The client should rest quietly for 5 minutes before the reading is taken. Option C: The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every six (6) months to ensure accuracy.

Crohn's disease can be described as a chronic relapsing disease. Which of the following areas in the GI system may be involved with this disease? 1. The entire length of the large colon 2. Only the sigmoid area 3. The entire large colon through the layers of mucosa and submucosa 4. The small intestine and colon; affecting the entire thickness of the bowel

4. The small intestine and colon; affecting the entire thickness of the bowel Crohn's disease can involve any segment of the small intestine, the colon, or both, affecting the entire thickness of the bowel. Answers 1 and 3 describe ulcerative colitis, answer 2 is too specific and therefore, not likely.

Which of the following types of pain is most characteristic of angina? 1. Knifelike 2. Sharp 3. Shooting 4. Tightness

4. Tightness The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms.

Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema? 1. To promote oxygen intake 2. To strengthen the diaphragm 3. To strengthen the intercostal muscles 4. To promote carbon dioxide elimination

4. To promote carbon dioxide elimination Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

Which of the following associated disorders may a client with ulcerative colitis exhibit? 1. Gallstones 2. Hydronephrosis 3. Nephrolithiasis 4. Toxic megacolon

4. Toxic megacolon

Colon cancer is most closely associated with which of the following conditions? 1. Appendicitis 2. Hemorrhoids 3. Hiatal hernia 4. Ulcerative colitis

4. Ulcerative colitis

A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? 1. Potassium level and weight 2. BUN and creatinine levels 3. VS and BUN 4. VS and weight.

4. VS and weight. Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine the effectiveness of fluid extraction. Options A, B, and C: Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.

A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? 1. Continued dyspnea 2. Fever of 102*F 3. Respiratory rate of 32 breaths/minute 4. Vesicular breath sounds in right base

4. Vesicular breath sounds in right base

The healthcare provider is teaching a patient who is diagnosed with genital herpes about the disease. Which of the following will be included in the teaching plan for this patient? (Select all that apply) A. "There is no cure for genital herpes but outbreaks can be shortened with medication." B. "This infection also increases your risk of human immunodeficiency (HIV) virus infection." C. "Use condoms between outbreaks to reduce the risk of transmission." D. "You will not be contagious when you are taking your antiviral medications." E. "Your infection is caused by a corkscrew bacteria called a spirochete." F. "Transmission of the virus can occur even if there are no visible herpes sores."

A, B, C, F

A patient diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the healthcare provider include in this patient's plan of care? (select all that apply) A. Monitor the patient's blood glucose B. Monitor the patient's protime (PT) C. Institute droplet precautions D. Assess deep tendon reflexes E. Provide high-protein feedings

A, B, D

Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply: A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia

A, C, D A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience thrombocytopenia (low platelet count), increased PT/INR (means it takes the patient a long time to stop bleeding), and leukopenia (low white blood cells). The spleen stores platelets and WBCs. An enlarged spleen can develop due to portal hypertension, which causes the platelets and WBCs to become stuck inside the spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body's access to these important cells for survival).

Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A. Assessing the client's neurologic status every 2 hours B. Monitoring the client's hemoglobin and hematocrit levels C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily E. Preparing to insert an esophageal tamponade tube F. Making sure the client's fingernails are short

A, C, D Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.

A nurse is assessing an older adult who is at risk of impaired skin integrity. The nurse is using the Braden Scale for assessment. Which of the following is an element of the Braden Scale? Select all that apply. A. Sensory perception B. Circulation C. Moisture D. Activity E. Edema

A, C, D The Braden Scale is a measurement tool used to assess skin integrity for patients at risk. Some elements of the Braden Scale include assessment of activity and moisture levels as well as the patient's sensory perception.

The healthcare provider is teaching a group of senior citizens about risk factors for heart failure. Which of these factors will the healthcare provider include in the teaching? (Select all that apply) A. History of preeclampsia B. Increased high density lipoproteins (HDL) C. Obesity D. High sodium intake E. Sleep apnea F. Hypertension

A, C, D, E, F

Signs and/or symptoms of Cushing's Disease include: (check correct boxes) A. moon face B. fatty limbs C. osteoporosis D. acne E. euphoria

A, C, and D

A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? (select all that apply) A. Ensure the patient has an empty bladder before the procedure B. Provide a mechanical soft diet for before the procedure C. Review the patient's baseline liver function tests D. Help the patient assume a left lateral position after the procedure E. Monitor the patient's vital signs after the procedure F. Ensure the patient's clotting profile is within normal limits

A, E, F

A patient diagnosed with viral hepatitis is in the pre-icteric phase. When assessing the patient, which of these findings should the healthcare provider anticipate? (Select all that apply) A.Nausea B. Pruritis C. Tarry stools D. Anorexia E. Dark urine

A and D

A physician orders a CBC for a male patient who has been admitted to the hospital for pneumonia. Which of the following results would be considered abnormal on the CBC? Select all that apply. A. RBC 3.8/mcL B. WBC 8,000/mcL C. Hematocrit 50% D. Hemoglobin 10.1 g/dL E. Platelets 200,000 cells/mcL

A and D

Which instruction about insulin administration should nurse Kate give to a client? A. "Always follow the same order when drawing the different insulins into the syringe." B. "Shake the vials before withdrawing the insulin." C. "Store unopened vials of insulin in the freezer at temperatures well below freezing." D. "Discard the intermediate-acting insulin if it appears cloudy."

A. "Always follow the same order when drawing the different insulins into the syringe." The client should be instructed always to follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin also should never be frozen because the insulin protein molecules may be damaged. Intermediate-acting insulin is normally cloudy.

A female client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? A. Depression B. Neuropathy C. Hypoglycemia D. Hyperthyroidism

A. Depression Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

The nurse is preparing to teach a client with iron-deficiency anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? A. Eggs B. Lettuce C. Citrus fruits D. Cheese

A. Eggs A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Options B and C: Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Option D: Cheese is a good source of calcium.

A patient has suffered a bruise on her elbow from being assisted in bed for repositioning. Which best describes how the nurse can prevent this injury from becoming a point of skin breakdown? A. Encourage the patient to increase fluid intake B. Apply a bandage with adhesive over the site C. Wrap the arm in rolled gauze D. Wrap the area in a net gauze and keep it covered

A. Encourage the patient to increase fluid intake A patient with mobility impairments may be at risk of skin breakdown after being injured, even if the injury did not initially break the skin. The patient with a bruise may develop skin breakdown in the area if it is not properly maintained. The nurse should encourage fluid intake to maintain hydration and to keep the skin from drying out.

Which of the following blood components is decreased in anemia? A. Erythrocytes B. Granulocytes C. Leukocytes D. Platelets

A. Erythrocytes Anemia is defined as a decreased number of erythrocytes (red blood cells). Option B: Granulocytopenia is a decreased number of granulocytes (a type of white blood cells). Option C: Leukopenia is a decreased number of leukocytes (white blood cells). Option D: Thrombocytopenia is a decreased number of platelets.

When teaching a group of students about chlamydia, which of the following points is most important for the healthcare provider to emphasize? A. Most people infected with chlamydia are unaware that they are infected B. Good handwashing technique is the best way to prevent chlamydial infections C. Chlamydia is the least common of all the major sexually transmitted diseases D. Burning and pain with urination is a frequent symptom of chlamydial infections

A. Most people infected with chlamydia are unaware that they are infected

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? A. Mushroom and blueberry. B. Beans and banana. C. Fish and tomato juice. D. Potato and spinach.

A. Mushroom and blueberry. A renal diet is one that is low in sodium, phosphorous, potassium and protein. Options B, C, and D are high in sodium, phosphorus, and potassium.

Who are considered to be the first responders to site of injury and begin to phagocytize the threat? A. Neutrophils B. Macrophages C. Lymphoctyes D. Monocytes

A. Neutrophils

A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensure to do which of the following actions? A. Take another bottle of solution. B. Runs the bottle solution under a warm water. C. Rolls the bottle solution gently. D. Shake the bottle solution vigorously.

A. Take another bottle of solution. Fat emulsions are used as dietary supplements for patients who are unable to get enough fat in their diet, usually because of certain illnesses or recent surgery. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or the accumulation of froth. The nurse should not hang a fat emulsion if any of these observed and should return the solution to the pharmacy.

A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? (Select all that apply.) A. Range of motion every 4 hours B. Turn and reposition every 2 hours C. Abdominal and foot massages every 2 hours D. Alternating air pressure mattress E. Sit in chair for 30 minutes each shift

B, D Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the level of heart or higher so Fowler's position should be employed. An air pressure mattress, careful repositioning can prevent skin breakdown.

A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A. "It's important for me to remember to wash my hands after I use the bathroom." B. "I might get liver cancer someday because I have this infection." C. "Before I take any over-the-counter medicines I should call the clinic." D. "I will wash raw fruits and vegetables thoroughly before I eat them."

B. "I might get liver cancer someday because I have this infection."

Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis? A. Increase fluid intake to 3000 ml per day B. Adequate bed rest C. Bland diet D. Administer antibiotics as ordered

B. Adequate bed rest Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.

Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? A. Pitting edema of the legs B. An irregular apical pulse C. Dry mucous membranes D. Frequent urination

B. An irregular apical pulse . Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

A patient with a history of malnutrition has skin breakdown in several areas with bony prominences. The nurse first determines the patients age in the initial assessment. Which best describes the rationale for this measure? A. An older patient is most likely incontinent of urine B. An older patients skin has a greater chance of skin breakdown C. The patients age is directly associated with albumin production D. The patient is at higher risk of tissue edema with advancing age

B. An older patients skin has a greater chance of skin breakdown

A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia

B. Anemia EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.

For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility B. Applying pressure to injection sites C. Administering antibiotics as prescribed D. Increasing nutritional intake

B. Applying pressure to injection sites The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.

During a class on exercise for diabetic clients, a female client asks the nurse educator how often to exercise. The nurse educator advises the clients to exercise how often to meet the goals of planned exercise? A. At least once a week B. At least three times a week C. At least five times a week D. Every day

B. At least three times a week Diabetic clients must exercise at least three times a week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once a week wouldn't achieve these goals. Exercising more than three times a week, although beneficial, would exceed the minimum requirement.

The nurse is instructing a client with hyperkalemia on the importance of choosing foods low in potassium. The nurse should teach the client to limit which of the following foods? A. Grapes. B. Carrot. C. Green beans. D. Lettuce.

B. Carrot. Carrots has 320 mg of potassium per 100 mg serving; green beans give 209 mg of potassium, 194 mg for lettuce, and 191 mg for grapes all in 100 mg serving. Other foods that are low in potassium include: applesauce, blueberries, pineapple, and cabbage.

A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response? A. Assess for potential abuse B. Check for diminished sensations C. Document the findings D. Clean and dress the area

B. Check for diminished sensations Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. Option A: The burn could be related to abuse, but this conclusion would require more supporting data. Option C: The findings should be documented, but the nurse would want to address the client's sensations first. Option D: The decision of how to treat the burn should be determined by the physician.

For Rico who has chronic pancreatitis, which nursing intervention would be most helpful? A. Allowing liberalized fluid intake B. Counseling to stop alcohol consumption C. Encouraging daily exercise D. Modifying dietary protein

B. Counseling to stop alcohol consumption Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention

A nurse gets back results on a pt who may have hyperthyroidism. What lab values might the nurse expect? A. Decreased T3 and Increased T4 B. Decreased TSH and Increased T3 and T4 C. Increased TSH and decreased T3 and T4 D. Increased T3 and Decreased T4

B. Decreased TSH and Increased T3 and T4

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? A. Elevated hemoglobin level B. Elevated serum bilirubin level C. Elevated blood urea nitrogen level D. Decreased erythrocyte sedimentation rate

B. Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

What laboratory finding is the primary diagnostic indicator for pancreatitis? A. Elevated blood urea nitrogen (BUN) B. Elevated serum lipase C. Elevated aspartate aminotransferase (AST) D. Increased lactate dehydrogenase (LD)

B. Elevated serum lipase Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

Lorazepam (Ativan) 1 mg IV is ordered for a 45-year-old male patient before a scheduled surgery. Which of the following is the most appropriate action for the nurse to take before the administration of this medication? A. Ask the patient about an allergy to iodine or shellfish. B. Encourage or assist the patient to the bathroom to void. C. Explain that the medication is used to prevent postoperative nausea. D. Check the laboratory results for the most recent serum potassium level.

B. Encourage or assist the patient to the bathroom to void

While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis

B. Fetor Hepaticus

A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has a bounding pulse, jugular distension, and weight gain greater than desired. The nurse determines that the client is experiencing which complication of PN therapy? A. Air embolism. B. Hypervolemia. C. Hyperglycemia. D. Sepsis.

B. Hypervolemia. The client's sign and symptoms are consistent with hypervolemia. This happen when the client receives excessive fluid administration or administration of fluid too rapidly.

A patient who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this patient to correct the situation? A. No intervention but continue to monitor the patients hemodynamic status B. IV administration of potassium C. Oral intake of potassium by electrolyte preparations D. Encouraged intake of potassium-rich foods, such as bananas

B. IV administration of potassium

Assessment findings for a patient diagnosed with alcoholic hepatitis and portal hypertension include oliguria and increasing blood urea nitrogen (BUN). Which additional assessment finding would be consistent with this diagnosis? A. Hypotension and pallor B. Increased serum creatinine C. Increased urine sodium D. Flank pain and proteinuria

B. Increased serum creatinine

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury

B. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.

A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."

C. "I'm hoping that surgery will be an option for me in the future." SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.

A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, nurse Sharmaine would be most accurate in stating: A. "The test needs to be repeated following a 12-hour fast." B. "It looks like you aren't following the prescribed diabetic diet." C. "It tells us about your sugar control for the last 3 months." D. "Your insulin regimen needs to be altered significantly."

C. "It tells us about your sugar control for the last 3 months." The glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary instructions if she selects which of the following from her menu? A. Nuts and fish. B. Oranges and dark green leafy vegetables. C. Butter and margarine. D. Sugar and candy.

B. Oranges and dark green leafy vegetables. Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption.

Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? A. Rice cereal, whole milk, and yellow vegetables B. Potato, peas, and chicken C. Macaroni, cheese, and ham D. Pudding, green vegetables, and rice

B. Potato, peas, and chicken Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

Nurse Oliver should expect a client with hypothyroidism to report which health concerns? A. Increased appetite and weight loss B. Puffiness of the face and hands C. Nervousness and tremors D. Thyroid gland swelling

B. Puffiness of the face and hands Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter)

Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client's respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

B. Respiratory Acidosis

The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to side, if possible, with the head flexed forward

B. Restraining the client's limbs The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.

A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency? A. Bradycardia B. Retinopathy C. Urinary retention D. Jaundice

B. Retinopathy

Nurse Sierra is assessing the skin of a client suffering from psoriasis. She understands that which characteristic is associated with this skin disorder? A. Red-purplish scaly lesions. B. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions. C. Clear, thin nail beds. D. Oily skin and absence of pruritus.

B. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions. Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Option A: The lesions in psoriasis are not red-purplish scaly lesions. Option C: Thickening, pitting, and discoloration of the nails occurs. Option D: Pruritus may occur.

A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube? A. Inhale and exhale simultaneously. B. Take a long breath and hold it. C. Do a Valsalva maneuver. D. Blow the nose.

B. Take a long breath and hold it. Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose. and this method will also prevent aspiration.

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently

B. The client has weakness on the right side of the body, including the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition

A patient has been admitted to the cardiac unit with a diagnosis of right ventricular failure. Which of the following assessment findings would the healthcare provider expect to observe? is most likely to be observed by the healthcare provider? A. Fatigue and hemoptysis B. Bradycardia and circumoral cyanosis C. Peripheral edema and jugular vein distension D. Dyspnea and pulmonary crackles

C. Peripheral edema and jugular vein distension

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? A. Turn and reposition the client at least once every 8 hours. B. Vigorously massage lotion into bony prominences. C. Post a turning schedule at the client's bedside. D. Slide the client, rather than lifting, when turning.

C. Post a turning schedule at the client's bedside. A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight gain D. Insomnia and excitability

C. Progressive weight gain

When providing dietary counseling for the parents of a child diagnosed with celiac disease, the healthcare provider should include which of the following information in the teaching plan? A. "Instead of breads you may serve pasta products." B. "Avoid starchy vegetables like peas and potatoes." C. "Wheat, corn, and rice should be avoided." D. "Be sure to read all food labels carefully."

D. "Be sure to read all food labels carefully."

When obtaining a health history of a patient admitted with a diagnosis of heart failure, which statement made by the patient supports the diagnosis of heart failure? A. "I often feel pain in my lower legs when I take my walk." B. "I sometimes feel pain in the middle of my chest during exercise." C. "I get hot and break out in a sweat during the night." D. "I get out of breath when I go up a flight of stairs."

D. "I get out of breath when I go up a flight of stairs."

A patient asks the healthcare provider about the benefits of receiving the human papillomavirus (HPV) vaccine. Which statement is the most appropriate response by the healthcare provider? A. "You will no longer need to get a routine cervical exam." B. "You will need to have a booster vaccination each year." C. "The HPV vaccine will protect you from all types of the virus." D. "The HPV vaccine can help prevent cervical cancer."

D. "The HPV vaccine can help prevent cervical cancer."

During a home health visit, you are assessing how a patient takes the prescribed pancreatic enzyme. The patient is unable to swallow the capsule whole, so they open the capsule and mix the beads inside the capsule with food/drink. Which food or drink is safe for the patient to mix the beads with? A. Pudding B. Ice cream C. Milk D. Applesauce

D. Applesauce

Nurse Kate is providing dietary instructions to a male client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: A. Increasing saturated fat intake and fasting in the afternoon. B. Increasing intake of vitamins B and D and taking iron supplements. C. Eating a candy bar if lightheadedness occurs. D. Consuming a low-carbohydrate, high protein diet and avoiding fasting

D. Consuming a low-carbohydrate, high protein diet and avoiding fasting. To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

You assess a patient with Cushing's disease. For which finding will you notify the physician immediately? A. Purple striae present on abdomen and thighs B. Weight gain of 1 pound since the previous day C. +1 dependent edema in ankles and calves D. Crackles bilaterally in lower lobes of lungs

D. Crackles bilaterally in lower lobes of lungs The presence of crackles in the patient's lungs indicate excess fluid volume doe to excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients Cushing's disease. These findings should be monitored, but are not urgent.

A 55 year old male patient is diagnosed with chronic kidney disease. The patient's recent GFR was 25 mL/min. What stage of chronic kidney disease is this known as? A. Stage 1 B. Stage 3 C. Stage 4 D. Stage 5

C. Stage 4 This is known as Stage 4 of CKD because the GFR (glomerular filtration rate) for this stage is 15-29 mL/min (patient's GFR is 25 mL/min). The other stage's criteria are as follows: Stage 1: Kidney damage with normal renal function GFR >90 ml/min but with proteinuria (3 months or more); Stage 2: Kidney damage with mild loss of renal function GFR 60-89 ml/min with proteinuria (3 months or more); Stage 3: Mild-to-severe loss of renal function GFR 30-59 mL/min; Stage 4: Severe loss renal function GFR 15-29 mL/min; Stage 5: End stage renal disease GRF less 15 mL/min

A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? A. Dysuria B. Leg cramps C. Tachycardia D. Blurred vision

C. Tachycardia Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.

A nurse is preparing to remove a nasogastric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube? A. Exhale B. Inhale and exhale quickly C. Take and hold a deep breath D. Perform a Valsalva maneuver

C. Take and hold a deep breath When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

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

C. Thrombocytopenia

The priority nursing intervention in the prevention of pressure ulcers is what? A. Put heating pads on suspicious areas. B. Have the client wear socks. C. Turn the client frequently. D. Give the client protein shakes daily.

C. Turn the client frequently.

Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? A. "Jaundice is associated with pressure ulcer formation." B. "Jaundice impairs urea production, which produces pruritus." C. "Jaundice produces pruritus due to impaired bile acid excretion." D. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."

C. "Jaundice produces pruritus due to impaired bile acid excretion." Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.

A patient diagnosed with celiac disease tells the healthcare provider, "I've been on a gluten-free diet for 3 months but this week I have had diarrhea, bloating, and gas." Which response would be most appropriate for the healthcare provider to make? A. "We'll need to take a biopsy of your small intestine to see if your disease is progressing." B. "Try adding more fiber to your daily diet and see if that resolves the problem" C. "Let's sit down and make a list of all the foods you ate this week." D. "You'll need to be compliant with your diet if you want to avoid these problems."

C. "Let's sit down and make a list of all the foods you ate this week."

A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A. Adds dried fruit to cereal and baked goods B. Cooks tomato-based foods in iron pots C. Drinks coffee or tea with meals D. Adds vitamin C to all meals

C. Drinks coffee or tea with meals Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Option A: Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Option B: Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Option D: Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

A patient is admitted to the medical unit with possible Graves' disease (hyperthyroidism). Which assessment finding supports this diagnosis? A. Periorbital edema B. Bradycardia C. Exophthalmos D. Hoarse voice

C. Exophthalmos Exophthalmos (abnormal protrusion of the eye) is characteristic of patients with hyperthyroidism due to Graves' disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss

C. Hand tremors Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia? a. Has hemoglobin A1C of 8.5% b. Has several seasonal allergies c. Has body mass index of 48.8 kg/m2 d Has history of postoperative vomiting

C. Has body mass index of 48.8 kg/m2 The patient's body mass index is the priority because it indicates the patient is severely obese. -The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. -The other factors are not the prioriy

When considering physiological changes common in geriatric patients, the healthcare provider understands that which of these factors may increase the risk of heart failure in older patients? A. Increased myocardial contractility B. Decreased sympathetic activity C. Impaired diastolic filling D. Increased stroke volume

C. Impaired diastolic filling

A nurse gets back results on a pt who may have hypothyroidism. What lab values might the nurse expect? A. Decreased T3 and Increased T4 B. Increased TSH and Increased T3 and T4 C. Increased TSH and decreased T3 and T4 D. Increased T3 and Decreased T4

C. Increased TSH and decreased T3 and T4

During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level

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

For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? A. Cool, clammy skin B. Distended neck veins C. Increased urine osmolarity D. Decreased serum sodium level

C. Increased urine osmolarity In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glycosuria and polyuria, losing body fluids and experiencing fluid volume deficit. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

Of the options below, is NOT a symptom of BPH? A. Urinary incontinence B. Difficulty urinating C. Intestinal pain D. Sexual dysfunction

C. Intestinal pain. Recent studies suggest that there is a correlation between lower urinary tract symptoms and sexual dysfunction in aging patients. In fact, the severity of urinary symptoms and the degree of sexual dysfunction are strongly correlated, indepently of age. In particular, community-based studies have found that a significant number of patients with symptomatic BPH have sexual dysfunction.

An allergy to bananas or kiwi may indicate a risk for reaction to which of the following? A. Propofol B. Povidone-Iodine C. Latex D. Soybean

C. Latex

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A. Whole grains B. Green leafy vegetables C. Meats and dairy products D. Broccoli and Brussels sprouts

C. Meats and dairy products Good sources of vitamin B12 include meats and dairy products. Option A: Whole grains are a good source of thiamine. Option B: Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Option D: Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

Ricky's grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

C. Metabolic Alkalosis

A patient diagnosed with hepatitis and cirrhosis has developed ascites. When assessing the patient, the healthcare provider notes an increased temperature and a decreased level of consciousness. What assessment should the healthcare provider perform next? A. Measure the patient's abdominal girth B. Auscultate the patient's lung sounds C. Obtain a urine sample for laboratory analysis D. Palpate the abdomen for tenderness

C. Obtain a urine sample for laboratory analysis

A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise B. Taking excess medication C. Omitting doses of medication D. Increasing intake of fatty foods

C. Omitting doses of medication Myasthenic crisis often is caused by under medication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger

Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Vince should expect the dose's: A. Onset to be at 2 p.m. and its peak to be at 3 p.m. B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m. C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. D. Onset to be at 4 p.m. and its peak to be at 6 p.m.

C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called? A. Turner's Sign B. McBurney's Sign C. Homan's Sign D. Cullen's Sign

D. Cullen's Sign This is known as Cullen's Sign. It represents retroperitoneal bleeding from the leakage of digestive enzymes from the inflamed pancreas into the surrounding tissues which is causing bleeding and it is leaking down to umbilicus tissue. Remember the C in Cullen for "circle" and the belly button forms a circle. The patient can also have Turner's Sign which is a bluish discoloration at the flanks (side of the abdomen). Remember this by TURNER ("turn her" over on her side) which is where the bluish discoloration will be.

A nurse is inserting a nasogastric tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action? A. Quickly insert the tube B. Notify the physician immediately C. Remove the tube and reinsert when the respiratory distress subsides D. Pull back on the tube and wait until the respiratory distress subsides

D. Pull back on the tube and wait until the respiratory distress subsides During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

A nurse is caring for a 40-year-old patient who is recovering from surgery and who has been prescribed a Dilaudid PCA. In order to best prevent pulmonary complications from opioid use, which of the following interventions should the nurse implement? A. Review the set up parameters for the PCA whenever the drug has not been used with the patient before B. Teach the patient that only he or a family member should push the button for pain medication C. Ask an anesthesiologist to help set up the PCA to ensure that the patient receives the correct amount D. Read the PCA order and double-check it with another nurse while setting the machine limits

D. Read the PCA order and double-check it with another nurse while setting the machine limits Patient-controlled analgesia (PCA) can lessen the potential for errors when the patient uses it correctly. The patient receives pain medication when he needs it and the machine locks out after a certain point to be sure that the patient does not receive too much. To uphold the safety of the patient while using PCA, the nurse should double-check the orders and the set of the PCA with another nurse before starting the system with the patient.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? A. An elevated hemoglobin level B. A decreased reticulocyte count C. An elevated RBC count D. Red blood cells that are microcytic and hypochromic

D. Red blood cells that are microcytic and hypochromic The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated

Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take? A. Discard the residual amount. B. Hold the due feeding. C. Skip the feeding and administer the next feeding due in 4 hours. D. Reinstill the amount and continue with administering the feeding.

D. Reinstill the amount and continue with administering the feeding. If the residual feeding is less than 100ml, feeding is administered.

A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury? A. Monitor blood glucose twice a day. B. Instruct the relative to stay with the nurse. C. Measure 24-hour intake and output. D. Secure all connections in the parenteral system.

D. Secure all connections in the parenteral system. The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart.

The nurse is examining a client who reports they have pain in the LLQ of their abdomen. The nurse knows which of the following is located in the LLQ? A. Gallbladder B. Pancreas C. Appendix D. Sigmoid colon

D. Sigmoid colon Pain in this area may indicate ulcerative colitis

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? A. Potassium B. Phosphate C. Chloride D. Sodium

D. Sodium

The physician orders a patient with pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly?* A. Abdominal girth is decreased B. Skin turgor is less than 2 seconds C. Blood glucose is 250 D. Stools appear formed and solid

D. Stools appear formed and solid Pancreatic enzymes help the body break down carbs, proteins, and fats because the body is not sufficiently producing digestive enzymes anymore. Hence, the stool will not appear as oily or greasy (decrease in steatorrhea) but appear solid and formed.

A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? A. Hyperglycemia B. HIV C. Rheumatoid Arthritis D. Systemic lupus erythematosus (SLE)

D. Systemic lupus erythematosus (SLE)

A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

D. Take measures to prevent injury. Protecting the client from injury is the immediate priority during a seizure.

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals B. Doing muscle-strengthening exercises C. Doing all chores early in the day while less fatigued D. Taking medications on time to maintain therapeutic blood levels

D. Taking medications on time to maintain therapeutic blood levels Taking medications correctly to maintain blood levels that are not too low or too high is important.

A nurse is conducting a follow-up home visit to a client who has been discharged with a parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy? A. Blood pressure and temperature. B. Blood pressure and pulse rate. C. Height and weight. D. Temperature and weight.

D. Temperature and weight. The client's temperature is monitored to identify signs of infection which is one of the complications of this therapy. While the weight is monitored to detect hypervolemia and to determine the effectiveness of this nutritional therapy.

Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? A. TURP is the most common operation for BPH. B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free.

D. He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

A patient is being assessed for possible heart failure. Which of these laboratory results will provide support this diagnosis? A. Decreased C-reactive protein B. Increased creatine kinase C. Decreased serum sodium D. Increased brain natriuretic peptide (BNP)

D. Increased brain natriuretic peptide (BNP)

A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensure the availability of which medical equipment before hanging the solution? A. Glucometer. B. Dressing tray. C. Nebulizer. D. Infusion pump.

D. Infusion pump. The nurse should prepare an infusion pump prior hanging a parenteral solution. The use of an infusion pump is important to make sure that the solution does not infuse too quickly or delayed since the parenteral nutrition has a high glucose content. Option A: A glucometer is also needed since the client's glucose level is monitored every 4 to 6 hours, but it is not an essential item needed. Options B and C are not used before hanging a PN solution.

