Custom: RN Adult Med Surg Practice Extra (90)

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.) -Discontinue suction when assessing for peristalsis -Irrigate the NG tube with 0.9% sodium chloride irrigation solution. -Place sequential compression devices on the bilateral lower extremities. -Reposition the client from side to side every 2 hr. -Encourage the use of an incentive spirometer every 2 hr while the client is awake.

Discontinue suction when assessing for peristalsis is correct. The nurse should turn off suction while auscultating the abdomen to determine the return of peristalsis because the suction masks any present bowel sounds. Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. The client requires the NG tube for gastric decompression, so the nurse must make sure it remains patent. Irrigating the NG tube with normal saline irrigation solution every 4 hr will ensure patency. Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow for clients who have mobility limitations and help prevent venous thromboembolism in the lower extremities. Reposition the client from side to side every 2 hr is correct. The nurse should reposition the client from side to side at least every 2 hr but should also assist with early ambulation to improve ventilation and help mobilize secretions. Encourage the use of an incentive spirometer every 2 hr while the client is awake is incorrect. Use of the incentive spirometer helps prevent atelectasis. The client should use the device each hour while awake.

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) Green Beans Tomatoes Bananas Asparagus Raisins

Green beans are incorrect. Green beans are not high in potassium and can be eaten by a client who is on a potassium-restricted diet. Tomatoes is correct. Tomatoes are high in potassium and should be avoided by a client who is on a potassium- restricted diet. Bananas is correct. Bananas are high in potassium and should be avoided by a client who is on a potassium-restricted diet. Asparagus is incorrect. Asparagus is safe to eat by a client who is on a potassium-restricted diet. Raisins is correct. Raisins are high in potassium and should be avoided by a client who is on a potassium-restricted diet.

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) Hypertension Tremors Moon face Purple striations Buffalo hump

Hypertension is correct. Hypertension is a manifestation of Cushing's syndrome, caused by the presence of excess glucocorticoids. Tremors is incorrect. Tremors are not a common manifestation of Cushing's syndrome. Moon face is correct. Moon face, which is manifested by a round, red, full face, is a common manifestation of Cushing's syndrome. Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are common manifestations of Cushing's syndrome. Buffalo hump is correct. Buffalo hump, which is a collection of fat between the shoulder blades, is a common manifestation of Cushing's syndrome.

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) Increased heart rate Increased blood pressure Increased respiratory rate Increase hematocrit Increased temperature

Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss.

A nurse is caring for a client. Notes: Day 1 - Oriented to person, place, & time. Speech is slow. Unilateral resting tremors noted in R. arm. Gait is slow & rigid. 6 mo later - Oriented to person and place, disoriented to date and time. Speech is slow and slurred. Bilateral resting tremors noted in extremities and generalized muscle stiffness. Facial rigidity and drooling noted. Gait is slow and client shuffles their feet when ambulating. For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, or multiple sclerosis. Each finding can support more than 1 disease process. -Muscle movements -Speech -Ambulation pattern -Facial rigidity -Orientation status

Orientation status is consistent with Parkinson's disease, stroke, and multiple sclerosis. Cognitive impairment can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Cognitive impairment is consistent with a stroke due to an interruption in cerebral perfusion. Ambulation pattern is consistent with Parkinson's disease. The client is experiencing slowed movement and shuffling gait which are consistent with Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine. Muscle movements are consistent with Parkinson's disease. The client is experiencing resting tremors which are consistent with Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine. Speech is consistent with Parkinson's disease, stroke, and multiple sclerosis. The client is experiencing slurred speech which can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Slurred speech is also consistent with a stroke due to an interruption in cerebral perfusion. Facial rigidity is consistent with Parkinson's disease. Facial rigidity can occur in Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine.

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.) Provide oral fluids. Monitor for nausea. Maintain fetal position. Check level of consciousness. Check sensation in the toes.

