Custom: Custom: ATI PRACTICE ASSESSMENT A # 7 ( RACIEL )
A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? "I flavor my meat with lemon juice. "I eat two eggs for breakfast each morning." "I cook my food with canola oil." "I take an omega-3 supplement daily."
"I eat two eggs for breakfast each morning." Clients should limit egg yolks to two to three per week.
A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching? "The type of foods I eat does not affect this condition." "I will sleep on my left side." "I will eat a snack just before going to bed." "I will sleep with the head of my bed elevated."
"I will sleep with the head of my bed elevated." The client should sleep with the head of the bed elevated by 6 to 12 inches to prevent reflux at night.
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? Glucocorticoid medications Dextrose 5% in 0.45% sodium chloride Oral hypoglycemic medications 0.9% sodium chloride IV bolus
0.9% sodium chloride IV bolus The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs.
A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight? A female client who has a body mass index of 24 A male client who has a body mass index of 29 A female client who has a waist circumference of 101.6 cm (40 in) A male client who has a waist circumference of 96.52 cm (38 in)
A male client who has a body mass index of 29 A client who has a BMI of 25 to 29.9 is classified as overweight.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which Initiating oxygen therapy Providing immediate rest for the client Positioning the client in high-Fowler's Administering a nebulized beta-adrenergic
Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma has a high mortality rate. Basal cell carcinoma is aggressive and rapid growing. Basal cell carcinoma develops from a nevi or mole.
Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma is a localized lesion that seldom metastasizes.
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Mottled skin Blood pressure 115/68 mmHg Heart rate 160/min Hypokalemia
Blood pressure 115/68 mmHg The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) Raise all side rails on the client's bed. Obtain a prescription to restrain the client PRN. Check on the client hourly. Instruct the client in the use of the call light. Apply an ambulation alarm to the client's leg.
Check on the client hourly is correct. Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach. Instruct the client about the use of the call light is correct. Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use. Apply an ambulation alarm to the client's leg is correct. The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.
A nurse is assessing a client who has malnutrition. Which of the follo wing findings should the nurse expect? Increased vital capacity Moist skin Heat intolerance Decreased mental status
Decreased mental status Lethargy and depression are manifestation of malnutrition. The brain requires glucose to function. When the body lacks adequate glucose, the body will metabolize tissue such as muscle and fat. The resulting metabolic acidosis can further decrease the client's mental status.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? All visitors from entering the client's room Fresh flowers and potted plants in the room Oral fluid intake to between meals only Activities that could result in bleeding
Fresh flowers and potted plants in the room Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed
A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome. The nurse should plan to monitor which of the following laboratory values? BUN Glucose Liver function Thyroid-stimulating hormone
Glucose Polycystic ovarian syndrome is a disease in which many estrogen producing cysts develop on the ovaries. Manifestations include irregular menstruation, hyperinsulinemia, and glucose tolerance dysfunction. The nurse should anticipate that the client will require a glucose test to monitor for type 2 diabetes mellitus.
A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records. Diagnostic Results HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates. UrinalysisResultExpected Reference RangeAppearanceClearClearColorAmberYellowpH5.84.6 to 8.0Specific gravity1.0121.005 to 1.030Leucocyte esteraseNegativeNegative NitratesNoneNoneCrystalsNoneNoneCastsNoneNoneGlucose0NegativeWBC00 to 4 per low-power fieldRBC0less than or equal to 2 Medication Administration Record Glargine U 100 25 units subcutaneous at bedtimeFingerstick/random blood glucose before breakfast & bedtime with regular insulin subcutaneous sliding scale coverage: Less than 160 mg/dL: no coverage160 to 220 mg/dL: 2 units221 to 280 mg/dL: 3 units281 to 340 mg/dL: 6 units341to 400 mg/dL: 8 unitGreater than 400: call physician Aldactone 50 mg PO twice dailyDigoxin 0.25 mg PO every morningCarvedilol 25 mg PO twice daily Vital Signs BP 120/72 mm HgTemperature 36.8º C (98.2º F)Pulse rate 88/minRespirations 20/min Nurses' Notes Client received to emergency department from home via private vehicle. Reports fatigue, blurred vision, dizziness, and headache x 2 days. Reports running out of blood glucose strips and Humulin regular insulin due to lack of financial means. States that they are afraid of possible falls from fatigue and dizziness. Lives at home alone. Orders received; will increase glargine from 20 units to 25 units at bedtime. Other meds taken at home remain the same at this time. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should teach the client signs of hyperglycemia and assess their feet for sensation because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is indicative of diabetes. The nurse will need to assess for the potential diabetic complication of peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood glucose. This will allow the nurse to determine whether the medication and diet are effective in controlling the client's glucose level
A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include? Take an antiemetic 1 hr following administration. Drink 2 to 3 L of water per day. Take the medication with an NSAID. Rinse mouth 2 times per day with an alcohol based mouthwash.