A patient is brought to the emergency department for treatment. His potassium levels are 5.9 mEq/L. Based on these results, which symptoms would the nurse most likely see? A. Hypotension B. Constipation C. Flushed face D. Irregular pulse

D. Irregular pulse

While palpating a female client's right upper quadrant (RUQ), the nurse would expect to find which of the following structures? A. Sigmoid colon B. Appendix C. Spleen D. Liver

D. Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

A patient is admitted to the medical unit with a diagnosis of hepatitis. When preparing to administer intravenous medications, the healthcare provider understands that the patient's diagnosis primarily impacts which phase of pharmacokinetics? A. Distribution B. Excretion C. Absorption D. Metabolism

D. Metabolism

A nurse is caring a client who disconnected the tubing of the parenteral nutrition from the central line catheter. A nurse suspects an occurrence of an air embolism. Which of the following is an appropriate position for the client in this kind of situation? A. On the right side, with head higher than the feet. B. On the right side, with head lower than the feet. C. On the left side, with the head higher than the feet. D. On the left side, with head lower than the feet

D. On the left side, with head lower than the feet. Air embolism happens because of the entry of air into the catheter system. If it occurs, the client should be placed in a left-side-lying position with the head be lower than the feet. This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart.

A patient receiving parenteral nutrition is administered via the following routes except: A. Subclavian line. B. Central Venous Catheter. C. PICC (Peripherally inserted central catheter) line. D. PEG tube.

D. PEG tube. Percutaneous endoscopic gastrostomy (PEG tube) is inserted into a person's stomach through the abdominal wall that is used to provide a means of feeding when oral intake is not adequate. While Parenteral nutrition bypasses the digestive system by the administration to the bloodstream.

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D. Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

The results of an adult patient's blood pressure screening on three occasions are: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information? A. Normal blood pressure B. Hypertension Stage 2 C. Hypertension Stage 1 D. Prehypertension

D. Prehypertension

a nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? a. "I will plan to limit my fiber daily" b. "I will restrict fluid intake during meals" c. "I was switched to black tea instead of drinking coffee" d. "I will try to eat cold foods rather than warm when my stomach feels upset"

a. "I will plan to limit my fiber daily"

A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate? a. "Tell me more about situations that are causing you stress." b. "You need to see a family therapist for some help with stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

a. "Tell me more about situations that are causing you stress." The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment

a nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. which of the following instructions should the nurse include? a. Rise slowly when standing b. expect urine to become a dark colored c. avoid foods containing tyramine d. report any skin discoloration

a. Rise slowly when standing

A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the anesthesia care provider is notified? a. Surgery will be done as scheduled. b. Surgery will be rescheduled for the following day. c. Surgery will be postponed for 8 hours after the fluid intake. d. A nasogastric tube will be inserted to remove the fluids from the stomach.

a. Surgery will be done as scheduled. The preoperative fasting recommendations of the American Society of Anesthesiology indicate that clear liquids may be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? a. 59-year-old patient with an acute myocardial infarction and a temperature of 99.8° F b. 6-month-old patient with bacterial meningitis and a temperature of 104.2° F c. 82-year-old patient after hip replacement surgery and a temperature of 100.4° F d. 14-year-old patient with infectious mononucleosis and a temperature of 101.6° F

b. 6-month-old patient with bacterial meningitis and a temperature of 104.2° F Moderate fevers (up to 103° F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104° F) should be treated with antipyretics. High fevers can damage body cells, and delirium and seizures can occur.

a nurse is providing teaching about colon cancer to a group of females 45 to 65 years of age. Which of the following statements should the nurse include in the teaching? a. Colonoscopies Four individuals with no family history of cancer should begin at age 40 b. A sigmoidoscopy is recommended every five years beginning at age 60 c. Fecal occult blood tests should be done annually beginning at age 50 d. An MRI provides a definite diagnosis of colon cancer

b. A sigmoidoscopy is recommended every five years beginning at age 60

Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

b. Application of cold packs before exercise may decrease joint pain. Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A 17-year-old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. Witness the permit after consent is obtained by the surgeon. b. Call a parent or legal guardian to sign the permit, since the patient is under 18. c. Obtain verbal consent, since written consent is not necessary for emancipated minors. d. Investigate your state's nurse practice act related to emancipated minors and informed consent.

a. Witness the permit after consent is obtained by the surgeon. An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.

a nurse is teaching a client who has a new prescription for Clopidogril. Which of the following instructions should the nurse include? (Select all that apply) a. avoid taking herbal supplements while taking this medication b. monitor for the presence of black, tarry stool c. take this medication when you have pain d. schedule a weekly PT test e. limit food sources containing vitamin K while taking this medication

a. avoid taking herbal supplements while taking this medication b. monitor for the presence of black, tarry stool

a nurse is reviewing the medical records of a client who has suspected ovarian cancer. Which of the following findings should the nurse identify as a risk factor for ovarian cancer? Select all that apply a. previous treatment for endometriosis b. family history of colon cancer c. 1st pregnancy at age 24 d. report a first period at age 14 e. use of oral contraceptives for 10 years

a. previous treatment for endometriosis b. family history of colon cancer

After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says, a. it is important for me to perform my prescribed exercises every day b. I should perform most of my daily chores in the morning when my energy level is highest c. an ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints

b. I should perform most of my daily chores in the morning when my energy level is highest

a nurse is providing dietary teaching about calcium rich foods to a client who has osteoporose sis. Which of the following foods should the nurse include in the instructions? a. White bread b. Kale c. apples d. Brown rice

b. Kale

A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should... a. give the patient a bed bath to conserve her energy b. allow the patient a rest period before showering with the nurses' help c. tell the patient that she can skip bathing if she will walk in the hall later d. inform the patient that it is important for her to maintain self-care activities

b. allow the patient a rest period before showering with the nurses' help

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. Fluctuations in blood pressure b. loss of cognitive function c. ineffective coughing d. drooping eyelids

b. loss of cognitive function

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (Select all that apply) a. history of consuming one glass of wine daily b. lost in height of two inches c. body mass index of 18 d. kyphotic curve at upper thoracic spine e. history of lactose intolerant

b. lost in height of two inches c. body mass index of 18 d. kyphotic curve at upper thoracic spine e. history of lactose intolerant

a nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? a. Apply heat to you puncture site b. place the client in a supine position c. turn the client every one hour d. ambulat the client within the first hour post procedure

b. place the client in a supine position

a nurse is caring for a client who has Parkinson's disease in his starting to display Brady kinesia. Which of the following is an appropriate action by the nurse? a. Teach a client to walk more quickly when ambulating b. complete passive range of motion exercises daily c. place the client on a low protein, low calorie diet d. give the client extra time to perform activities

d. give the client extra time to perform activities

Laboratory findings that the nurse would expect to be present in the patient with RA include... a. polycythemia b. increased IgG c. decreased WBC d. increased C-reactive protein (CRP)

d. increased C-reactive protein (CRP)

A nurse is reviewing the plan of care for a client who has leukemia it has developed thrombocytopenia. Which of the following actions should the nurse take first? a. Instruct the client to take rest periods throughout the day b. encourage the clients reposition in bed every two hours c. check temperature every four hours d. monitor platelet count

d. monitor platelet count

A nurse is assessing a client who has chronic peripheral arterial disease. Which of the following findings should the nurse expect? a. Edema around the ankles and feet b. ulceration around the medial malleoli c. scaling eczema of the lower legs with stasis dermatitis d. pallor on elevation of the limbs, and rubor when the limbs are dependent

d. pallor on elevation of the limbs, and rubor when the limbs are dependent

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." An appropriate nursing diagnosis for the patient is... a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

d. social isolation related to embarrassment about the effects of SLE. The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

a nurse is teaching a client who was multiple sclerosis and a new prescription for Baclofen. Which of the following statements should the nurse include in the teaching? a. This medication will help you with your tremors b. this medication will help you with your bladder function c. this medication can cause your skin to bruise easily d. this medication can cause you to experience dizziness

d. this medication can cause you to experience dizziness

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. 1. The R to R intervals are relatively consistent 2. One P wave precedes each QRS complex 3. Four to eight complexes occur in a 6-second strip 4. The ST segment is higher than the PR interval 5. The QRS complex ranges from 0.12 to 0.20 second.

1 and 2 The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. Option C: The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Option D: Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. Option E: The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.

The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 2. Head is tilted down while inhaling the medication 3. Client waits 5 minutes between puffs. 4. Mouth is rinsed with water following administration 5. Client lies supine for 15 minutes following administration.

1 and 4

Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds 2. Auscultation of bowel sounds 3. Presence of chest pain. 4. Presence of peripheral edema 5. Color of nail beds

1, 3, 5. A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn't understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: 1. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities." 2. "Here we teach you to gradually change your lifestyle to accommodate your heart disease." 3. "You are probably right but we can gradually increase your activities so that you can live a more active life." 4. "Do you feel that you will have to make some changes in your life now?"

1. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities." Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell on his negativity about it.

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. A 55-year-old African American male. African Americans have twice the rate of CVA's as Caucasians; males are more likely to have strokes than females except in advanced years. Option 2: Oriental's have a lower risk, possibly due to their high omega-3 fatty acids. Option 4: Pregnancy is a minimal risk factor for CVA.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? 1. A change in the pattern of her pain 2. Pain during sex 3. Pain during an argument with her husband 4. Pain during or after an activity such as lawn mowing

1. A change in the pattern of her pain The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD.

A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which intervention do you include in his plan of care? 1. Apply pressure to the needle site upon discontinuing hemodialysis 2. Keep the head of the bed elevated 45 degrees 3. Place the left arm on an arm board for at least 30 minutes 4. Keep the left arm dry

1. Apply pressure to the needle site upon discontinuing hemodialysis Apply pressure when discontinuing hemodialysis and after removing the venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in some patients.

After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated? 1. Disequilibrium syndrome 2. Respiratory distress 3. Hypervolemia 4. Peritonitis

1. Disequilibrium syndrome Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body's cells into the vascular system.

You're caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before her paracentesis, you instruct her to: 1. Empty her bladder. 2. Lie supine in bed. 3. Remain NPO for 4 hours. 4. Clean her bowels with an enema.

1. Empty her bladder. A full bladder can interfere with paracentesis and be punctured inadvertently.

The dialysis solution is warmed before use in peritoneal dialysis primarily to: 1. Encourage the removal of serum urea. 2. Force potassium back into the cells. 3. Add extra warmth into the body. 4. Promote abdominal muscle relaxation.

1. Encourage the removal of serum urea. The main reason for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Options B and D: The warmed solution does not force potassium into the cells or promote abdominal muscle relaxation. Option C: Warmed dialyzing solution also contributes to client comfort by preventing chilly sensations, but this is a secondary reason for warming the solution.

If a client continues to hypoventilate, the nurse will continually assess for a complication of: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood.

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? 1. Incorporate physical exercise as tolerated into the treatment plan. 2. Monitor peak flow numbers after meals and at bedtime. 3. Eliminate stressors in the work and home environment 4. Use sedatives to ensure uninterrupted sleep at night.

1. Incorporate physical exercise as tolerated into the treatment plan. Physical exercise is beneficial and should be incorporated as tolerated into the client's schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Peak flow does not need to be monitored after each meal. Stressors in the client's life should be modified but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.

Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD? 1. Increased anteroposterior chest diameter 2. Underdeveloped neck muscles 3. Collapsed neck veins 4. Increased chest excursions with respiration

1. Increased anteroposterior chest diameter

Which of the following symptoms is common in clients with TB? 1. Weight loss 2. Increased appetite 3. Dyspnea on exertion 4. Mental status changes

1. Weight loss TB typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats.

When assessing a patient for signs of fluid overload, the nurse would expect to observe: A. bounding pulse B. flat neck veins C. poor skin turgor D. vesicular

A. bounding pulse

Adrenocorticotropic hormone (ACTH) from the pituitary stimulates the __________ glands to release _________. A. pineal, cortisol B. adrenal, cortisol C. pineal, TSH D. adrenal, TSH

B. adrenal, cortisol

An allergy to shellfish may indicate a risk for reaction to which of the following? A. Propofol B. Povidone-Iodine C. Latex D. Soybean

B. Povidone-Iodine

Cushing's Syndrome is a hormone disorder caused by high levels of what? A. Y Chromosomes B. Fiber in the digestive tract C. Cortisol in the blood D. Unprotected sexual contact

C. Cortisol in the blood

A nurse is reviewing the laboratory test results of a client with acute exacerbation of Crohn's Disease. Which of the following blood labs would the nurse expect to be elevated? (select all the apply) a) HCT b) erythrocyte sedimentation rate c) WBC d) Folic Acid e) albumin

b) erythrocyte sedimentation rate c) WBC HCT would be decreased folic acid would be decreased albumin would be decreased

A nurse is completing discharge teaching to a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? a. decrease intake of calorie dense foods b. drink canned protein supplements c. increase intake of high fiber foods d. eat high residual foods

b. drink canned protein supplements Crohn's disease: increase protein, low-fiber, and low residual foods

In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that... a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low-dose hydrocortisone d. CFS is characterized by progressive memory impairment

b. many symptoms are similar to fibromyalgia syndrome Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that cause headaches. The nurse should recommend that the client avoid which of the following foods? a. baked salmon b. salted cashews (tyramine) c. frozen strawberries d. fresh asparagus

b. salted cashews (tyramine)

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is... a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

c. "It is important to start methotrexate early to decrease the extent of joint damage." Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

A nurse is teaching a client who has a new prescription of sulfasalazine. which of the following instructions should the nurse include in the teaching? a. "Take the medication 2 hours before eating" b. "discontinue this medication if your skin turns yellow-orange" c. "notify the provider if you experience a sore throat" d. "expect your stool to turn black"

c. "notify the provider if you experience a sore throat"

Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management? a. Avoid use of over-the-counter antihistamines or decongestants. b. A low-residue, low-fiber diet will reduce any abdominal distention. c. A gradual increase in your daily exercise may help decrease fatigue. d. Chronic fatigue syndrome usually progresses as patients become older.

c. A gradual increase in your daily exercise may help decrease fatigue. A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with chronic fatigue syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. Chronic fatigue syndrome usually does not progress

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

c. C-reactive protein level C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

a nurse any clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. which of the following statements by the client indicates understanding of the teaching? a. This medication will relieve my symptoms by causing my blood vessels to dilate b. I should take this medication daily to prevent the headache from occurring c. I should expect facial flushing when I take this medication d. this medication will lower my sensitivity to food triggers

c. I should expect facial flushing when I take this medication

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a.Tell the patient to come back tomorrow, since he ate a meal. b. Proceed with the preoperative checklist, including site identification. c. Notify the anesthesia care provider of when and what the patient last ate. d. Have the patient void before administering any preoperative medications

c. Notify the anesthesia care provider of when and what the patient last ate. The nothing by mouth (NPO) protocol of each surgical facility should be followed. -Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. -If a patient has not followed the NPO instructions, surgery may be delayed or canceled. -The nurse should notify the anesthesia care provider immediately.