Provide oral fluids is correct. Adequate hydration will decrease the risk of a spinal headache. Spinal headaches occur when cerebral spinal fluid (CSF) is decreased suddenly. Adequate hydration will aid in the replacement of CSF. Monitor for nausea is correct. Nausea and vomiting might occur with an increase in intracranial pressure or meningitis. If the client develops persistent nausea or vomiting, the nurse should monitor for other manifestations and report the findings to the provider. Additional findings to report include change in vital signs, headache, change in level of consciousness, nuchal rigidity, drainage, redness, or swelling at the puncture site. Maintain fetal position is incorrect. Following a lumbar puncture (LP), the client should be kept flat and still, often in a prone position. This helps decrease leakage of cerebral spinal fluid (CSF) from the LP site. The fetal position is used during the LP procedure, not after. Check level of consciousness is correct. A change in the client's level of consciousness (LOC) might indicate meningitis or a loss of cerebral spinal fluid (CSF). Check sensation in the toes is correct. A lumbar puncture could cause injury to the spinal cord. The nurse should monitor the client's neurological status in both lower extremities. Sensation to touch and position should be checked, as well as the ability to flex toes and move the feet. The neurological exam should be modified to maintain the client in a flat, still position. A neurological deficit should be reported.

A nurse is caring for a client on a med-surg unit. 1230 - A nurse was called to the bedside & found the client on the floor. Client states: "I fell out of bed trying to get to the bathroom." GCS 15. 1300 - Client states, "my head hurts." Anxious & alert. Grimacing when moving their head. GCS 15. 1400 - Client experiencing Tonic-clonic seizure noted for approximately 1 minute. GCS 14. Client is not oriented to time. 1430 - The client states "I'm scared I'm going to die! My head really hurts." Agitated & restless. HR is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated. GCS 13. They are confused and unable to follow commands. The client is at highest risk for developing __ AEB the __. Dropdown 1: -Intracranial hemorrhage -Ventricular taachycardia -Hypoxia Dropdown 2: -GCS -HR -O2 Sat

The nurse should determine that the priority hypothesis the client is experiencing intracranial hemorrhage as evidenced by the client's Glasgow coma scale following the client's fall. Intracranial hemorrhage is a hematoma or clot in the brain often caused by injury. The nurse should monitor the client's neurological status and vital signs, along with seizure activity which can increase ICP and be life threatening.

A nurse is caring for a client on the med-surg unit. Notes: Day 1, 0800 - Client admitted for evaluation & treatment of cellulitis. Warmth, swelling, and tenderness noted to the R. lower extremity. No drainage noted. Day 3, 0800 - Hyperactive bowel sounds noted. R. lower extremity minimally rend with no tenderness or warmth to palpation. Client states that abdominal cramping and pain started yesterday evening. Client states that they have "been up pooping and haven't been able to stop having bowel movements since. I have been going about every 30 minutes, all night. Can you give me something to slow it down? I've never had diarrhea like this before." 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.

Upon recognizing and analyzing the client cues of abdominal pain and acute onset of diarrhea after the administration of a high dose IV antibiotics, the nurse's priority hypotheses is that this client is most likely experiencing C. difficile colitis. It is important to generate solutions and take actions that will protect others from infection and treat the symptoms of volume depletion caused by diarrhea. Therefore, the nurse should prepare to start IV fluids and place the client on contact precautions. To evaluate therapy, the nurse should monitor the client's serum potassium and for signs of volume depletion (hypotension) as these can be a consequence of severe diarrhea.

A nurse is caring for a client on the med-surg unit for treatment of acute pancreatitis. Lab Results: Day 1, 1200 Calcium 9.0 (9 to 10.5) Magnesium 1.8 (1.3 to 2.1) Potassium 5.0 (3.5 to 5) Sodium 144 mEq/L (136 to 145) Chvostek sign present and positive Trousseau sign. 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. Actions to Take: -Anticipate prescription to increase IV fluid rate -Prepare to check a serum albumin level -Assess the client for alcohol use disorder -Request a STAT ECG -Initiate seizure precautions Potential Conditions: -Hypomagnesemia -Hypocalcemia -Hypernatremia -Hyperkalemia Parameters to Monitor: -Serum bicarbonate level -Impaired memory -I&O -Bowel sounds -Ataxia

Upon recognizing and analyzing the client cues of acute pancreatitis and a history of end-stage renal disease with new-onset diarrhea and positive Chvostek and Trousseau signs, the nurse's priority hypotheses is that the potential condition this client can be experiencing is hypocalcemia. It is important to generate solutions and take actions that will ensure client safety and further evaluate the validity and cause of the hypocalcemia. Therefore, the nurse should prepare to check a serum albumin and (initiate seizure precautions because hypocalcemia can increase irritability of the central and peripheral nervous systems and cause seizure activity. To evaluate these interventions the nurse should monitor the client's bowel sounds and any signs of impaired memory. Hypocalcemia can cause impaired memory, confusion, and delirium as well as hyperactive bowel sounds.

