EAQs

A client has chronic asthma. For which complication should the nurse monitor this client? A. Atelectasis B. Pneumothorax C. Pulmonary edema D. Respiratory alkalosis

A. Atelectasis

A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup? A.Crash cart with bed board B.Tracheostomy set and oxygen C.Ampule of sodium bicarbonate D.Airway and nonrebreather mask

B.Tracheostomy set and oxygen

The client is scheduled for an abdominal hysterectomy with a bilateral oophorectomy. As the nurse prepares to have her sign the informed consent, she asks how long she should wait to become pregnant. What would be the best response? A. Have the client sign the informed consent form. B. Ask the client if she understands what the surgery entails. C. Tell her that she will not be able to get pregnant after the surgery. D. Call the surgeon immediately and hold preoperative medications.

D. Call the surgeon immediately and hold preoperative medications. Reasoning: The surgeon should be notified immediately that the informed consent is not going to be signed as the client does not appear to understand the procedure. Also notify the provider that preoperative medication is being held until the situation is worked out. An informed consent involves the health care provider telling the client in understandable terms about the diagnosis, treatment, likely outcome, alternative treatments, and possible complications. If there are questions before signing the consent, the provider must be contacted to provide further explanation.

A client is admitted to the hospital with the diagnosis of pneumonia. The client's pulse rate increases from 88 beats per minute on admission to 120 to 140 beats per minute on the second day of hospitalization. The client is more restless, complains of a headache, and is diaphoretic. Assuming that all the following choices are possible, the most appropriate action by the nurse is to: A. Prepare for pleural fluid analysis B. Arrange for repeat blood cultures C. Test for the Mycobacterium avium complex. D. Check for results of arterial blood gas values.

D. Check for results of arterial blood gas values. Rationale: The signs and symptoms are those of hypoxia, possibly indicating respiratory failure; arterial blood gases will confirm or refute this suspicion and permit the health care provider and nurse to proceed appropriately on the strength of all available data. Preparing for pleural fluid analysis is not the initial action; if pleural effusion is suspected, a thoracentesis to obtain fluid for culture may be performed. Respiratory status is the priority; however, septicemia or worsening infection is possible, and repeating blood cultures should be considered after checking blood gases, especially if the latter are not remarkable. If M. avium complex is the cause of the client's problem, the client's clinical findings also will include night sweats, weight loss, abdominal pain, and diarrhea.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L. The nurse should recommend which drink to be included in the client's diet? A. Milk B. Tea C. Orange juice D. Tomato juice

B. Tea Reasoning: The client is hyperkalemic, and potassium intake should be limited; apple juice is very low in potassium Milk should be avoided; one cup of milk contains 754 mg of potassium. Orange juice should be avoided; one cup of orange juice contains 496 mg of potassium. Tomato juice should be avoided; one cup of tomato juice contains 550 mg of potassium.

A client is admitted to the hospital with a diagnosis of a large cancerous tumor of the transverse colon, and surgery for a colon resection is scheduled. What clinical finding does the nurse expect when completing this client's nursing admission history and physical? A. Diarrhea B. Dehydration C. Rectal bleeding D. Ribbon-shaped stool

C. Rectal bleeding Reasoning: Tumors of the sigmoid colon are associated with rectal bleeding. Diarrhea alternating with constipation frequently occurs. Dehydration usually does not occur unless there is severe vomiting or severe prolonged diarrhea. A change in the shape of stool occurs with tumors in the descending colon and sigmoid colon.

A nurse notes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment? A. Vital signs B. Fluid balance C. Serum glucose level D. Dietary calorie count

C. Serum glucose level

The nurse identifies a 5-cm nodule on the upper arm of a client with type 1 diabetes. The client says to the nurse, "That is where I give myself insulin shots." The nurse concludes that the nodule, which is neither warm nor painful, is a result of: A. Keratosis B. An allergy C. An infection D. Lipodystrophy

D. Lipodystrophy Reasoning: Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits. Injections of insulin will not cause a horny growth such as a wart or callus. An allergic response will precipitate a localized or systemic inflammatory response. Hyperthermia and localized heat, erythema, and pain are associated with an infection.