The nurse is caring for clients on a medical floor. Which client should the nurse assess first? a. The client diagnosed with advanced Rheumatoid Arthritis who is complaining of pain at a "3" on a 1-10 scale b. The client diagnosed with Systemic Lupus Erythematosus who has a rash across the bridge of the nose c. The client diagnosed with advanced Rheumatoid Arthritis who is receiving antineoplastic drugs IV d. The client diagnosed with COPD who's oxygen saturation is at 90%

c. The client diagnosed with advanced Rheumatoid Arthritis who is receiving antineoplastic drugs IV

a nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant Melanoma? select all that apply a. Diffuse vesicles b. Uniformly colored papule c. area of asymmetric borders d. rough, scaly Patch e. irregular colored mole

c. area of asymmetric borders e. irregular colored mole

a nurse is assessing a client who has been taking prednisone following an exacerbation of IBD. the nurse should recognize which of the following findings as the priority/ a. client reports difficulty sleeping b. the client's urine is positive for glucose c. client reports having an elevated body temp d. client reports gaining 4 lbs. in the last 6 months

c. client reports having an elevated body temp

A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that a. RA is usually more severe in older adults b. older patients are not as likely to comply with treatment regimens c. drug interactions and toxicity are more likely to occur with multidrug therapy d. laboratory and other diagnostic tests are not effective in identifying RA in older adults

c. drug interactions and toxicity are more likely to occur with multidrug therapy

a nurse is caring for a client who has a deep vein thrombosis and has been taking unfractionated heparin for one week. Two days ago, the provider has prescribed Warfarin. The client asks the nurse about receiving both heparin an warfarin at the same time. Which of the following statements should the nurse give? a. I will remind you provided that you were already receiving heparin b. your laboratory findings indicate that two anticoagulants are needed c. it takes three to four days before therapeutic effects of warfarin are achieved, and then the heparin it can be discontinued d. only one of these medications is being given to treat your deep vein thrombosis

c. it takes three to four days before therapeutic effects of warfarin are achieved, and then the heparin it can be discontinued

A nurse is caring for a client who displays manifestations of stage three Parkinson's disease. Which of the following actions should the nurse include? a. Recommend a community support group b. integrate a daily exercise routine c. provide a walker for ambulation d. perform ADLs for the client

c. provide a walker for ambulation

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release and leave the ring on. b. Tape the wedding ring securely to the patient's finger. c. Tell the patient that the hospital is not liable for loss of the ring. d. Suggest that the patient give the ring to a family member to keep.

d. Suggest that the patient give the ring to a family member to keep.

a nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse asked to identify the aura type of migraine headaches? a. Do the headaches occur multiple times each day? b. Is your headache accompanied by profuse facial sweating? c. Does your headache occur on one side of your head? d. Do you have the same manifestations each time the headache occurs?

d. Do you have the same manifestations each time the headache occurs?

A patient is seen in the emergency department for a sprain. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? a. Hyperbaric therapy and passive range of motion b. Antipyretic and antibiotic drug therapy c. Warm, moist heat and debridement d. Rest, ice, compression, and elevation

d. Rest, ice, compression, and elevation Rationale: Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.

Which intervention has the highest priority when caring for a client diagnosed with RA? a. Encourage the client to ventilate feelings about the disease process b. Discuss the effects of disease on the client's career and other life roles c. Instruct the client to perform most important activities in the morning d. Teach the client the proper use of hot and cold therapy to provide pain relief

d. Teach the client the proper use of hot and cold therapy to provide pain relief

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.

d. The patient's father died after receiving general anesthesia for abdominal surgery.

a nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a. Use music therapy for relaxation when the onset of the headache b. increased physical activity when a headache is present c. drink beverages that contain artificial sweeteners to prevent headaches d. apply a cool cloth to the face during a headache

d. apply a cool cloth to the face during a headache

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they... a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.

d. avoid activities that require repetitive use of the same muscles and joints. Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? 1. Asterixis 2. Chvostek's sign 3. Trousseau's sign 4. Hepatojugular reflex

1. Asterixis Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? 1. Body image 2. Ostomy care 3. Sexual concerns 4. Skin care

2. Ostomy care Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge.

The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's outflow is less than the inflow. Select actions that the nurse should take. (select all that apply) 1. Place the client in good body alignment 2. Check the level of the drainage bag 3. Contact the physician 4. Check the peritoneal dialysis system for kinks 5. Reposition the client to his or her side

1, 2, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

Which of the following nursing interventions should be included in the client's care plan during dialysis therapy? 1. Limit the client's visitors 2. Monitor the client's blood pressure 3. Pad the side rails of the bed 4. Keep the client NPO.

2. Monitor the client's blood pressure Because hypotension is a complication of peritoneal dialysis, the nurse records intake, and output, monitors VS, and observes the client's behavior. Option A: The nurse also encourages visiting and other diversional activities. Options C and D: A client on PD does not need to be placed in bed with padded side rails or kept NPO.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? 1. Notify the physician 2. Monitor the client 3. Elevate the head of the bed 4. Medicate the client for nausea

1. Notify the physician Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsant medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified

Which of the following instructions should be included in the discharge teaching for a patient discharged with a transdermal nitroglycerin patch? 1. "Apply the patch to a non hairy, nonfatty area of the upper torso or arms." 2. "Apply the patch to the same site each day to maintain consistent drug absorption." 3. "If you get a headache, remove the patch for 4 hours and then reapply." 4. "If you get chest pain, apply a second patch right next to the first patch."

1. "Apply the patch to a nonhairy, nonfatty area of the upper torso or arms." A nitroglycerin patch should be applied to a nonhairy, nonfatty area for the best and most consistent absorption rates. Option B: Sites should be rotated to prevent skin irritation. Option C: The drug should be continued if headache occurs because tolerance will develop. Option D: Sublingual nitroglycerin should be used to treat chest pain.

A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? 1. Administer oxygen 2. Elevate the foot of the bed 3. Restrict the client's fluids 4. Prepare the client for hemodialysis.

1. Administer oxygen Airway and oxygenation are always the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try to increase his levels by administering oxygen. Option B: The foot of the bed may be elevated to reduce edema, but this isn't the priority. Options C and D: The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia.

You are developing a care plan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? 1. Administering a lactulose enema as ordered. 2. Encouraging a protein-rich diet. 3. Administering sedatives, as necessary. 4. Encouraging ambulation at least four times a day.

1. Administering a lactulose enema as ordered. You may administer the laxative lactulose to reduce ammonia levels in the colon.

Hepatic encephalopathy develops when the blood level of which substance increases? 1. Ammonia 2. Amylase 3. Calcium 4. Potassium

1. Ammonia Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter systemic circulation, which carries it to the brain.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge versus intravenous.

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II

1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.

Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of: 1. Cerebrovascular accident 2. Liver disease 3. Myocardial infarction 4. Pulmonary disease

1. Cerebrovascular accident Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, hypertension may go undetected. CVA's can be related to long-term hypertension. Option B and D: Liver or pulmonary disease is generally not associated with hypertension. Option C: Myocardial infarction is generally related to coronary artery disease

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: 1. Check the client status and lead placement 2. Press the recorder button on the electrocardiogram console. 3. Call the physician 4. Call a code blue

1. Check the client status and lead placement Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.

When turning a client the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean area with mild soap, and dry. 2. Apply a dilute hydrogen peroxide and water mixture, and use a heat lamp on the area 3. Soak the area in normal saline solution 4. Wash the area with an astringent

1. Clean area with mild soap, and dry. The skin should be cleansed and completely dried. Option 2 - Hydrogen peroxide can be irritating to the tissue and should not be used. A heat lamp is not necessary and would increase the client's risk of an accidental burn. Option 3 - The area should not be soaked, as this may lead to maceration of the skin. Option 4 - The area should not be cleansed with an astringent. An astringent may cause excessive drying of the tissue.

Which of the following is the most significant sign of peritoneal infection? 1. Cloudy dialysate fluid 2. Swelling in the legs 3. Poor drainage of the dialysate fluid 4. Redness at the catheter insertion site

1. Cloudy dialysate fluid Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and symptoms of infection are fever, hyperactive bowel sounds, and abdominal pain. Option B: Swollen legs may be indicative of congestive heart failure. Option C: Poor drainage of dialysate fluid is probably the result of a kinked catheter. Option D: Redness at the insertion site indicates local infection, not peritonitis. However, a local infection that is left untreated can progress to the peritoneum.

Fistulas are most common with which of the following bowel disorders? 1. Crohn's disease 2. Diverticulitis 3. Diverticulosis 4. Ulcerative colitis

1. Crohn's disease The lesions of Crohn's disease are transmural; that is, they involve all thickness of the bowel. These lesions may perforate the bowel wall, forming fistulas with adjacent structures. Fistulas don't develop in diverticulitis or diverticulosis. The ulcers that occur in the submucosal and mucosal layers of the intestine in ulcerative colitis usually don't progress to fistula formation as in Crohn's disease.

A 45-year-old male client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that leg ulcers of this nature are usually caused by: 1. Decreased arterial blood flow secondary to vasoconstriction 2. Decreased arterial blood flow leading to hyperemia 3. Atherosclerotic obstruction of the arteries 4. Trauma to the lower extremities

1. Decreased arterial blood flow secondary to vasoconstriction Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved.

When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? 1. Develop infections easily 2. Maintain current status 3. Require less supplemental oxygen 4. Show permanent improvement.

1. Develop infections easily A client with COPD is at high risk for development of respiratory infections. COPD is a slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

he nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate? 1. Excess fluid volume related to the kidney's inability to maintain fluid balance. 2. Increased cardiac output related to fluid overload. 3. Ineffective tissue perfusion related to interrupted arterial blood flow. 4. Ineffective Therapeutic Regimen Management related to lack of knowledge about therapy.

1. Excess fluid volume related to the kidney's inability to maintain fluid balance. Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fluid volume, a common complication in chronic renal failure. The client's fluid status should be monitored carefully for imbalances on an ongoing basis.

You're developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include? 1. Omit fluids with meals. 2. Increase carbohydrate intake. 3. Decrease protein intake. 4. Decrease fat intake.

1. Omit fluids with meals. Gastric emptying time can be delayed by omitting fluids from your patient's meal. A diet low in carbs and high in fat & protein is recommended to treat dumping syndrome.

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: 1. Headache 2. High blood pressure 3. Shortness of breath 4. Stomach cramps

1. Headache Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or sit down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps.

A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure? 1. Hypoalbuminemia 2. Increased capillary permeability 3. Abnormal peripheral vasodilation 4. Excess rennin release from the kidneys

1. Hypoalbuminemia Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney's aren't direct ramifications of liver failure.

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: 1. Hypotension and dizziness 2. Nausea and vomiting 3. Hypertension and headache 4. Flat neck veins

1. Hypotension and dizziness The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? 1. It is likely that the client is developing a secondary bacterial pneumonia. 2. The assessment findings are consistent with influenza and are to be expected. 3. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions. 4. The client has not been taking her decongestants and bronchodilators as prescribed.

1. It is likely that the client is developing a secondary bacterial pneumonia. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.

The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: 1. MOM can cause magnesium toxicity 2. MOM is too harsh on the bowel 3. Metamucil is more palatable 4. MOM is high in sodium

1. MOM can cause magnesium toxicity Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. Option B: MOM is harsher than Metamucil, but magnesium toxicity is a more serious problem. Option C: A client may find both MOM and Metamucil unpalatable. Option D: MOM is not high in sodium.

Which of the following is a priority goal for the client with COPD? 1. Maintaining functional ability 2. Minimizing chest pain 3. Increasing carbon dioxide levels in the blood 4. Treating infectious agents

1. Maintaining functional ability A priority goal for the client with COPD is to manage the s/s of the disease process so as to maintain the client's functional ability. Chest pain is not a typical sign of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet? 1. Meats and beans. 2. Butter and gravies. 3. Potatoes and pastas. 4. Cakes and pastries.

1. Meats and beans. Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted.

A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of: 1. Meats and citrus fruits 2. Grains and broccoli 3. Eggs and spinach 4. Potatoes and fish

1. Meats and citrus fruits The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C.

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: 1. Normal sinus rhythm 2. Sinus bradycardia 3. Sinus tachycardia 4. Atrial flutter

1. Normal sinus rhythm

Using the Braden scale, which client is at highest risk for developing a pressure ulcer? 1. One with a score of 15 2. One with a score of 18 3. One with a score of 20 4. One with a score of 23

1. One with a score of 15 clients with a score of less than 18 are at risk for developing a pressure ulcer. A maximum score is 23.

A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device? 1. Insert I.V. lines above the fistula. 2. Avoid taking blood pressures in the arm with the fistula. 3. Palpate pulses above the fistula. 4. Report a bruit or thrill over the fistula to the doctor.

2. Avoid taking blood pressures in the arm with the fistula. Don't take blood pressure readings in the arm with the fistula because the compression could damage the fistula. Option A: IV lines shouldn't be inserted in the arm used for hemodialysis. Option C: Palpate pulses below the fistula. Option D: Lack of bruit or thrill should be reported to the doctor.

Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include? 1. "You'll need to lie on your stomach during the test." 2. "You'll need to lie on your right side after the test." 3. "During the biopsy you'll be asked to exhale deeply and hold it." 4. "The biopsy is performed under general anesthesia."

2. "You'll need to lie on your right side after the test." After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage.

A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is: 1. A bloody, productive cough 2. A cough with the expectoration of mucoid sputum 3. Chest pain 4. Dyspnea

2. A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.

A client with chronic renal failure has asked to be evaluated for a home continuous ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage of this approach is that it: 1. Is relatively low in cost 2. Allows the client to be more independent 3. Is faster and more efficient than standard peritoneal dialysis 4. Has fewer potential complications than standard peritoneal dialysis

2. Allows the client to be more independent The major benefit of CAPD is that it frees the client from daily dependence on dialysis centers, home health care personnel, and machines for life-sustaining treatment. The independence is a valuable outcome for some people. Option A: CAPD is costly and must be done daily. Option D: Side effects and complications are similar to those of standard peritoneal dialysis.

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: 1. Open and dilate the blocked coronary arteries 2. Assess the extent of arterial blockage 3. Bypass obstructed vessels 4. Assess the functional adequacy of the valves and heart muscle

2. Assess the extent of arterial blockage Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: 1. Sinus tachycardia 2. Atrial fibrillation 3. Ventricular tachycardia 4. Ventricular fibrillation

2. Atrial fibrillation Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective? 1. Pruritus 2. Dyspnea 3. Jaundice 4. Peripheral Neuropathy

2. Dyspnea Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient's breathing. The others are signs of cirrhosis that aren't relieved by paracentesis.

The most common early sign of kidney disease is: 1. Sodium retention 2. Elevated BUN level 3. Development of metabolic acidosis 4. Inability to dilute or concentrate urine

2. Elevated BUN level Increased BUN is usually an early indicator of decreased renal function.

What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? 1. Activity intolerance 2. Fluid volume excess 3. Knowledge deficit 4. Pain

2. Fluid volume excess Fluid volume excess because the kidneys aren't removing fluid and wastes. The other diagnoses may apply, but they don't take priority.

A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first? 1. Take a full medication history 2. Give a bronchodilator by nebulizer 3. Apply a cardiac monitor to the client 4. Provide emotional support to the client.