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? a. "These organs support immunity." b. "These organs are used in digestion." c. "These organs regulate electrolyte balance." d. "These organs assist vitamin absorption."

a. "These organs support immunity." The nurse should inform the client that the function of the thymus, spleen, and lymph nodes is to support immunity and fight infection.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? a. "Without treatment, glaucoma can cause blindness." b. "Double vision is a common symptom of glaucoma." c. "Glaucoma is caused by inadequate production of fluid within the eye." d. "Use of eye drops will improve vision over time."

a. "Without treatment, glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available? a. 10% dextrose in water (D10W) b. 0.45% sodium chloride (0.45% NaCl) c. Lactated Ringer's solution d. 5% dextrose in lactated Ringer's solution (D5LR)

a. 10% dextrose in water (D10W) TPN solution has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if there is not another bag of TPN solution available. This will ensure that the client receives the adequate amount of glucose and a solution with the appropriate osmolarity until another TPN solution is available.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? a. A room with air exhaust directly to the outdoor environment b. A room with another nonsurgical client c. A room in the ICU d. A room that is within view of the nurses' station

a. A room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? a. An acute infectious process b. Neutropenia c. Allergic reaction d. A resolving inflammatory process

a. An acute infectious process The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process.

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? a. Arterial insufficiency b. Venous insufficiency c. Within the expected range d. Thrombus formation in the vein

a. Arterial insufficiency To test capillary refill, a nurse presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. If the skin color takes longer than 3 seconds to return to normal, this indicates impaired arterial blood flow to the extremity.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? a. Drink 3 L of fluid every day. b. Take 3,000 mg of vitamin C daily. c. Restrict calcium intake to one serving per day. d. Eat 12 oz of animal protein daily.

a. Drink 3 L of fluid every day. The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include? a. Empty the pouch when it is 1/2 full. b. Hold pressure on the skin barrier for 10 to 15 sec to secure the seal. c. Clean the peristomal skin four times a day. d. Expect firm fecal content

a. Empty the pouch when it is 1/2 full. The nurse should instruct the client to empty the pouch when it is 1/3 to 1/2 full.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? a. Establish the ability to communicate effectively. b. Compensate for loss of depth perception. c. Learn to control impulsive behavior. d. Improve left-side motor function.

a. Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is reviewing the laboratory results of a client who has acute radiation syndrome and notes the client has leukopenia. Which of the following assessment findings should the nurse identify as being consistent with leukocytosis? a. Fever b. Bruising c. Pallor d. Petechiae

a. Fever Acute radiation syndrome results in a decrease in many of the blood cell types including lymphocytes, leukocytes, thrombocytes, and red blood cells. A fever would be an expected finding of a decreased number of white blood cells (leukopenia).

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? a. Have the client lie flat in bed. b. Keep the affected leg slightly flexed. c. Elevate the head of the bed 45°. d. Keep the client NPO for 4 hr.

a. Have the client lie flat in bed. The nurse should have the client on lie flat in bed. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure? a. High-Fowler's b. Side-lying c. Leaning forward d. Supine

a. High-Fowler's Sitting upright facilitates pooling of peritoneal fluid for easier drainage.

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. Then nurse should identify that the client is likely experiencing which of the following conditions? a. Hypoglycemia b. Hyperglycemia c. Neuropathy d. Hypokalemia

a. Hypoglycemia Hypoglycemia is a complication of diabetes indicating a blood glucose level less than 70 mg/dL. It can occur when excessive insulin or oral hypoglycemic are administered, with excessive physical activity, or when too little food is consumed. The manifestations of hypoglycemia include sweating, tremor, tachycardia, palpitations, headache, fatigue, nervousness, and hunger.

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take? a. Log roll the client every 2 hr. b. Assist the client to sit upright in a chair for 4 hr at a time. c. Expect clear drainage on the spinal dressing. d. Elevate the client's legs when he is sitting in a chair.

a. Log roll the client every 2 hr. The nurse should log roll the client from side to back or back to side every 2 hr.