Drink 2 to 3 L of water per day. Methotrexate can cause renal toxicity. The client should drink 2 to 3 L of water per day to promote excretion of the medication.
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." "Exercise is good for you and good for your heart." "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." With this response, the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation for the client.
A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure? "This procedure determines the extent of joint damage." "This procedure will fuse my point to reduce my pain." "This procedure will prevent further joint damage." "This procedure will replace my joint to improve function."
"This procedure will replace my joint to improve function." Arthroplasty is the reconstruction or replacement of a joint. This procedure is done to relieve pain, improve or maintain range of motion, and correct the present deformity.
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? Positive Kernig's sign Positive Homan's sign Dull, aching calf pain Soft, pliable calf muscle
Dull, aching calf pain Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.
A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. Vital Signs Temperature 36.6° C (97.8° F)Apical pulse 42/minRespiratory rate 26/minBlood pressure 104/68 mm HgOxygen saturation 94% on room air Physical Examination 0800: Alert and oriented to person and placeSkin pale and dryPupils equal, round, and reactive to light and accommodation Mucous membranes moist and pinkHeart sounds regular and moderatePeripheral pulses moderateCapillary refill 3 secondsLungs sounds clear to auscultation bilaterallyRespirations labored at restAbdomen soft and nontender, active bowel sounds x 4 quadrantsNo peripheral edemaReports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scaleStates they have been weak for the past 4 months with dizziness. Denies dizziness at this time. 1300: Returns to room after insertion of permanent pacemakerAlert and oriented to person, needs cues for time and placeSkin cool and dryHeart sounds regular, heart rate 72/minLung sounds are coarse bilaterallyHyperresonance noted upon percussion of chest wallRespiratory rate 24/min and slightly laboredOxygen saturation 2 L/min per nasal cannula 98%Reports slight incisional pain left upper chest areaSmall amount red drainage present on dressing over incisional site CBC:RBC count 5.2 million/mm3 (4.7 to 6.1 million/mm3)WBC count 7,000 mm3 (5,000 to 10,000 mm3)Hemoglobin 15.4 g/dL (14 to 18 g/dL)Hematocrit 48% (42% - 52%)Platelets 250,000/mm3 (150,000 to 400,000/mm3) Basic Metabolic Profile:BUN 18 mg/dL (10 to 20 mg/dL)Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)Carbon Dioxide 27 mEq/L (23 to 30 mEq/L)Chloride 101 mEq/L (98 to 106 mEq/L)Glucose 80 mg/dL (74 to 106 mg/dL)Potassium 5.1 mEq/L (3.5 to 5 mEq/L)Sodium 140 mEq/L (136 to 145 mEq/L) The nurse is caring for the client immediately following the insertion of the permanent pacemaker. Complete the following sentence by using the list of options. The nurse should monitor the client for Select... and Select... following
Dropdown 1: Incisional site bleeding is correct. The incisional site should be monitored for bleeding and hematoma post implantation. The dressing over the site should remain clean and dry. Pulmonary edema is incorrect. Pulmonary edema is not a complication of permanent pacemaker insertion. Dropdown 2: Bradycardia is correct. The nurse should closely monitor the client's ECG rhythm following permanent pacemaker insertion to ensure that the pacemaker is preventing bradycardia. Hypokalemia is incorrect. Hypokalemia is not a complication of permanent pacemaker insertion. Acute kidney injury is incorrect. Acute kidney injury is not a complication of permanent pacemaker insertion.