2. Give a bronchodilator by nebulizer The client is having an acute asthma attack and needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First, resolve the acute phase of the attack ad how to prevent attacks in the future. It may not be necessary to place the client on a cardiac monitor because he's only 19-years-old, unless he has a past medical history of cardiac problems.

A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should the nurse give the client? 1. Low fiber, low-fat 2. High fiber, low-fat 3. Low fiber, high-fat 4. High-fiber, high-fat

2. High-fiber, low-fat The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of: 1. Infection 2. Hyperglycemia 3. Fluid overload 4. Disequilibrium syndrome

2. Hyperglycemia An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis

A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: 1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. 2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. 3. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for this to begin. 4. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic.

2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information given if the client states to record the daily: 1. Pulse and respiratory rate 2. Intake, output, and weight 3. BUN and creatinine levels 4. Activity log

2. Intake, output, and weight The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: 1. Elevating the limb above heart level 2. Lowering the limb so it is dependent 3. Massaging the limb after application of cold compresses 4. Placing the limb in a plane horizontal to the body

2. Lowering the limb so it is dependent

The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1. Monitor the client's level of consciousness 2. Maintain strict aseptic technique 3. Add heparin to the dialysate solution 4. Change the catheter site dressing daily

2. Maintain strict aseptic technique The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option D may assist in preventing infection, this option relates to an external site.

A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? 1. Absence of bruit on auscultation of the fistula. 2. Palpation of a thrill over the fistula 3. Presence of a radial pulse in the left wrist 4. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand.

2. Palpation of a thrill over the fistula The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. Option A: The presence of a thrill and bruit indicate patency of the fistula. Options C and D: Although the presence of a radial pulse in the left wrist and capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand are normal findings; they do not assess fistula patency.

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? 1. An acute obstruction in the vessels of the legs 2. Peripheral vascular problems in both legs 3. Diabetes 4. Calcium deficiency

2. Peripheral vascular problems in both legs Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. Option A: If an obstruction were present, the leg pain would persist when the client stops walking. Option D: Low calcium levels may cause leg cramps but would not necessarily be related to walking.

Atherosclerosis impedes coronary blood flow by which of the following mechanisms? 1. Plaques obstruct the vein 2. Plaques obstruct the artery 3. Blood clots form outside the vessel wall 4. Hardened vessels dilate to allow blood to flow through

2. Plaques obstruct the artery Option A: Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Option C: Atherosclerosis is a direct result of plaque formation in the artery. Option D: Hardened vessels can't dilate properly and, therefore, constrict blood flow.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram

2. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Option 1: Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Option 3: Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. Option 4: An echocardiogram is not needed for the client with a thrombotic stroke.

Which of the following symptoms is associated with ulcerative colitis? 1. Dumping syndrome 2. Rectal bleeding 3. Soft stools 4. Fistulas

2. Rectal bleeding

Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad

2. Sitting in Fowler's position None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.

The nurse notes a client's skin is reddened, with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

2. Stage II This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater. 1. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. The description is not consistent with a stage I pressure ulcer. 3. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through the muscle. The description is not consistent with a stage III pressure ulcer. 4. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The description is not consistent with a stage IV pressure ulcer.

When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that: 1. Moderate doses of two different types of diuretics are more effective than a large dose of one type 2. This combination promotes diuresis but decreases the risk of hypokalemia 3. This combination prevents dehydration and hypovolemia 4. Using two drugs increases osmolality of plasma and the glomerular filtration rate

2. This combination promotes diuresis but decreases the risk of hypokalemia Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-losing diuretic. Giving these together minimizes electrolyte imbalance.

In planning teaching strategies for the client with chronic renal failure, the nurse must keep in mind the neurologic impact of uremia. Which teaching strategy would be most appropriate? 1. Providing all needed teaching in one extended session. 2. Validating frequently the client's understanding of the material. 3. Conducting a one-on-one session with the client. 4. Using videotapes to reinforce the material as needed.

2. Validating frequently the client's understanding of the material. Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Option A: Because the client's ability to concentrate is limited, short lesions are most effective. Option C: If family members are present at the sessions, they can reinforce the material. Option D: Written materials that the client can review are superior to videotapes, because the clients may not be able to maintain alertness during the viewing of the videotape.

Which technique is considered the gold standard for diagnosing DVT? 1. Ultrasound imaging 2. Venography 3. MRI 4. Doppler flow study

2. Venography

A 2-gram sodium diet is prescribed for a client with severe hypertension. The client does not like the diet, and the nurse hears the client request that the spouse "Bring in some good home-cooked food." It would be most effective for the nurse to plan to: 1. Call in the dietician for client teaching 2. Wait for the client's family and discuss the diet with the client and family 3. Tell the client that the use of salt is forbidden, because it will raise BP 4. Catch the family members before they go into the client's room and tell them about the diet.

2. Wait for the client's family and discuss the diet with the client and family Clients' families should be included in dietary teaching; families provide support that promotes adherence

Which of the following diagnostic tests is definitive for TB? 1. Chest x-ray 2. Mantoux test 3. Sputum culture 4. Tuberculin test

3. Sputum culture The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative.

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: 1. At least 12 hours 2. The first 24 hours 3. 2-3 days 4. 1 week

3. 2-3 days

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma

3. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Option 1: High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Option 2: Bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. Option 3: Cancer is not a precursor to stroke.

Which of the following clients would least likely be at risk of developing skin breakdown? 1. A client incontinent of urine feces 2. A client with chronic nutritional deficiencies 3. A client with decreased sensory perception 4. A client who is unable to move about and is confined to bed

3. A client with decreased sensory perception Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options 1, 2, and 4 identify physiological conditions, which are the risk priorities.

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: 1. The presence of occasional coupled beats 2. Long pauses in an otherwise regular rhythm 3. A continuous and totally unpredictable irregularity 4. Slow but strong and regular beats

3. A continuous and totally unpredictable irregularity In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.

A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to oxygen, the first nursing action would be to: 1. Wait until the client's lab work is done. 2. Not administer oxygen unless ordered by the physician. 3. Administer oxygen at 2 L flow per minute. 4. Administer oxygen at 10 L flow per minute and check the client's nail beds.

3. Administer oxygen at 2 L flow per minute. Administer oxygen at 2 L/minute and no more, for if the client if emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function.

A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication: 1. 30 minutes before meals 2. On an empty stomach 3. After meals 4. On arising

3. After meals

In order to prevent the development of tolerance, the nurse instructs the patient to: 1. Apply the nitroglycerin patch every other day 2. Switch to sublingual nitroglycerin when the patient's systolic blood pressure elevates to >140 mm Hg 3. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night 4. Use the nitroglycerin patch for acute episodes of angina only

3. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each day.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature

3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.

A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? 1. Change the client's position. 2. Call the physician. 3. Check the catheter for kinks or obstruction. 4. Clamp the catheter and instill more dialysate at the next exchange time

3. Check the catheter for kinks or obstruction. The first intervention should be to check for kinks and obstructions because that could be preventing drainage. After checking for kinks, have the client change position to promote drainage. Don't give the next scheduled exchange until the dialysate is drained because abdominal distention will occur, unless the output is within parameters set by the physician. If unable to get more output despite checking for kinks and changing the client's position, the nurse should then call the physician to determine the proper intervention.

A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? 1. Adult respiratory distress syndrome (ARDS) 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

3. Chronic obstructive bronchitis Because of his extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough or peripheral edema

The term "blue bloater" refers to which of the following conditions? 1. Adult respiratory distress syndrome (ARDS) 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

3. Chronic obstructive bronchitis Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Clients with asthma don't exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and wasting)

30. A client with acute asthma is prescribed short-term corticosteroid therapy. What is the rationale for the use of steroids in clients with asthma? 1. Corticosteroids promote bronchodilation 2. Corticosteroids act as an expectorant 3. Corticosteroids have an anti-inflammatory effect 4. Corticosteroids prevent development of respiratory infections.

3. Corticosteroids have an anti-inflammatory effect Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

In a client with Crohn's disease, which of the following symptoms should not be a direct result of antibiotic therapy? 1. Decrease in bleeding 2. Decrease in temperature 3. Decrease in body weight 4. Decrease in the number of stools

3. Decrease in body weight

The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which of the following early symptoms? 1. Urge incontinence 2. Nocturia 3. Decreased force in the stream of urine 4. Urinary retention

3. Decreased force in the stream of urine Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan? 1. Clubbing of nail beds 2. Hypertension 3. Peripheral edema 4. Increased appetite

3. Peripheral edema Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan which of the following as a priority action? 1. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration. 2. Encourage increased vegetables in the diet 3. Place the client on a cardiac monitor 4. Check the sodium level

3. Place the client on a cardiac monitor The client with hyperkalemia is at risk for developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Option A: Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Option B: Vegetables are a natural source of potassium in the diet, and their use would not be increased. Option D: The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action at this time.

A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this? 1. Aortic 2. Mitral 3. Pulmonic 4. Tricuspid

3. Pulmonic Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Option A: Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Option B: Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Option D: Tricuspid valve abnormalities are heard at the 3rd and 4th intercostal spaces along the sternal border.

A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first? 1. Monitor the apical pulse rate 2. Instruct the client to take medication with food 3. Question the physician about the order 4. Caution the client to rise slowly when standing.

3. Question the physician about the order Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. The other responses are appropriate actions for a client receiving propranolol, but questioning the physician takes priority. The client's apical pulse should always be checked before giving propranolol; if the pulse rate is extremely low, the nurse should withhold the drug and notify the physician. Options A, B, and D: The other responses are appropriate actions for a client receiving propranolol, but questioning the physician takes priority. The client's apical pulse should always be checked before giving propranolol; if the pulse rate is extremely low, the nurse should withhold the drug and notify the physician.

A client's ABG results are as follows: pH: 7.16; PaCO2 80 mm Hg; PaO2 46 mm Hg; HCO3- 24 mEq/L; SaO2 81%. This ABG result represents which of the following conditions? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Option 1: rt-PA is contraindicated. Options 2 and 4: Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient? 1. Serum creatinine and BUN 2. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) 3. Serum amylase and lipase 4. Cardiac enzymes

3. Serum amylase and lipase Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis.

During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting a friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? 1. Visit her friend earlier in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down once she reaches the friend's apartment

3. Take a nitroglycerin tablet before climbing the stairs. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain-free. Option A: Visiting her friend early in the day would have no impact on decreasing pain episodes. Option B: Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? 1. Take one tablet every 2 to 5 minutes until the pain stops. 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. 3. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets. 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain persists 5 minutes later, call the physician.

3. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets. The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures.

3. Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Option 1: Current medications are relevant, but the onset of current stroke takes priority. Option 2: A complete history is not possible in emergency care. Option 4: Upcoming surgical procedures will need to be delay if t-PA is administered.

When caring for Mr. Roberto's AV shunt on his right arm, you should: 1. Cover the entire cannula with an elastic bandage 2. Notify the physician if a bruit and thrill are present 3. User surgical aseptic technique when giving shunt care 4. Take the blood pressure on the right arm instead

3. User surgical aseptic technique when giving shunt care

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principal effects are produced by: 1. Antispasmodic effect on the pericardium 2. Causing an increased myocardial oxygen demand 3. Vasodilation of peripheral vasculature 4. Improved conductivity in the myocardium

3. Vasodilation of peripheral vasculature Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

When teaching a client with a cardiac problem, who is on a high-unsaturated fatty-acid diet, the nurse should stress the importance of increasing the intake of: 1. Enriched whole milk 2. Red meats, such as beef 3. Vegetables and whole grains 4. Liver and other glandular organ meats

3. Vegetables and whole grains Vegetables and whole grains are low in fat and may reduce the risk for heart disease

A client underwent a TURP, and a large three-way catheter was inserted into the bladder with continuous bladder irrigation. In which of the following circumstances would the nurse increase the flow rate of the continuous bladder irrigation? 1. When the drainage is continuous but slow 2. When the drainage appears cloudy and dark yellow 3. When the drainage becomes bright red 4. When there is no drainage of urine and irrigating solution

3. When the drainage becomes bright red The decision made by the surgeon to insert a catheter after a TURP or prostatectomy depends on the amount of bleeding that is expected after the procedure. During continuous bladder irrigation after a TURP or prostatectomy, the rate at which the solution enters the bladder should be increased when the drainage becomes brighter red. The color indicates the presence of blood. Increasing the flow of irrigating solution helps flush the catheter well so clots do not plug it. Option B: There would be no reason to increase the flow rate when the return is continuous or when the return appears cloudy and dark yellow. Option D: Increasing the flow would be contraindicated when there is no return of urine and irrigating solution.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is: 1. The same as the client's own baseline level 2. Lower than the needed therapeutic level 3. Within the therapeutic range 4. Higher than the therapeutic range

3. Within the therapeutic range The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range.

The nurse reviews the ABG values of a client. The results indicate respiratory acidosis. Which of the following values would indicate that this acid-base imbalance exists? 1. pH of 7.48 2. PCO2 of 32 mm Hg 3. pH of 7.30 4. HCO3- of 20 mEq/L

3. pH of 7.30

A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority? 1. Maintain complete bedrest 2. Administer oxygen therapy 3. Provide frequent linen changes. 4. Provide fluid intake of 3 L/day

4. Provide fluid intake of 3 L/day A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.

A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide? 1. "Eat foods high in potassium." 2. "Take daily potassium supplements." 3. "Discontinue sodium restrictions." 4. "Avoid salt substitutes."

4. "Avoid salt substitutes." Because Spironolactone is a potassium-sparing diuretic, the client should avoid salt substitutes because of their high potassium content. Options A, B, and C: The client should also avoid potassium-rich foods and potassium supplements. To reduce fluid volume overload, sodium restrictions should continue.

When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include? 1. "Drink 6 glasses of fluid each day." 2. "Avoid grain products and nuts." 3. "Add at least 4 grams of bran to your cereal each morning." 4. "Be sure to get regular exercise.

4. "Be sure to get regular exercise." Exercise helps prevent constipation. Fluids and dietary fiber promote normal bowel function. The client should drink eight to ten glasses of fluid each day. Although adding bran to cereal helps prevent constipation by increasing dietary fiber, the client should start with a small amount and gradually increase the amount as tolerated to a maximum of 2 grams a day.

Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics? 1. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart. 2. How to increase his oxygen therapy. 3. How to treat respiratory infections without going to the physician. 4. How to recognize the signs of an impending respiratory infection.

4. How to recognize the signs of an impending respiratory infection. Respiratory infection in clients with a respiratory disorder can be fatal. It's important that the client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate for the wife to listen to his lung sounds, besides, you can't purchase stethoscopes from Wal-Mart. If the client has signs and symptoms of an infection, he should contact his physician at once.

You're discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient? 1. "Now I can never get hepatitis again." 2. "I can safely give blood after 3 months." 3. "I'll never have a problem with my liver again, even if I drink alcohol." 4. "My family knows that if I get tired and start vomiting, I may be getting sick again."