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? a. Notify the provider of the client's allergy. b. Attach a wrist band indicating the client's allergy. c. Ask the client if any other foods cause such a reaction. d. Notify the dietary department of the client's allergy.

a. Notify the provider of the client's allergy. The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure, because shellfish also contains iodine. A steroid and/or antihistamine will be given to a client with an iodine allergy to prevent or minimize a reaction.

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? a. Output of burgundy colored urine b. Pulse rate of 88/min c. Oral temperature of 38.2° C (100.76° F) d. An urge to void despite having an indwelling urinary catheter

a. Output of burgundy colored urine Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? a. Poor impulse control b. Unable to discriminate words and letters c. Deficits in the right visual field d. Motor retardation

a. Poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication? a. Potassium b. Hemoglobin c. Creatinine d. Blood urea nitrogen

a. Potassium Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L a. Respiratory acidosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory alkalosis

a. Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? a. Speak to the client about one idea at a time. b. Ask the client to multi-task. c. Limit questions to yes and no answers. d. Focus on a single form of communication.

a. Speak to the client about one idea at a time. The nurse should speak using sentences that contain one clear thought or idea for better communication and understanding.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? a. To prevent fluid from accumulating in the wound b. To limit the amount of bleeding from the surgical site c. To provide a means for medication administration d. To eliminate the need for wound irrigations

a. To prevent fluid from accumulating in the wound. The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? a. "Don't worry; most clients dislike the prep more than the procedure itself." b. "Before the examination, your provider will give you a sedative that will make you sleepy." c. "I know you're anxious, but this procedure is recommended for people your age." d. "After you have signed the consent form, we can talk more about this."

b. "Before the examination, your provider will give you a sedative that will make you sleepy." This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? a. "My eye really itches, but I'm trying not to rub it." b. "I need something for the pain in my eye. I can't stand it." c. "It's hard to see with a patch on one eye. I'm afraid of falling." d. "The bright light in this room is really bothering me."

b. "I need something for the pain in my eye. I can't stand it." Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. "I should soak my feet before trimming my nails." b. "I should buy new shoes late in the day." c. "I should wear a clean pair of nylon socks every day." d. "I should use a heating pad at night when my feet feel cold."

b. "I should buy new shoes late in the day." The client's feet are larger later in the day. Therefore, this is the best time to buy new shoes.

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching? a. "I will not smoke prior to my test." b. "I'll take my heart medications the morning of my test." c. "I'll get 8 hours of sleep the night before the test." d. "I'll skip my coffee the morning of my test."

b. "I'll take my heart medications the morning of my test." The provider will give the client specific instructions about his medications, but generally the client should avoid medications that will prevent fluctuations in heart rate during the test, such as calcium channel blockers and beta blockers.

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? a. "The laxative will prevent the absorption of magnesium." b. "The laxative helps eliminate the barium." c. "The laxative is the protocol at this facility." d. "The laxative makes the barium turn brown."

b. "The laxative helps eliminate the barium." The nurse's statement that the laxative will help eliminate the barium is appropriate and provides the client with the reason for the laxative.

A nurse is teaching about levothyroxine with a client who has primary hypothyroidism. Which of the following statements should the nurse use when teaching the client? a. "Take this medication until your symptoms are gone and then discontinue." b. "Tremors, nervousness, and insomnia may indicate your dose is too high." c. "Symptoms improve immediately after starting the medication." d. "The medication decreases the overproduction of the thyroid hormone thyroxine."

b. "Tremors, nervousness, and insomnia may indicate your dose is too high." The nurse should teach that tremors, nervousness, and insomnia may indicate an overdose of the medication and to notify the provider.

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching? a. "You should limit fluids for 12 hr following the procedure." b. "You may have pink-tinged urine after this procedure." c. "You can eat a full liquid meal up to 1 hour before the procedure." d. "You will be placed on your right side during the procedure."

b. "You may have pink-tinged urine after this procedure." The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.

A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect? a. Flaccid muscles b. Client report of numbness in his hands c. Negative Chvostek's sign d. Client report of anorexia

b. Client report of numbness in his hands. Numbness and tingling in the client's hands and feet are manifestations of hypoparathyroidism due to hypocalcemia.