A client with quadriplegia is placed on a tilt table daily. The client asks why the angle of the head of the table is gradually increased. How should the nurse respond? A. It facilitates turning. B. This prevents pressure ulcers. C. It promotes hyperextension of the spine. D. This limits loss of calcium from the bones.

D. This limits loss of calcium from the bones.

When providing care for a client in the first 24 hours after a thyroidectomy, the nurse should: A. Check the back and sides of the operative site B. Support the head during mild range-of-motion (ROM) exercises C. Encourage the client to ventilate feelings about the surgery D. Advise the client that regular activities can be resumed immediately

A. Check the back and sides of the operative site

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply. A. Edema B. Rapid weight gain C. Fatigue in the afternoon D. Unpredictable changes in mood E. Increased frequency of urination

A. Edema B. Rapid weight gain Reasoning: Fludrocortisone has a strong effect on sodium retention by the kidneys, which leads to fluid retention, causing edema and weight gain. Fatigue may occur with adrenal insufficiency and is not related to cortisone therapy. Unpredictable changes in mood commonly occur but are not as serious a threat as fluid retention. Fluid retention, and thus decreased urination, may occur.

A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. What is the priority nursing intervention for this client? A.Provide pain medication B. Obtain an electrocardiogram (ECG) C. Transfer to the coronary care unit D. Have a blood specimen drawn for enzyme studies

A.Provide pain medication Reasoning: Providing for comfort reduces anxiety and subsequently decreases catecholamine release, indirectly decreasing myocardial oxygen requirements. Obtaining an electrocardiogram is important, but pain relief is the priority; the ECG is significant to examine for progressive myocardial changes. The client's condition should be stabilized before transfer; relief of pain facilitates stabilization. Securing blood for enzyme studies is not an emergency intervention, although a blood sample for cardiac enzymes is important for a definitive diagnosis.

A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? A. Feel for a pulse. B. Begin chest compressions. C. Leave to call for assistance. D. Perform the abdominal thrust maneuver.

B. Begin chest compressions. Reasoning According to the 2010 American Heart Association Guidelines for CPR, the first step is to feel for a pulse. In this case, it has been established the patient has no pulse, therefore, chest compressions are initiated. Do not leave the patient to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

The nurse is providing postoperative care to a client with lung cancer that had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. The nurse describes this assessment finding as: A. Stridor B. Crepitus C. Pitting Edema D. Chest Distention

B. Crepitus Rationale: There is air in the tissues, and palpation results in a crackling sound referred to as crepitus. Stridor is a harsh high-pitched sound usually produced on inspiration because of airway obstruction. Pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which diagnostic intervention by the health care provider promotes identification of the cause of this incontinence? A. Abdominal percussion B. Digital rectal examination C. Urine culture and sensitivity test D. Pelvic and abdominal ultrasound

B. Digital rectal examination Reasoning: Fecal impaction is the primary cause of liquid fecal incontinence. A digital rectal examination will determine the presence of a fecal impaction. Abdominal percussion will not assist in the diagnosis of impaction. Urine culture and sensitivity test will identify urinary tract infection; urinary, not fecal, incontinence is associated with urinary tract infection. Pelvic and abdominal ultrasound might be done if earlier assessments are inconclusive and additional evaluations are required.