4. "My family knows that if I get tired and start vomiting, I may be getting sick again." Hepatitis B can recur. Patients who have had hepatitis are permanently barred from donating blood. Alcohol is metabolized by the liver and should be avoided by those who have or had hepatitis B.

Which of the following family members exposed to TB would be at highest risk for contracting the disease? 1. 45-year-old mother 2. 17-year-old daughter 3. 8-year-old son 4. 76-year-old grandmother

4. 76-year-old grandmother Elderly persons are believed to be at higher risk for contracting TB because of decreased immunocompetence. Other high-risk populations in the US include the urban poor, AIDS, and minority groups.

Which of the following clients is at greatest risk for developing acute renal failure? 1. A dialysis client who gets influenza 2. A teenager who has an appendectomy 3. A pregnant woman who has a fractured femur 4. A client with diabetes who has a heart catheterization

4. A client with diabetes who has a heart catheterization Clients with diabetes are prone to renal insufficiency and renal failure. The contrast used for heart catheterization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. A dialysis client already has end-stage renal disease and wouldn't develop acute renal failure. Options B and C: A teenager who has an appendectomy and a pregnant woman with a fractured femur isn't at increased risk for renal failure

Which of the following factors causes the nausea associated with renal failure? 1. Oliguria 2. Gastric ulcers 3. Electrolyte imbalances 4. Accumulation of waste products

4. Accumulation of waste products Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. Options A and C: The client has electrolyte imbalances and oliguria, but these don't directly cause nausea.

The main indicator of the need for hemodialysis is: 1. Ascites 2. Acidosis 3. Hypertension 4. Hyperkalemia

4. Hyperkalemia

The nurse is reviewing a list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response knowing that the glucose: 1. Prevents excess glucose from being removed from the client. 2. Decreases risk of peritonitis. 3. Prevents disequilibrium syndrome 4. Increased osmotic pressure to produce ultrafiltration.

4. Increases osmotic pressure to produce ultrafiltration. Increasing the glucose concentration makes the solution increasingly more hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange.

A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client? 1. Initiate oxygen therapy and reassess the client in 10 minutes. 2. Draw blood for an ABG analysis and send the client for a chest x-ray. 3. Encourage the client to relax and breathe slowly through the mouth 4. Administer bronchodilators

4. Administer bronchodilators In an acute asthma attack, diminished or absent breath sounds can be an ominous sign of indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing an ABG and obtaining a chest x-ray. It would be futile to encourage the client to relax and breathe slowly without providing necessary pharmacologic intervention.

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: 1. Promises to do pursed lip breathing at home. 2. States actions to reduce pain. 3. States that he will use oxygen via a nasal cannula at 5 L/minute. 4. Agrees to call the physician if dyspnea on exertion increases.

4. Agrees to call the physician if dyspnea on exertion increases. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? 1. Intake and output 2. Baseline peripheral pulse rates 3. Height and weight 4. Allergy to iodine or shellfish

4. Allergy to iodine or shellfish This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.

A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which of the following interventions is included in this client's plan of care? 1. Keep the AV fistula site dry. 2. Keep the AV fistula wrapped in gauze. 3. Take the blood pressure in the left arm 4. Assess the AV fistula for a bruit and thrill

4. Assess the AV fistula for a bruit and thrill Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. Option A: When not being dialyzed, the AV fistula site may get wet. Option B: Immediately after a dialysis treatment, the access site is covered with adhesive bandages. Option C: No blood pressures or venipunctures should be taken in the arm with the AV fistula.

Surgical management of ulcerative colitis may be performed to treat which of the following complications? 1. Gastritis 2. Bowel herniation 3. Bowel outpouching 4. Bowel perforation

4. Bowel perforation

The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client's temperature is 100.2. Which of the following is the most appropriate nursing action? 1. Encourage fluids 2. Notify the physician 3. Monitor the site of the shunt for infection 4. Continue to monitor vital signs

4. Continue to monitor vital signs The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected, and a blood sample would be obtained as prescribed for culture and sensitivity purposes.

Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet, which food should be included in the diet? 1. Fruit 2. Whole grains 3. Milk and cheese products 4. Dark green, leafy vegetables

4. Dark green, leafy vegetables Dark green, leafy vegetables are rich in calcium.

The client who has a cold is seen in the emergency room with inability to void. Because the client has a history of BPH, the nurse determines that the client should be questioned about the use of which of the following medications? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4. Decongestants

A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? 1. Acute pain related to lung expansion secondary to lung infection 2. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever. 3. Anxiety related to dyspnea and chest pain. 4. Ineffective airway clearance related to retained secretions.

4. Ineffective airway clearance related to retained secretions. Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.

The term "pink puffer" refers to the client with which of the following conditions? 1. ARDS 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

4. Emphysema Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They're pink and usually breathe through pursed lips, hence the term "puffer". Clients with ARDS are usually acutely short of breath. Clients with asthma don't have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders? 1. ARDS 2. Asthma 3. Chronic obstructive bronchitis 4. Emphysema

4. Emphysema These are classic signs and symptoms of a client with emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching

4. Headache, deteriorating level of consciousness and twitching. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, and vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

Which of the following diets would be most appropriate for a client with COPD? 1. Low fat, low cholesterol 2. Bland, soft diet 3. Low-Sodium diet 4. High calorie, high-protein diet

4. High-calorie, high-protein diet The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated.

A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? 1. Nonproductive or productive cough 2. Anorexia and weight loss 3. Chills and night sweats 4. High-grade fever

4. High-grade fever The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

Your patient with chronic renal failure reports pruritus. Which instruction should you include in this patient's teaching plan? 1. Rub the skin vigorously with a towel 2. Take frequent baths 3. Apply alcohol-based emollients to the skin 4. Keep fingernails short and clean

4. Keep fingernails short and clean Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to excoriation and breaks in the skin that increase the patient's risk of infection. Keeping fingernails short and clean helps reduce the risk of infection.

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 1. Cancer 2. Hypertension 3. Liver disease 4. Myocardial infarction

4. Myocardial infarction Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within four (4) to six (6) hours after infarction (Remember, less than 90 mg/L is normal).

Which of the following substances is most likely to cause gastritis? 1. Milk 2. Bicarbonate of soda, or baking soda 3. Enteric coated aspirin 4. Nonsteriodal anti-inflammatory drugs

4. Nonsteroidal anti-inflammatory drugs NSAIDS are a common cause of gastritis because they inhibit prostaglandin synthesis. Milk, once thought to help gastritis, has little effect on the stomach mucosa. Bicarbonate of soda, or baking soda, may be used to neutralize stomach acid, but it should be used cautiously because it may lead to metabolic acidosis. ASA with enteric coating shouldn't contribute significantly to gastritis because the coating limits the aspirin's effect on the gastric mucosa.

What is the best way to check for patency of the arteriovenous fistula for hemodialysis? 1. Pinch the fistula and note the speed of filling on release 2. Use a needle and syringe to aspirate blood from the fistula 3. Check for capillary refill of the nail beds on that extremity 4. Palpate the fistula throughout its length to assess for a thrill

4. Palpate the fistula throughout its length to assess for a thrill The vibration or thrill felt during palpation ensures that the fistula has the desired turbulent blood flow. Pinching the fistula could cause damage. Aspirating blood is a needless invasive procedure.

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

A nurse instructs a client to use the pursed lip method of breathing. The client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed lip breathing is: 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination Pursed lip breathing facilitates maximum expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate

4. Protamine sulfate The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Option A: Vitamin K is an antidote for warfarin.

A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which statement, if made by one of the students, indicates further instruction is needed? A) "Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube." B) "Enteral nutrition is preferred because it is less expensive than parenteral nutrition and maintains functioning of the gut." C) "An example of the parenteral route is subcutaneous or IM injections, or the IV route." D) "Gastric feedings may be given to patients with a low risk of aspiration. If there is a risk of aspiration, jejunal feeding is the preferred method. Parenteral nutrition is provided if the patient's GI tract is nonfunctional."

A) "Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube."

a nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? Select all that apply. a. Areas of paresthesia b. involuntary eye movements c. alopecia d. increased salivation e. ataxia

A, B and E

Which of the following sign and symptoms would indicate a client is having a systemic inflammatory response? A. Increased white blood cells B. Decreased white blood cells with greater than 10% bands C. Increased respiratory rate D. Increased urine output E. Decreased urine output

A, B, C Systemic Inflammatory Response Syndrome (SIRS) criteria include: Increased temperature, increased heart rate, increased respiratory rate, increased WBC OR decreased WBC with greater than 10% bands, and increased blood glucose. A client needs to only meet to of these criteria to be considered a SIRS client. Urine output is not a factor is SIRS.

A nurse who works in a long-term care facility has been certified as a wound and ostomy nurse. Based on the nurse's knowledge, the nurse knows that which of the following situations would increase a person's risk for pressure ulcers? Select all that apply. A. Older age B. Cognitive disability C. Malnutrition D. A diagnosis of diabetes E. A history of hyperlipidemia

A, B, C, D Pressure ulcers occur as a consequence of immobility, poor nutrition, and improper moving techniques. A nurse should be familiar with the risk factors associated with pressure ulcers and perform routine skin checks on all patients. Examples of conditions that increase the risk of pressure ulcers include older age, cognitive disability, and malnutrition.

a nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply) a. remove throw rugs in walkways b. use prescribed assistive devices c. remove clutter from the environment d. wear soft bottom shoes e. maintain lighting of doorway areas

A, B, C, E

A patient with a lung infection must undergo an ABG. The patient asks the nurse why he needs to have this lab test. Which of the following should the nurse include that would explain the reasons for this test? Select all that apply. A. The test checks to see how well the lung treatments are working B. The test will determine if the patient needs extra oxygen C. The test verifies the need for a patient's blood transfusion D. The test will diagnose the type of lung infection the patient has E. The test will assess for the acid and base balances in the bloodstream

A, B, E

What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)? a. How pain will be controlled b. Any fluid and food restrictions c. Characteristics of monitoring equipment d. What odors and sensations may be experienced e. Technique and practice of coughing and deep breathing, if appropriate

A, B, E Procedural information includes what will or should be done for surgical preparation, including what to bring and what to wear to the surgery center, length and type of food and fluid restrictions, physical preparation required, pain control, need for coughing and deep breathing (if appropriate), and procedures done before and during surgery (such as vital signs, IV lines, and how anesthesia is administered). The other options are sensory and process information (see Table 18-6).

A client is at an increased risk of pressure ulcers in which situations? Select all that apply. A. Increased time in a wheelchair B. Obesity C. Gait disturbances D. Increased age E. Malnutrition

A, D, E Risk factors for pressure ulcers include bedrest, increased time in a wheelchair, increased age, inability to move, malnutrition, dementia, and incontinence.

The client is being evaluated for a low calcium condition. Clinical manifestations of low calcium include the following. Select all that apply. A. Tetany B. Muscle flaccidity C. Negative Trousseau's sign D. Positive Chvostek's sign E. Skeletal fractures

A, D, E Signs of low calcium include tetany and muscular irritability, positive Trousseau's sign, positive Chvostek's sign, longer clotting times and skeletal fractures. VTach and EKG changes can also happen.

An HIV-infected patient is in the hospital after developing an opportunistic infection. The patient's spouse is in the hospital with him and helping to provide care. What information should the nurse provide to this patient's caregiver about providing care and treatment for this patient at home? Select all that apply. A. Ask for help with completing tasks that are difficult B. Avoid immunizations and exposure to infectious illnesses C. Decrease fiber intake and drink more water D. Wash fruits and vegetables before eating them E. Get out of bed at least once a day and change positions frequently

A, D, E The caregiver of an HIV-infected patient typically needs support and help as much as the patient himself. The caregiver in this situation should receive guidance and instruction about protecting the patient from infection while at home, since he is immunocompromised. This involves careful food preparation and control of exposure to infectious materials.

A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition (Select all that apply) A. Slurred speech B. Bloody emesis C. Retroperitoneal bleeding D. Shortened attention span E. Hypersomnia F. Involuntary hand tremor

A, D, E, F

You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct: Select all that apply A. Excessive coughing B. Sleeping on the back C. Drinking juice D. Alcohol consumption E. Straining during a bowel movement F. Vomiting

A, D, E, F Esophageal varices are dilated vessels that are connected from the throat to the stomach. They can become enlarged due to portal hypertension in cirrhosis and can rupture (this is a medical emergency). The patient should avoid activities that could rupture these vessels, such as excessive cough, vomiting, drinking alcohol, and constipation (straining increases thoracic pressure.)

The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching? (Select all that apply) A. "It's important for me to use barrier protection when I have sex." B. "I'll plan to do all my activities in the morning when I'm most rested." C. "I should avoid sharing drinking cups and eating utensils with my family." D. "I should not drink any wine, beer or other alcoholic beverages." E. "Acetaminophen is the best medication for me if I have a headache." F. "I should get vaccinated for hepatitis A and hepatitis B."

A, D, F

Dr. Kennedy prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a male client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide? A. "Be sure to take glipizide 30 minutes before meals." B. "Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly." C. "You won't need to check your blood glucose level after you start taking glipizide." D. "Take glipizide after a meal to prevent heartburn."

A. "Be sure to take glipizide 30 minutes before meals." The client should take glipizide twice a day, 30 minutes before a meal, because food decreases its absorption. The drug doesn't cause hyponatremia and therefore doesn't necessitate monthly serum sodium measurement. The client must continue to monitor the blood glucose level during glipizide therapy.

Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a female client with type 2 diabetes mellitus. During discharge planning, nurse Pauleen would be aware of the client's need for additional teaching when the client states: A. "If I have hypoglycemia, I should eat some sugar, not dextrose." B. "The drug makes my pancreas release more insulin." C. "I should never take insulin while I'm taking this drug." D. "It's best if I take the drug with the first bite of a meal."

A. "If I have hypoglycemia, I should eat some sugar, not dextrose." Acarbose delays glucose absorption, so the client should take an oral form of dextrose rather than a product containing table sugar when treating hypoglycemia. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. It's safe to be on a regimen that includes insulin and an alpha-glucosidase inhibitor. The client should take the drug at the start of a meal, not 30 minutes to an hour before.

A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food on the item list? A. Chocolate milk. B. Broccoli. C. Apple. D. Salmon.

A. Chocolate milk. Chocolate milk is a high-fat food. Options B and C: Fruits and vegetables are low in fat because they do not come from animal sources. Option D: Salmon is naturally lower in fat.

A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A. "What activities were you able to do 6 months ago compared to the present?" B. "How long have you had this problem?" C. "Have you been able to keep up with all your usual activities?" D. "Are you more tired now than you used to be?"

A. "What activities were you able to do 6 months ago compared with the present?" It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Option B: Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Option C: Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Option D: Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? A. "You may have eaten contaminated restaurant food." B. "You could have gotten it by using I.V. drugs." C. "You must have received an infected blood transfusion." D. "You probably got it by engaging in unprotected sex."