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include? a. Perform vigorous exercise when blood glucose is less than 100 mg/dL. b. Do not exercise if ketones are present in your urine. c. Avoid eating for 2 hr before exercise. d. Examine your feet weekly.

b. Do not exercise if ketones are present in your urine. The nurse should instruct the client not exercise if ketones are present in her urine because this is an indication of inadequate insulin and increases the risk for hyperglycemia.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? a. Dehydration b. Fungal infection c. Compartment syndrome d. Pleural effusion

b. Fungal infection The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction.

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly? a. Turn the client on his left side. b. Sit the client upright. c. Prepare to add insulin to the TPN infusion. d. Stop the TPN infusion.

b. Sit the client upright. Fluid overload can cause dyspnea. The nurse should slow the infusion rate and sit the client upright to help prevent or treat dyspnea. The nurse should also administer oxygen if necessary.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? a. Transient ischemic attack (TIA) b. Hemorrhagic stroke c. Thrombotic stroke d. Embolic stroke

b. Hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse is caring for a client who has end-stage kidney disease (ESKD) and reports having shortness of breath and swelling in his lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations? a. Hypovolemia b. Hypervolemia c. Hyperkalemia d. Hyponatremia

b. Hypervolemia A client who has ESKD experiences excess fluid volume. The increase in circulating fluid causes hypertension which, along with the anemia that occurs in ESKD, ultimately causes heart failure. The client's manifestations of dyspnea, crackles, and edema indicate the client is experiencing heart failure.

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor? a. Hypermagnesemia b. Hypokalemia c. Hyperkalemia d. Hypomagnesemia

b. Hypokalemia If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrhythmia.

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? a. Instruct the client to take antibiotics until dysuria is no longer present. b. Instruct the client to avoid drinking carbonated beverages. c. Instruct the client to drink 240 mL of tomato juice each day. d. Instruct the client to drink 1 L of fluid each day.

b. Instruct the client to avoid drinking carbonated beverages. The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? a. It decreases the client's level of anxiety. b. It facilitates the client's deep breathing. c. It enhances the client's ability to sleep. d. It reduces the client's blood pressure.

b. It facilitates the client's deep breathing. When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? a. Suggest that the client use a salt substitute. b. Obtain a 12-lead ECG. c. Advise the client to add citrus juices and bananas to her diet. d. Obtain a blood sample for a serum sodium level.

b. Obtain a 12-lead ECG. This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes.

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? a. Hypernatremia b. Oliguria c. Weight loss d. Increased thirst

b. Oliguria The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? a. Prepare for chest tube insertion. b. Place the client on his left side in Trendelenburg position. c. Remove the catheter. d. Replace the infusion system.

b. Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? a. Sodium 136 mEq/L b. Potassium 2.3 mEq/L c. Chloride 99 mEq/L d. Calcium 10 mg/dL

b. Potassium 2.3 mEq/L A serum potassium below 3 mEq/L is a critical laboratory value. The nurse should report this finding to the provider immediately and monitor the client for dysrhythmias.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? a. Chest x-ray b. Sputum culture for acid-fast bacillus c. Sputum smear d. Mantoux test

b. Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.

A nurse is providing teaching to a client who has a diabetes mellitus about carbohydrate intake needs when exercising. Which of the following foods should the nurse include as containing a 15 g serving of carbohydrates? a. 2 slices bread b. 1 cup sugar-free yogurt c. 1 cup milk d. 1 cup regular ice cream

c. 1 cup milk The nurse should instruct the client that 1 cup of milk contains 15 g of carbohydrates.

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? a. Medications will need to be taken for the rest of the client's life, even if the client feels better. b. Medications will need to be taken until the Mantoux test is negative. c. A typical course of treatment involves 6 to 9 months of consistent medication use. d. The client's family will also need to take medications to prevent infection

c. A typical course of treatment involves 6 to 9 months of consistent medication use. Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? a. Assess the client's level of consciousness. b. Administer epinephrine. c. Auscultate for wheezing. d. Monitor for hypotension.

c. Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia? a. Position the head of the client's bed in the flat position. b. Turn the client every 4 hr. c. Brush the client's teeth with a suction toothbrush every 12 hr. d. Provide humidity by maintaining moisture within the ventilator tubing.