A client with a history of severe intermittent claudication has a femoropopliteal bypass graft. An appropriate postoperative intervention on the day after surgery is to: A. Keep the client on bed rest B. Have the client sit in a chair C. Assist the client with ambulation D. Encourage the client to keep the legs elevated

C. Assist the client with ambulation

Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to: A. Administer an oral hypoglycemic B. Institute urine glucose monitoring C. Give supplemental doses of regular insulin D. Decrease the rate of the intravenous infusion

C. Give supplemental doses of regular insulin

The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are found with which condition? A. Glaucoma B. Hypertension C. Hyperthyroidism D. Sinus infection

C. Hyperthyroidism

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply. A. Constipation B. Hypokalemia C. Irregular pulse rate D. Change in visual acuity E. Orthostatic hypotension

C. Irregular pulse rate E. Orthostatic hypotension Reasoning: Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan. It also may precipitate angina pectoris, myocardial infarction, and brain attack (cerebrovascular accident, CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.

A nurse plans an evening snack of milk, crackers, and cheese for a client who is receiving NPH insulin (Novolin N). What does this snack provide? A. Encouragement to stay on the diet B. Added calories to promote weight gain C. Nourishment to counteract late insulin activity D. High-carbohydrate nourishment for immediate use

C. Nourishment to counteract late insulin activity

A health care provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide as to why the client needs to follow this diet? A. "The use of salt probably contributed to the disease." B. "Excess weight will be gained if sodium is not limited." C. "The loss of excess sodium and potassium in the urine requires less renal stimulation." D. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

D. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. What is the nurse's most appropriate action? A. Administer insulin to the client B. Give the client lunch immediately C. Encourage the client to drink fluids D. Assess the client's blood glucose level

D. Assess the client's blood glucose level

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? A. Slow, deep respirations B. Normal oral temperature C. Dry, unproductive cough D. Diminished breath sounds

D. Diminished breath sounds Rationale: Because atelectasis involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply. A. Iced tea B. Red meat C. Club soda D. Hot cocoa E. Chocolate pudding

A. Iced tea D. Hot cocoa E. Chocolate pudding

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure? A. 110 to 119 mm Hg B. 120 to 129 mm Hg C. 130 to 139 mm Hg D. 140 to 159 mm Hg

D. 140 to 159 mm Hg Reasoning: Systolic blood pressure associated with stage 1 hypertension is between 140 and 159 mm Hg. Optimal systolic blood pressure is less than 120 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg.

The nurse is assessing the client admitted with diabetic ketoacidosis. The nurse knows the client needs further education on sick day management when the client states: A. "I need to stop taking my insulin when I am ill because I am not eating." B. "I will check my urine for ketones when my blood sugar is over 250." C. "I will try and take in Gatorade and water when I am sick." D. "I will continue all my insulin including my lantus when I am sick.

A. "I need to stop taking my insulin when I am ill because I am not eating." Reasoning: The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness. The client checking the urine for ketones when blood sugar is over 250, drinking water and Gatorade, and continuing insulin indicate that the client has an understanding of the basic sick day rules.

A client on a low-residue diet asks the nurse about foods that must be avoided. Which foods should the nurse instruct the client to avoid? Select all that apply. A. Fresh fruit B. Broiled fish C.Poached eggs D. Buttered white rice E. Whole wheat bread

A. Fresh fruit E. Whole wheat bread Reasoning: Fresh fruit contains fiber and should be avoided on a low-residue diet. Whole wheat bread contains fiber and should be avoided on a low-residue diet. Broiled fish, poached eggs, and buttered white rice are permitted on a low-residue diet.

A client who sustained chest trauma in an accident has bilateral chest tubes inserted. What is the nurse's primary responsibility when caring for this client? A. Maintaining a closed system B. Placing the client in the supine position C. Encouraging deep breathing and coughing D. Monitoring the client's oxygen saturation level

A. Maintaining a closed system Reasoning: maintaining an airtight system is needed to reestablish negative pressure and reinflate the lung. A low-Fowler or higher, not supine, position is preferred to facilitate respirations. Although encouraging deep breathing and coughing will be done, it is not the priority. Although monitoring the client's oxygen saturation level will be done, it is not the priority.