A. "You may have eaten contaminated restaurant food." Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

A nurse is making initial rounds at the beginning of the shift and notice that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? A. 10% dextrose in water. B. 5% dextrose in water. C. 5% dextrose in normal saline. D. 5% dextrose in lactated Ringer solution.

A. 10% dextrose in water. The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available.

Nurse Ryan is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted? A. 3.5 B. 7.0 C. 7.35 D. 7.5

A. 3.5 If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH

Which of the following individuals is least likely to be at risk of developing psoriasis? A. A 32 year-old-African American B. A woman experiencing menopause C. A client with a family history of the disorder D. An individual who has experienced a significant amount of emotional distress

A. A 32 year-old-African American Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations.

A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client's history and note in which of the following may cause about by the complaint of the client? A. Allergy to an egg. B. Allergy to peanut. C. Allergy to shellfish. D. Allergy to corn

A. Allergy to an egg. Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies.

While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as: A. Steatorrhea B. Melena C. Currant D. Hematochezia

A. Steatorrhea Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis. This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats. Fats are not being broken down; therefore, it is being excreted into the stool. Melena is used to describe tarry/black stool, hematochezia is used to describe red stools, and currant are jelly type stools.

What is the relationship between prostate cancer and the condition of an enlarged prostate, also known as BPH? A. BPH and prostate cancer are unrelated B. BPH causes prostate cancer C. BPH is a symptom of prostate cancer D. BPH is the same thing as prostate cancer

A. BPH and prostate cancer are unrelated

A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts

A. Beef tips and broccoli rabe Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.

A patient receiving dialysis should avoid what type of foods? A. Canned soups, cold cut sandwiches, and Chinese take-out B. Fresh fruits and vegetable, poultry, and beans C. Steamed broccoli, broiled mackerel, and artificial sweeteners D. Microwaved sweet potatoes, boiled cabbage, and artichokes

A. Canned soups, cold cut sandwiches, and Chinese take-out Patients who are receiving dialysis have renal disease and therefore should follow a sodium restricted diet. Canned soups, cold cut sandwiches, and Chinese take-out are all high in sodium.

A patient has been diagnosed with primary syphilis. When assessing the patient, which of these findings will the healthcare provider anticipate? A. Firm and painless genital ulcers B. Reddish rash on the palms of the hands C. Sore throat and swollen lymph glands D. Muscle weakness and visual changes

A. Firm and painless genital ulcers

Which is an obvious sign or sympton of Cushing's Syndrome? A. Gaining a large amount of weight B. Losing a lot of weight C. Becoming constipated D. Kidney Failure

A. Gaining a large amount of weight

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids B. Thickening liquids to the consistency of oatmeal C. Placing food on the unaffected side of the mouth D. Allowing plenty of time for chewing and swallowing

A. Giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. Option B: Liquids are thickened to avoid aspiration. Option C: Food is placed on the unaffected side of the mouth. Option D: The client is assisted with meals as needed and is given ample time to chew and swallow.

Dr. Smith has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D

A. Hepatitis A Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

A nurse assesses an 86-year-old patient who is a client at a long-term care facility. The nurse uses the Braden scale to determine the patients level of risk for skin breakdown. After completing the assessment the nurse gives the patient a score of 8. Which of the following best describes this patients risk of skin breakdown? A. High risk B. Moderate risk C. Very low risk D. Mild risk

A. High risk The Braden Scale is an assessment tool used to determine the level of risk a patient has for skin breakdown. The Braden Scale uses several measures that can contribute to skin breakdown; the nurse then gives the patient a score based on these measures and adds the total. A low score of 8 indicates that the patient is at high risk of skin breakdown.

Which change in vital signs would you instruct a nursing assistant to report immediately for a patient with hyperthyroidism? A. Increased and rapid heart rate B. Decrease systolic blood pressure C. Increased respiratory rate D. Decreased oral temperature

A. Increased and rapid heart rate The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate.

When assessing a patient with chronic heart failure, the healthcare provider would expect to identify which of these clinical manifestations? A. Inspiratory crackles B. Asymmetrical chest expansion C. Expiratory wheezing D. Subcutaneous crepitus

A. Inspiratory crackles

A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a: A. Low protein, low sodium, low potassium, low phosphate diet B. High protein, low sodium, low potassium, high phosphate diet C. Low protein, high sodium, high potassium, high phosphate diet D. Low protein, low sodium, low potassium, high phosphate diet

A. Low protein, low sodium, low potassium, low phosphate diet The patient should follow this type of diet because protein breaks down into urea (remember patients will have increased urea levels), low sodium to prevent fluid retention, low potassium to prevent hyperkalemia (remember glomerulus isn't filtering out potassium/phosphate as it should), and low phosphate to prevent hyperphosphatemia.

The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test B. A decreased TSH level C. An increase in the TSH level after 30 minutes during the TSH stimulation test D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stools

A. Passage of two or three soft stools daily Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.

Which gland does Cushing's Syndrome originate in? A. Pituitary B. Pineal C. Pancreas D. Gonads

A. Pituitary

A nurse is caring for a client with quadrapelegia. The nurse knows that this patient is at major risk for pressure ulcers. What should the nurse do to help prevent the pressure ulcers from happening? A. Turning the client every 2 hours B. Practicing range of motion daily C. Give client a bed bath D. Turning the client every 4 hours

A. Turning the client every 2 hours

An 86-year-old patient has developed protein energy malnutrition as a result of poor eating habits and difficulties with chewing and swallowing. Which best describes how poor nutrition contributes to skin breakdown in an elderly client? A. Poor nutrition contributes to poor circulation B. The patient has less energy for activities and is less mobile C. An elderly patient secretes less aldosterone, which dries out the skin D. Poor nutrition affects keratinocytes, which increases the risk of sloughing

A. Poor nutrition contributes to poor circulation Advancing age can increase the risk of nutrient deficiencies and overall malnutrition in older adults. A patient who has developed malnutrition because of difficulties with eating may also be at risk of skin breakdown. Poor nutrition can affect circulation, and the skin and peripheral tissues may not receive adequate perfusion when the patient has poor food and nutrient intake. Decreased perfusion increases the risk of skin breakdown and potential wound development.

After undergoing a subtotal thyroidectomy, a female client develops hypothyroidism. Dr. Smith prescribes levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent? A. Primary hypothyroidism B. Graves' disease C. Thyrotoxicosis D. Euthyroidism

A. Primary hypothyroidism Levothyroxine is the preferred agent to treat primary hypothyroidism and cretinism, although it also may be used to treat secondary hypothyroidism. It is contraindicated in Graves' disease and thyrotoxicosis because these conditions are forms of hyperthyroidism. Euthyroidism, a term used to describe normal thyroid function, wouldn't require any thyroid preparation.

An allergy to eggs or soybeans may indicate a risk for reaction to which of the following? A. Propofol B. Povidone-Iodine C. Latex D. Shellfish

A. Propofol

A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

A. Respiratory Alkalosis

Nurse Troy is aware that the most appropriate for a client with Addison's disease? A. Risk for infection B. Excessive fluid volume C. Urinary retention D. Hypothermia

A. Risk for infection Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.

In a 29-year-old female client who is being successfully treated for Cushing's syndrome, nurse Lyzette would expect a decline in: A. Serum glucose level. B. Hair loss. C. Bone mineralization. D. Menstrual flow.

A. Serum glucose level. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administering the furosemide to the patient, which laboratory result should the healthcare provider to review? A. Serum potassium B. Serum troponin C. Serum sodium D. Blood urea nitrogen (BUN)

A. Serum potassium

A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A. Should be taken in the morning B. May decrease the client's energy level C. Must be stored in a dark container D. Will decrease the client's heart rate

A. Should be taken in the morning

A female client has just been diagnosed with Human Papillomavirus (HPV). What information is appropriate to tell this client? A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. D. HPV can't be transmitted during oral sex

A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

A 55-year old client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, Nurse Gerry asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? A. Transurethral resection of the prostate (TURP) B. Suprapubic prostatectomy C. Retropubic prostatectomy D. Transurethral laser incision of the prostate

A. Transurethral resection of the prostate (TURP) TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Options B, C, and D: Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; they all require an incision.

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles

A. Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis.

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: A. turn him frequently. B. perform passive range-of-motion (ROM) exercises. C. reduce the client's fluid intake. D. encourage the client to use a footboard.

A. turn him frequently. The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? a. 59-year-old patient with an acute myocardial infarction and a temperature of 99.8° F b. 6-month-old patient with bacterial meningitis and a temperature of 104.2° F c. 82-year-old patient after hip replacement surgery and a temperature of 100.4° F d. 14-year-old patient with infectious mononucleosis and a temperature of 101.6° F

ANS: B Rationale: Moderate fevers (up to 103° F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104° F) should be treated with antipyretics. High fevers can damage body cells, and delirium and seizures can occur.

The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which of the following food items, if selected by the client, would indicate an understanding of this dietary restriction? 1. Cantaloupe 2. Spinach 3. Lima beans 4. Strawberries

Answer: 3. Lima beans Lima beans (1/3 c) averages three (3) mEq per serving. Option A: Cantaloupe (1/4 small) Option B: Spinach (1/2 cooked) Option D: Strawberries (1 ¼ cups) are high potassium foods and average 7 mEq per serving.

A client with a positive skin test for TB isn't showing signs of active disease. To help prevent the development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long? 1. 10 to 14 days 2. 2 to 4 weeks 3. 3 to 6 months 4. 9 to 12 months

Answer: 4. 9 to 12 months Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results.

A 57-year-old patient with peptic ulcer disease is being seen for abdominal pain. Which of the following interventions would the nurse employ to assess for hemorrhage in this patient? Select all that apply. A. Speak calmly to the patient to reduce anxiety B. Assess for symptoms of dizziness or nausea C. Monitor the patient's hemoglobin and hematocrit levels D. Record hourly urinary output E. Administer stool softeners

B and C

A patient with hypotension is in the emergency department being evaluated. The patients sodium level has come back at 146 mmol/L. What interventions by the nurse would be most appropriate in caring for this patient with hypernatremia? Select all that apply. A. Administer hypertonic solution by IV as ordered B. Perform neurological assessments at least every 4 hours C. Limit oral intake of sodium D. Encourage the patient to use incentive spirometry E. Provide pain medication as ordered prn

B and C Hypernatremia occurs when there is excess sodium in the bloodstream; the normal range of sodium is between 135 and 145 mmol/L. In this situation, the nurse should administer a hypotonic solution in the IV to increase fluid volume, limit oral intake of sodium, and perform neurological assessments, as hypernatremia can cause cognitive changes.

the nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? a. Decreased vision b. pill rolling tremors of the fingers c. shuffling gait d. drooling e. bilateral ankle edema f. lack of facial expression

B, C, D and F

The healthcare provider is caring for a patient diagnosed with gonorrhea. Which of the following assessment findings could indicate the patient is experiencing a complication from the disease? (Select all that apply) A. Excessive bruising B. Joint pain and stiffness C. Dysuria, urgency, or urinary frequency D. Vaginal pruritus and dyspareunia E. Pelvic or abdominal pain

B, C, D, E

A client presents to the Emergency Room complaining of right upper quadrant pain, the patient reports the pain is worse upon palpation and is experiencing clay colored stools. What testing do you think will be ordered? A. Influenza test B. CT scan C. Urinalysis D. Ultrasound E. Complete blood count (CBC)

B, C, D, E RUQ pain and clay colored stools are classic of gallstones and the client should be checked for increased bilirubin in both blood and urine, increased WBCs in the blood, and imaging such as CT scan or ultra sound.

You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply: A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes

B, C, E High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent).

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices

B, C, E Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.

The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? Select all that apply: A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis

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

a nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? select all that apply a. provide three large balanced meals daily b. record diet in fluid intake daily c. document weight every other week d. offer cold fluids such as milkshakes e. offer nutritional supplements between meals

B, D and E

A patient who received treatment for pancreatitis is being discharged home. You're providing diet teaching to the patient. Which statement by the patient requires immediate re-education about the diet restrictions? A. "It will be hard but I will eat a diet low in fat and avoid greasy foods." B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week." C. "I will concentrate on eating complex carbohydrates rather than refined carbohydrates." D. "I will purchase foods that are high in protein."

B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week." A patient with pancreatitis should AVOID any amount of alcohol because of its effects on the pancreas. Remember alcohol is a cause of both acute and chronic pancreatitis. All the other options are correct.

The healthcare provider is teaching a patient diagnosed with celiac disease about the disease process. Which of the following statements made by the patient would indicate a correct understanding of the teaching? A. "I have an allergy to the proteins that are found in wheat." B. "My immune system reacts to gluten and damages my gut." C. "The bacteria in my gut are not able to ferment the gluten." D. "I'm glad that I can still eat bread made with rye flour."

B. "My immune system reacts to gluten and damages my gut."

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? A. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." C. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." D. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. Options A, C, and D: The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.

A male client has just been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, Nurse Joy should include which guideline? A. "You'll need more insulin when you exercise or increase your food intake." B. "You'll need less insulin when you exercise or reduce your food intake." C. "You'll need less insulin when you increase your food intake." D. "You'll need more insulin when you exercise or decrease your food intake."

B. "You'll need less insulin when you exercise or reduce your food intake." Exercise, reduced food intake, hypothyroidism, and certain medications decrease the insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase the insulin requirements.

An agitated, confused female client arrives in the emergency department. Her history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: A. 2 to 5 g of a simple carbohydrate. B. 10 to 15 g of a simple carbohydrate. C. 18 to 20 g of a simple carbohydrate. D. 25 to 30 g of a simple carbohydrate.

B. 10 to 15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? A. Schilling's test elevated B. Intrinsic factor, absent. C. Sedimentation rate, 16 mm/hour D. RBCs 5.0 million

B. Intrinsic factor, absent. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Option A: Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. Option C: A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. Option D: An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

While assessing morning labs on your patient with CKD. You note the patient's phosphate level is 6.2 mg/dL. As the nurse, you expect to find the calcium level to be? A. Elevated B. Low C. Normal D. Same as the phosphate level

B. Low A normal phosphate level is 2.7-4.5 mg/dL. This patient is experiencing HYPERphosphatemia. When hyperphosphatemia presents the calcium level DECREASES because phosphate and calcium bind to each. When there is too much phosphate in the blood it takes too much calcium with it and it decreases the calcium in the blood. Therefore, the nurse would expect to find the calcium level decreased.

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client? A. Prevention of fluid volume excess B. Maintenance of adequate oxygenation C. Education about infection prevention D. Pain reduction

B. Maintenance of adequate oxygenation For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.

A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions? A. Adjust the infusion rate to catch up over the next hour. B. Make sure the infusion rate is infusing at the ordered rate. C. Increase the infusion rate to catch up over the next few hours. D. Adjust the infusion rate to full blast until the solution is back on time.

B. Make sure the infusion rate is infusing at the ordered rate. The nurse should maintain the prescribed rate of a fat emulsion even if the infusion's time consume is behind. Options A, C, and D are incorrect since increasing the rate will potentially cause a fluid overload.