c. Brush the client's teeth with a suction toothbrush every 12 hr. The nurse should brush the client's teeth every 12 hr and rinse the client's mouth with an antimicrobial rinse to reduce the growth of bacteria.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? a. Check the client's vital signs. b. Assess the client's pain level. c. Cover the wound with a moist, sterile gauze dressing. d. Obtain a culture and sensitivity of the wound drainage.

c. Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

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? a. Positive Kernig's sign b. Positive Homan's sign c. Dull, aching calf pain d. Soft, pliable calf muscle

c. 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 developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? a. Perform range-of-motion exercises b. Place suction equipment at the bedside c. Encourage the use of an incentive spirometer d. Administer an expectorant

c. Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? a. Hypocalcemia b. BMI less than 25 c. Family history d. Diuretic use

c. Family history Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation.

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus? a. HbA1c 5.5% b. 2 hr blood glucose 170 mg/dL c. Fasting blood glucose 155 mg/dL d. Casual blood glucose 180 mg/dL

c. Fasting blood glucose 155 mg/dL A fasting blood glucose above 126 mg/dL meets the criteria for a diagnosis of diabetes mellitus

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? a. Pain b. Nausea c. Gag reflex d. Level of consciousness

c. Gag reflex The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? a. Myringotomy b. Laparoscopic appendectomy c. Hip arthroplasty d. Cataract extraction

c. Hip arthroplasty Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? a. Immunoglobulin G (IgG) b. Immunoglobulin A (IgA) c. Immunoglobulin E (IgE) d. Immunoglobulin M (IgM)

c. Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.

A nurse is completing a physical examination of a client and notes that laboratory values indicate leukocytosis. The nurse should recognize that which of the following manifestations is associated with leukocytosis? a. Anemia b. Coagulation disorders c. Inflammation d. Renal disorder

c. Inflammation Infection and inflammation are associated with leukocytosis, which is an elevated WBC count.

A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan? a. Take the client's rectal temperature each day. b. Increase raw produce in the client's diet. c. Limit visitors to healthy adults. d. Instruct the client to floss his teeth daily.

c. Limit visitors to healthy adults. The expected reference range of absolute neutrophil count is 2500 to 8000/mm3. This client has a reduced absolute neutrophil count (neutropenia) and is immunosuppressed. A client who has neutropenia is at an increased risk for infection. The nurse should restrict visitors for a client who has neutropenia to healthy adults to reduce the risk for infection.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? a. Check the client's blood pressure. b. Auscultate heart tones. c. Perform a 12-lead ECG d. Determine if pain radiates to the left arm.

c. Perform a 12-lead ECG The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? a. Attending a class given about tracheostomy care b. Verbalizing all steps in the procedure c. Performing the procedure independently d. Asking appropriate questions about suctioning

c. Performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? a. Stoma oozing red drainage b. Shiny, moist stoma c. Purplish-colored stoma d. Rosebud-like stoma orifice

c. Purplish-colored stoma A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? a. Brachial pulse in the left arm b. Brachial pulse in the right arm c. Radial pulse in the left arm d. Radial pulse in the right arm

c. Radial pulse in the left arm Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? a. Lactulose b. Sevelamer c. Sodium polystyrene d. Darbepoetin alfa

c. Sodium polystyrene Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? a. The client's ECG tracing shows irregular heart rate without P waves. b. The client has an aPTT of 80 seconds. c. The client experiences sudden weakness of one arm and leg. d. The client's urine output is cloudy and odorous.

c. The client experiences sudden weakness of one arm and leg. Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache

A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated? a. Aspartate aminotransferase (AST). b. Unconjugated bilirubin c. Troponin I d. Serum amylase

c. Troponin I Cardiac troponin I and cardiac troponin T are biochemical markers that are specific to myocardial cell injury. A client who has myocardial cell damage can have elevated troponin levels within 2 to 3 hr. Cardiac troponin I levels can peak in 10 to 24 hr and stay elevated for 7 to 10 days. Cardiac troponin T levels can peak within 10 to 24 hr stay elevated for 10 to 14 days.

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? a. Sodium 165 mEq/L b. Potassium 5.2 mEq/L c. Urine specific gravity 1.020 d. Hct 62%

c. 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 nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? a. Blood pressure 102/66 mm Hg b. Straw-colored urine from an indwelling urinary catheter c. Yellow-green drainage on the surgical incision d. Respiratory rate 18/min

c. Yellow-green drainage on the surgical incision Thick yellow-green drainage is indicative of an infection and should be reported immediately.