A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? Monitor sensory perception of the lower extremities. Assist the client into a knee-chest position to manage postoperative discomfort. Maintain strict bed rest for the first 48 hr postoperative. Position the client in a high-Fowler's position if clear drainage is noted on the dressing.
Monitor sensory perception of the lower extremities. The nurse should perform neurologic assessments focusing on sensory perception of the lower extremities every 4 hr. Any decrease in sensation by the client requires immediate notification of the provider.
A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching? "I can wear heels up to 2 ½ inches in height." "I should sleep lying flat with my legs extended straight." "I should increase high potassium foods in my diet." "I should keep my weight within 10 percent of my ideal weight."
"I should keep my weight within 10 percent of my ideal weight." Excessive body weight can place increased stress on the structures of the lower back. The nurse should evaluate the client's weight and make a plan for weight reduction if needed to ease the stress on the client's lower back.
A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? "I will be able to eat solid food when I wake up from anesthesia." "I will have a glass of juice the morning of my surgery." "I understand what risks I can expect with this surgery." "I will take time to relax if I get nervous the night before surgery."
"I will be able to eat solid food when I wake up from anesthesia." Clients who undergo open abdominal surgery will usually have an NG tube in place. The client will remain NPO until the nurse removes the tube. Once the nurse removes the tube, the client can start to drink clear liquids and progress to more solid fluids as she is able to tolerate them.
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough A client who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the priority and the nurse should have the provider care for this client first.
A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results? Decreased thyroid-stimulating hormone (TSH) level Decreased triiodothyronine (T3) level Decreased thyroxine (T4) level Decreased thyroid-stimulating immunoglobulins (TSI) percentage
Decreased thyroid-stimulating hormone (TSH) level The nurse should expect a TSH level below the expected reference range in a client who has Graves' disease.
A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? Apply a new transdermal patch once a week. Apply the transdermal patch in the morning. Apply the transdermal patch in the same location as the previous patch. Apply a new transdermal patch when chest pain is experienced.
Apply the transdermal patch in the morning. The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.
A nurse is caring for a client who needs to increase his protein intake. The client tells the nurse some of the food he enjoys. Which of the following foods should the nurse recommend as the best source of protein among these suggestions? Yams Eggs Chicken Peanuts
Chicken One 3 oz portion of roasted chicken breast provides about 25 g of protein. This is the best source of protein among these options
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take? Keep the formula cold until instillation. Withhold the feeding if the residual volume is 150 mL. Cleanse the top of the can of formula with an alcohol wipe. Flush the tube with 30 mL of sterile water before the feeding.
Cleanse the top of the can of formula with an alcohol wipe. Surface bacteria and dust can contaminate the top of formula cans, so the nurse should disinfect them before opening them and introducing contaminants into the formula. The nurse should allow the can to air-dry before opening it to avoid introducing alcohol into the formula.
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? Nephrosclerosis Uremia Diverticulitis Cystitis
Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? Keep the container of solution at a level to maintain client comfort. Hold the container of solution 30 cm (12 in) above the anus. Hold the container of solution level with the client's upper hip. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
Hold the container of solution 30 cm (12 in) above the anus. The nurse should hold the container of solution 30 to 45 cm (12 to 18 in) above the anus when administering a cleansing enema to allow for a continuous, slow instillation of solution to promote evacuation of feces in the bowel
A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include? Keep a body map of skin lesions. Examine your body every 2 months for lesions. Avoid the sun after 3 p.m. Limit tanning bed use.