After having transurethral resection of the prostate (TURP), a Mr. Lim returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? A. The urine in the drainage bag appears red to pink. B. The client reports bladder spasms and the urge to void. C. The normal saline irrigant is infusing at a rate of 50 drops/minute. D. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.

B. The client reports bladder spasms and the urge to void. Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. Option A: After TURP, urine normally appears red to pink. Option C: The normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. Option D: The amount of retained fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? A. Diabetic ketoacidosis B. Thyroid crisis C. Hypoglycemia D. Tetany

B. Thyroid crisis Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.

A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood? A. Calcium B. Urea C. Phosphate D. Erythropoietin

B. Urea This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this as well.

The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12 Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.

The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client? A. Cold compress to the affected area B. Warm compress to the affected area C. Intermittent heat lamp treatments four times daily D. Alternating hot and cold compresses continuously

B. Warm compress to the affected area Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: A. severe abdominal pain radiating to the shoulder. B. anorexia, nausea, and vomiting. C. eructation and constipation. D. abdominal ascites.

B. anorexia, nausea, and vomiting. Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only effective if the client: A. prefers to take insulin orally. B. has type 2 diabetes. C. has type 1 diabetes. D. is pregnant and has type 2 diabetes.

B. has type 2 diabetes. Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't prescribed oral antidiabetic agents because the effect on the fetus is uncertain.

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia? A. hypotonic solution B. hypertonic solution C. isotonic solution D. normotonic solution

B. hypertonic solution

Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume? A. hypotonic FVD B. isotonic FVD C. hypertonic FVD D. isotonic FVE

B. isotonic FVD

A nurse is working with a client who has been confined to his bed for the past week because of illness. While turning this patient, the nurse notes a stage II pressure ulcer on his sacrum. Which action is most appropriate in responding to this finding? Select all that apply. A. Massage the area immediately B. Place a donut-shaped cushion below the area for support C. Apply a dressing and prescribed medication to the site D. Support the patients nutrition and mobility E. Relieve pressure using pillows or foam cushions

C, D, E Pressure ulcers are unfortunate consequences of immobility; if the nurse finds a pressure ulcer on a patient, she must respond quickly to avoid further complications. The nurse should apply a dressing and medication as ordered, as well as quickly relieve pressure from the site using foam cushions or pillows. The nurse must avoid donut-shaped ring devices for support as these place too much pressure in certain areas. The nurse also should not massage the site, as this can cause tissue damage.

Nurse Perry is caring for a female client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer: A. I.M. or subcutaneous glucagon. B. I.V. bolus of dextrose 50%. C. 15 to 20 g of a fast-acting carbohydrate such as orange juice. D. 10 U of fast-acting insulin.

C. 15 to 20 g of a fast-acting carbohydrate such as orange juice. This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

Continuous type of feedings is administered over a __ hour period.? A. 4. B. 12. C. 24. D. 36.

C. 24. Continuous feeding is administered for 24 hours. An infusion pump regulates the flow

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: A. 45 units/L B. 100 units/L C. 300 units/L D. 500 units/L

C. 300 units/L The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.

Which patient below is at MOST risk for CHRONIC pancreatitis? A. A 25 year old female with a family history of gallstones. B. A 35 year old male who reports social drinking of alcohol. C. A 15 year old female with cystic fibrosis. D. A 66 year old female with stomach cancer.

C. A 15 year old female with cystic fibrosis. Patients in options A and B are at slight risk for ACUTE pancreatitis not chronic. Remember the main causes of ACUTE pancreatitis are gallstones and alcohol consumption. In option C, the patient with cystic fibrosis is at MAJOR risk for CHRONIC pancreatitis because they are lacking the protein CFTR which plays a role in the movement of chloride ions to help balance salt and water in the epithelial cells that line the ducts of the pancreas. There is a decreased production of bicarbonate secretion by the epithelial cells. Therefore, this leads to thick mucus in the pancreatic ducts that can lead to blockage of the pancreatic ducts which can cause the digestive enzymes to activate and damage the pancreas. Overtime, the pancreas will experience fibrosis of the pancreas' tissue and will no longer produce digestive enzyme to help with food digestion.

Which patient below is NOT at risk for developing chronic kidney disease? A. A 58 year old female with uncontrolled hypertension. B. A 69 year old female with diabetes mellitus. C. A 45 year old female with polycystic ovarian disease. D. A 78 year old female with an intrarenal injury.

C. A 45 year old female with polycystic ovarian disease.

As the shift begins, you are assigned these patients. Which patient should you assess first? A. A 38-year-old patient with Graves' disease and a heart rate of 94/minute B. A 63-year-old patient with type 2 diabetes and fingerstick glucose of 137 mg/dL C. A 58-year-old patient with hypothyroidism and heart rate of 48/minute D. A 49-year-old patient with Cushing's disease and +1 dependent edema

C. A 58-year-old patient with hypothyroidism and heart rate of 48/minute Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48/minute may have significant implications for cardiac output and hemodynamic stability. Patients with Graves' disease usually have a rapid heart rate, but 94/minute is within limits. The diabetic patient may need sliding scale insulin. This is important but not urgent. Patients with Cushing's disease frequently have dependent edema

Which of the following clients would least likely be at risk of developing skin breakdown? A. A client incontinent of urine and feces B. A client with chronic nutritional deficiencies C. A client with decreased sensory perception D. A client who is unable to move about and is confined to bed

C. A client with decreased sensory perception Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options A, B, and D identify physiological conditions, which are the risk priorities

A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include: A. An epidermal and lymphatic infection caused by Staphylococcus. B. An inflammation of the epidermis only. C. A skin infection into the subcutaneous tissue and dermis. D. An acute superficial infection of the lymphatics and dermis.

C. A skin infection into the subcutaneous tissue and dermis. Cellulitis is an infection into deeper dermal and subcutaneous tissue that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces.

The primary purpose of the Schilling test is to measure the client's ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12

C. Absorb vitamin B12 Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should Nurse Anthony do first? A. Increase the I.V. flow rate. B. Notify the physician immediately. C. Assess the irrigation catheter for patency and drainage. D. Administer meperidine (Demerol), 50 mg I.M., as prescribed

C. Assess the irrigation catheter for patency and drainage. Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. Option A: Increasing the I.V. flow rate may worsen the pain. Option B: Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication. Option D: After assessing catheter patency, the nurse should administer an analgesic, such as meperidine, as prescribed.

A 15-year-old patient is being treated at the hospital for severe diarrhea following a bacterial infection. Which of the following interventions should the nurse use that would best prevent this patient from developing severe dehydration? A. Begin an infusion of insulin IV B. Administer a dose of bismuth subsalicylate (Pepto Bismol) and repeat as needed C. Assist the patient with taking in plenty of broth, fruit juice, and vegetable soup D. Help the patient to drink plenty of water

C. Assist the patient with taking in plenty of broth, fruit juice, and vegetable soup Severe diarrhea can lead to significant dehydration if the condition is not well managed. Children and older adults are at higher risk of complications from dehydration. In this case, the patient should be encouraged to drink fluids such as broth and fruit juice, which contain electrolytes in addition to fluid and can provide some replacement.

Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would: A. Position the client supine to assist in medication absorption B. Aspirate the nasogastric tube after medication administration to maintain patency C. Clamp the nasogastric tube for 30 minutes following administration of the medication D. Change the suction setting to low intermittent suction for 30 minutes after medication administration

C. Clamp the nasogastric tube for 30 minutes following administration of the medication If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration.

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there are redness and drainage at the insertion site. The nurse next assesses which of the following? A. Time of last dressing change. B. Allergy. C. Client's temperature. D. Expiration date.

C. Client's temperature. Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess.

The healthcare provider is teaching a youth group about how to avoid acquiring a sexually transmitted disease (STD) if they are sexually active. Which of the following is the best method of prevention? A. Human papillomavirus (HPV) vaccination B. Douching after intercourse C. Consistent condom use D. Use of spermicidal creams

C. Consistent condom use

Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: A. Hypotension. B. Thick, coarse skin. C. Deposits of adipose tissue in the trunk and dorsocervical area. D. Weight gain in arms and legs

C. Deposits of adipose tissue in the trunk and dorsocervical area. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

Etiologies associated with hypocalcemia may include all of the following except: A. renal failure B. inadequate intake calcium C. metastatic bone lesions D. vitamin D deficiency

C. metastatic bone lesions

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: A. Thyroid storm. B. Cretinism. C. myxedema coma. D. Hashimoto's thyroiditis.

C. myxedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

Nursing interventions for a patient with hyponatremia include: A. administering hypotonic IV fluids B. encouraging water intake C. restricting fluid intake D. restricting sodium intake

C. restricting fluid intake Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.

Which of the following accurately describes the greatest risk related to having a feeding tube? A) Electrolyte imbalance B) Fluid volume overload C) Infection D) Aspiration

D) Aspiration

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? A. "I'll limit my intake of protein." B. "I'll make sure that the bandage is wrapped tightly." C. "My foot should feel cold." D. "I'll eat plenty of fruits and vegetables."

D. "I'll eat plenty of fruits and vegetables." For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair). If the client's foot feels cold, circulation is impaired, thus inhibiting wound healing.

During her first prenatal visit, a woman asks why she is being screened for syphilis. Which of the following is the best response by the healthcare provider? Choose 1 answer: Choose 1 answer: A. "If you test positive you may need to be admitted to the hospital for care." B. "We must report all cases of syphilis to the health department." C. "If you have the infection, the safest time to treat you is during the first trimester." D. "Syphilis can be transferred from you to your baby through the placenta."

D. "Syphilis can be transferred from you to your baby through the placenta."

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A. "Take the medication with an antacid." B. "Take the medication with a glass of milk." C. "Take the medication with cereal." D. "Take the medication on an empty stomach."

D. "Take the medication on an empty stomach." Preferably, ferrous gluconate should be taken on an empty stomach. Options A, B, and C: Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

You are providing education to a patient with CKD about calcium carbonate. Which statement by the patient demonstrates they understood your teaching about this medication? A. "This medication will help keep my calcium level normal." B. "I will not take this medication with meals" C. "It is important I consume high amounts of oatmeal, poultry, fish, and dairy products while taking this medication." D. "This medication will help prevent my phosphate level from increasing."

D. "This medication will help prevent my phosphate level from increasing."

A nurse is checking the nasogastric tube position of a client receiving a long term therapy of Omeprazole (Prisolec) by aspirating the stomach contents to check for the PH level. The nurse proves that correct tube placement if the PH level is? A. 7.75. B. 7.5. C. 6.5. D. 5.5.

D. 5.5. Gastric placement is indicated by a pH of less than 4, but may increase to between pH 4-6 if the patient is receiving acid-inhibiting drugs.

A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A. Measuring serum potassium for hyperkalemia B. Assessing the client for hypervolemia C. Measuring the client's weight weekly D. Documenting precise intake and output

D. Documenting precise intake and output For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly

A patient has developed a pressure ulcer on his ankle from being in bed and lying in the same position for too long. The wound has become infected over time, and the patient eventually developed cellulitis. Which nursing intervention would be most appropriate in this situation? A. Check the patients skin for signs of incontinence B. Reposition the patient in bed every 4 hours C. Increase the patients level of activity to promote circulation D. Elevate the extremity and keep the skin off of the bed

D. Elevate the extremity and keep the skin off of the bed

Nurse Lily is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? A. Rashes on the palms of the hands and soles of the feet B. Cauliflower-like warts on the penis C. Painful red papules on the shaft of the penis D. Foul-smelling discharge from the penis

D. Foul-smelling discharge from the penis Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Option A: Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Option B: Cauliflower-like warts on the penis are a sign of human papillomavirus. Option C: Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

A patient who is newly diagnosed with stage 1 hypertension is being evaluated by a healthcare provider. Which of the following laboratory tests would indicate organ damage that may result from hypertension? A. Complete blood count B. Serum aldosterone C. Coagulation panel D. Urinalysis

D. Urinalysis

Which of the following nursing assessment is the most important in the patient with hyperthyroidism and risk for thyrotoxic crisis or thyroid storm? Intake and output Heart sounds Bowel sounds Vital signs

D. Vital signs

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? A. skin turgor B. intake and output C. osmotic pressure D. cardiac rate and rhythm

D. cardiac rate and rhythm

The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing? a. Witnessing the patient's signature b. Obtaining informed consent from the patient for the surgery c. Verifying that the consent for surgery is truly voluntary and informed d. Ensuring that the patient is mentally competent to sign the consent form

a. Witnessing the patient's signature The health care provider is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient's signature on the consent form. The nurse may be a patient advocate during the signing of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient's signature.

a nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply) a. a 40 year old client who has been taking Prednisone for four months b. a 30 year old client who jogs 3 miles daily c. a 45 year old client who takes phenytoin for seizures d. a 65 year old client who has a sedentary lifestyle e. a 70 year old client who has smoked for 50 years

a. a 40 year old client who has been taking Prednisone for four months c. a 45 year old client who takes phenytoin for seizures d. a 65 year old client who has a sedentary lifestyle e. a 70 year old client who has smoked for 50 years

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with.... a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

a. a warm bath followed by a short rest. Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I am going to join a soccer team to get more exercise." b. "I will need to stop drinking so much coffee and soda." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

b. "I will need to stop drinking so much coffee and soda." Dietitians frequently suggest that patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently, rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management

Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should take birth control pills to keep from getting pregnant." d. "I should avoid aspirin or nonsteroidal antiinflammatory drugs."

b. "I will use sunscreen when I am outside." Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

b. Alert the surgery center about a possible latex allergy.

What is the rationale for using preoperative checklists on the day of surgery? a. The patient is correctly identified. b. All preoperative orders and procedures have been carried out and records are complete. c. Patients' families have been informed as to where they can accompany and wait for patients. d. Preoperative medications are the last procedure before the patient is transported to the operating room.

b. All preoperative orders and procedures have been carried out and records are complete Preoperative checklists are a tool used to ensure that the many preparations and precautions performed before surgery have been completed and documented. Patient identification, instructions to the family, and administration of preoperative medications are often documented on the checklist, which ensures that no details are omitted.

Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

b. Elevated blood urea nitrogen (BUN) The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider about the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

b. The patient is trying to get pregnant before her disease becomes more severe. Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

b. The patient's blood glucose is 165 mg/dL. Corticosteroids have the potential to cause hyperglycemia. The finding of an elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication

When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next? a. Note this information in the patient's record as hay fever and food allergies. b. Place an allergy alert wristband that identifies the specific allergies on the patient. c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents. d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.

c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents. Risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity reactions to drugs used during anesthesia but the hay fever and fruit allergies are specifically related to latex allergy. After identifying the allergic reaction, the anesthesia care provider (ACP) should be notified, the allergy alert wristband should be applied, and the note in the record will include the allergies and reactions as well as the nursing actions related to the allergies.