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make? a. "You should ask your family to bring you some food from home." b. "Clients frequently complain about the taste of hospital food." c. "I would be happy to get you food that you prefer to eat." d. "Because of your surgery, you have an altered ability to smell and taste."

d. "Because of your surgery, you have an altered ability to smell and taste." Clients who have lost their larynx commonly complain of poor ability to smell and taste. This is because they now breathe through the tracheal stoma, rather than the mouth and nose, which bypasses the location of the olfactory and gustatory nerve cells.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? a. "I drink at least 2 quarts of fluid every day." b. "The last time I voided it was painful and red-tinged." c. "My period ended 2 days ago." d. "I don't eat shellfish because it gives me hives."

d. "I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching? a. "I will continue my low-dose aspirin therapy regimen." b. "I will refrain from eating raw fruits and vegetables." c. "I will avoid steak and other red meats." d. "I will continue taking my Coumadin as prescribed."

d. "I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? a. "It might help if I tried sleeping only on my back." b. "I'll sleep better if I take a sleeping pill at night." c. "I'll get a humidifier to run at my bedside at night." d. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

d. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea.

A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test? a. "This test measures the amount of thyroid hormone that attaches to a protein in your blood." b. "This test detects antithyroid antibodies in your blood." c. "This test measures the absorption of iodine and how it relates to the thyroid gland." d. "This test determines whether your thyroid gland is overactive, appropriately active, or underactive."

d. "This test determines whether your thyroid gland is overactive, appropriately active, or underactive." This describes the TSH test, which helps determine thyroid status and helps monitor the effectiveness and dosage of thyroid hormone replacement therapy.

A nurse is providing teaching to a client about completing a creatinine clearance test. Which of the following instructions should the nurse include in the teaching? a. "You will need to collect all of your urine for the next 12 hours." b. "You will need to store the urine container in a dark location." c. "You will need to start the collection time with your first urine specimen of the day." d. "You will need to avoid rigorous exercise during the test."

d. "You will need to avoid rigorous exercise during the test." The nurse should instruct the client to avoid exercising during the testing time because it can cause an increase in the creatinine values.

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? a. Glucocorticoid medications b. Dextrose 5% in 0.45% sodium chloride c. Oral hypoglycemic medications d. 0.9% sodium chloride IV bolus

d. 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 is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? a. A client who has a urine specific gravity of 1.010. b. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. c. A client who has a hematocrit of 45% d. A client who has a temperature of 39° C (102° F)

d. A client who has a temperature of 39° C (102° F). This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration.

A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? a. A client who has a fever of unknown origin b. A client who had a total hip arthroplasty c. A client who is HIV positive d. A client who is neutropenic

d. A client who is neutropenic Clients who have neutropenia (a low count of neutrophils, a type of WBC that helps fight infection) due to immune system compromise, such as clients who have leukemia or major burns or are receiving chemotherapy or allogenic hematopoietic stem cell transplants, require a protective environment to prevent the spread of pathogens to the clients requiring the protective environment. This means a private room with positive airflow.

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? a. Pain severity b. Wound drainage c. Tissue integrity d. Airway patency

d. Airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? a. Unequal pupils b. Hypertension c. Tympany upon chest percussion d. Confusion

d. Confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

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? a. Nephrosclerosis b. Uremia c. Diverticulitis d. Cystitis

d. 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 monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect? a. Hypokalemia b. Metabolic alkalosis c. Hypercalcemia d. Elevated BUN

d. Elevated BUN Client who are in acute kidney injury will have an elevated BUN as damage to the kidneys leads to a build-up of nitrogenous wastes in the blood.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? a. Collect a urine specimen for culture and sensitivity. b. Continue routine care because the results are within the expected reference range. c. Decrease the IV fluid infusion rate and limit oral fluid intake. d. Evaluate urine for amount and for specific gravity.

d. Evaluate urine for amount and for specific gravity. These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? a. Encourage fluid intake of 1500 mL/day. b. Position head of bed at 10 degrees. c. Cough and deep breathe every 8 hr. d. Obtain a sputum culture.

d. Obtain a sputum culture. The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for a. side effects of immunosuppressants. b. constipation. c. fatigue. d. bleeding

d. bleeding. Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding. In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client.