Keep a body map of skin lesions. A body map of scars, spots and lesions will help clients monitor for new growth and changes to lesions to help detect skin cancer.
A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe? 14 units 28 units 32 units 42 units
42 units Each order of for units of insulin is combined in the same syringe. The nurse should withdraw the regular insulin into the syringe first.
A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? Euphoria Rhinorrhea Hallucinations Dilated pupils
Euphoria Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors.
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? A client who is postoperative following a lobectomy and has a chest tube A client who is being discharged to a long-term care facility A client who needs teaching about insulin self-administration A client who needs teaching prior to initiating cardiac rehabilitation activities
A client who is postoperative following a lobectomy and has a chest tube According to evidenced-based practice, the nurse from the PACU is most qualified to care for the postoperative client. Nurses in the PACU care for clients with chest tubes after surgery. This is the right client, the right task, and the right circumstances for this nurse.
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? "Pyelonephritis increases a pregnant woman's risk for preterm labor." "Pyelonephritis is most often caused by Staphylococcus saprophyticus." "Pyelonephritis is an infection of the lower urinary tract." "Pyelonephritis often causes no symptoms in affected clients."
"Pyelonephritis increases a pregnant woman's risk for preterm labor." Pyelonephritis is a serious complication of pregnancy that can lead to preterm labor.
A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide? "Stop taking the pills and switch to a different contraceptive method. "Do not have vaginal intercourse until after your next period." "Take the missed dose now, then continue the medication as ordered." "Take a home pregnancy test."
"Take the missed dose now, then continue the medication as ordered." The nurse should tell the client to take the missed dose immediately, then continue with the pack as ordered. The nurse should also tell the client to use an additional form of contraception for 7 days.
A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client? Remove the parenteral nutrition solution from the refrigerator 2 hr before infusion. Remove unused parenteral nutrition after 12 hr of use. Monitor daily laboratory values and report as needed. Monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it falls behind.
Monitor daily laboratory values and report as needed. Laboratory data, as well as observation of clinical signs, are important to prevent the development of nutrient deficiencies or toxicities.
A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? Change in temperature of the toes. Pallor of the toes. Edema of the toes. Inability to move toes.
Pallor of the toes. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.
A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? Needs assistance raising her legs to put on socks Demonstrates mild dyspnea when eating breakfast Performs active range-of-motion (ROM) exercises of all extremities Develops fatigue when assisting with morning hygiene care
Performs active range-of-motion (ROM) exercises of all extremities During periods of immobility, it is important to have the client perform ROM exercises to reduce the hazards of immobility (contractures, loss of muscle mass, thrombosis). A client who is weak might need the nurse to support her extremities during movement (passive ROM). During active ROM, the client is doing the movement with little to no assistance.
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances? Serosanguineous drainage at this time is expected after abdominal surgery. Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage at this time is a manifestation of hemorrhage. Serosanguineous drainage at this time is a manifestation of infection.
Serosanguineous drainage at this time is a manifestation of possible dehiscence. Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.
A nurse is preparing to administer desipramine 150 mg PO daily to a client to treat diabetic neuropathy. The amount available is desipramine 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 1 tabletX tablet(s) = 100 mg Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 1 tablet150 mgX tablet(s) = × 100 mg1 dose Step 4: Solve for X. X tablet(s) = 1.5 tablets Step 5: Round if necessary. Step 6: Reassess to determine whether the amount to administer makes sense. If there are 100 mg/tablet and the prescription reads 150 mg, it makes sense to administer 1.5 tablets. The nurse should administer desipramine 1.5 tablets PO daily.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? The client's partner The client The client's daughter, who is the primary caregiver The client's son, who has a durable power of attorney
The client If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.
A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? The client has a 5 lb weight gain since yesterday. Flattened neck veins Oxygen saturation 93% Return of skin to previous position when the client's shin is palpated
The client has a 5 lb weight gain since yesterday. The nurse should identify that a gain of 2 lb per day is stable. A gain of more than 2 lb per day or 5 lb per week is an indication of fluid overload.
A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order of performance. Use all the steps.)
The nurse should first perform hand hygiene before assisting with the procedure as part of medical asepsis to reduce the growth and transmission of infectious agents. The nurse should then remove the bottle cap carefully to avoid touching inside the cap and the bottle, because these areas are sterile. After removing the cap, the nurse should place it with the inside of the cap face-up on a clean surface, because it is sterile on the inside. The nurse should pick up with the label against the palm of the hand This prevents the solution from running down the side of the bottle, which may damage the label. The nurse should then pour 1 to 2 mL of solution into a receptacle to be discarded. This cleans the inside lip of the bottle. The final step is to pour the solution onto the sterile gauze. The nurse should not hold the bottle over the sterile field. Make sure the lip of the bottle does not come into contact with the sterile gauze. Hold the bottle high enough to avoid splashing of the solution.
A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? Lower the height of the solution container. Encourage the client to bear down. Allow the client to expel some fluid before continuing. Stop the enema and document that the client did not tolerate the procedure.
Lower the height of the solution container. If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed.
A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs? To prevent postoperative hypotension To determine how the client will tolerate the procedure To assess the client's pain level To establish a baseline for postoperative assessment
To establish a baseline for postoperative assessment Preoperative vital signs are assessed in order to establish a baseline for postoperative assessments.
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? Sodium 165 mEq/L Urine specific gravity 1.020 Potassium 5.2 mEq/L Hct 62%
Urine specific gravity 1.020 In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the treatment is effective.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? analgesic anti-inflammatory antiplatelet aggregate antipyretic
antiplatelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.
A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching? "I will take the antiemetic as soon as the chemotherapy infusion is complete." "I will run my toothbrush in the dishwasher every month." "I'll call my doctor if I notice any unusual menstrual bleeding." "I will avoid crowds to keep from infecting others."
"I'll call my doctor if I notice any unusual menstrual bleeding." Clients should be taught bleeding precautions and to report bruising or excessive bleeding.
A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform? Administration of an enema Application of antiembolic stockings Assessing a client's sacrum for edema Assisting a client to cough and deep breathe
Assessing a client's sacrum for edema Assessment requires the nurse's specialized knowledge and cannot be delegated to an AP.
A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? Call the anesthesiologist to sedate the client. Notify the surgeon of the client's food and fluid consumption. Witness the surgical consent. Document the findings in the client's medical record.
Document the findings in the client's medical record. Whenever a nurse collects data from a client, documentation is essential. However, in this case, all these findings are expectations for a client who is preoperative, so there is no need for the nurse to take any action other than documenting.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? Extension of the arms Pronation of the hands Plantar flexion of the legs External rotation of the lower extremities
Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.
A nurse in the emergency department is caring for a female client. Nurses' Notes Nurses' Notes Client appears lethargic and reports fatigue, a decrease in appetite, and a 20 lb weight gain over a 6-month period. Client reports hair loss and numbness and tingling in fingers. Neck midline with a 1+ goiter. Skin is pale, cool, and dry. Client reports constipation. Abdomen is distended. Bowel sounds are hypoactive. Vital Signs Temperature 35.9º C (96.6º F)Blood pressure 88/60 mm HgHeart rate 58/minRespiratory rate 14/minOxygen saturation 93% on room air Diagnostic Results 0800:Cortisol (serum) 16 mcg/dL (5 to 23 mcg/dL)Serum T3 60 ng/dL (70 ng/dL to 205 ng/dL)Serum T4 (total) 3 mcg/dL (5 mcg/dL to 12 mcg/dL) Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should request a prescription for thyroid hormone replacement and provide the client with supplemental oxygen because the client is most likely experiencing hypothyroidism. The client has a decreased oxygen saturation and thyroid function. The nurse should monitor the client's oxygen saturation because the client is at risk for myxedema coma and respiratory failure. The nurse should monitor the client's bowel function to assess the client's progress.