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? A. Observe for fluid fluctuations in the water-seal chamber. B. Obtain a prescription for morphine to minimize agitation. C. Apply a thoracic binder to prevent excessive tension on the tube. D. Clamp the tubing securely to prevent a rapid decline in pressure.

A. Observe for fluid fluctuations in the water-seal chamber. Rationale: fluctuations occur with inspiration and expiration until the lung is fully expanded. If they do not occur, the chest tube may be clogged or kinked and coughing should be encouraged. The client may not be agitated; morphine decreases respirations and usually is avoided. The binder does not prevent tension o the tube; its use is contraindicated because it limits thoracic expansion. The tube should be clamped only if prescribed or if an air leak is suspected.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? A. Oliguria B. Bradypnea C. Pulse deficit D. High potassium levels

A. Oliguria Reasoning: A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs because as sodium is retained, potassium is excreted.

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply. A. Thirst B. Palpitations C. Diaphoresis D. Slurred speech E.Hyperventilation

B. Palpitations C. Diaphoresis D. Slurred speech Reasoning: Palpitations, an adrenergic symptom, occur as the glucose level decreases; the sympathetic nervous system is activated, and epinephrine and norepinephrine are secreted, causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the central nervous system (CNS) becomes depressed. Thirst occurs with hyperglycemia in response to dehydration associated with osmotic diuresis. Hyperventilation occurs with diabetic ketoacidosis; Kussmaul respirations are an effort to counteract the effects of a buildup of ketones as the body seeks acid-base balance.

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? Select all that apply. A.Lethargy B. Headache C. Diaphoresis D. Excessive thirst E. Deep respirations

B. Headache C. Diaphoresis Reasoning: Hypoglycemia affects the central nervous system, causing headache. Hypoglycemia affects the sympathetic nervous system, causing diaphoresis. Lethargy is associated with hyperglycemia because glucose is not being used for cellular metabolism. Excessive thirst is associated with hyperglycemia because fluid shifts along with the excess glucose being excreted by the kidneys, resulting in polyuria. Deep respirations (Kussmaul respirations) are associated with hyperglycemia because the body is attempting to blow off carbon dioxide to compensate for the metabolic acidosis.

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. The nurse should: A. Assess for obstructions in the chest tube B. Increase the amount of continuous suction C. Add Sterile water to the water-seal chamber D. Make preparations to remove the tube.

B. Increase the amount of continuous suction Rationale: Fluid in the water-seal chamber should rise and fall as the client breathes in and out (tidaling) until the lungs have expanded completely; a lack of of tidaling on the second postoperative day indicates that the tube is obstructed. Increasing the amount of suction is contraindicated without a prescription because it can traumatize pleural tissue. The level of the fluid, as long as it covers the tube in the water-seal chamber, does not affect tidaling. The lungs will not be fully expanded on the second postoperative day; the chest tube will remain in place.

A client with diabetic ketoacidosis, who is receiving intravenous fluids and insulin, complains of tingling and numbness of the fingers and toes and shortness of breath. The cardiac monitor shows the appearance of a U wave. The nurse concludes that these symptoms indicate: A. Hypokalemia B. Hypoglycemia C. Hypernatremia D. Hypercalcemia

A. Hypokalemia Reasoning: These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Symptoms of hypoglycemia are weakness, nervousness, tachycardia, diaphoresis, irritability, and pallor. Symptoms of hypernatremia are thirst, orthostatic hypotension, dry mouth and mucous membranes, concentrated urine, tachycardia, irregular heartbeat, irritability, fatigue, lethargy, labored breathing, and muscle twitching or seizures. Symptoms of hypercalcemia are lethargy, nausea, vomiting, paresthesias, and personality changes.

A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for: A. Hypotension B. Hyperglycemia C. Sodium retention D. Potassium excretion

A. Hypotension Reasoning: Because of instability of the vascular system and the lability of circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. Hyperglycemia is a sign of excessive adrenal hormones; after an adrenalectomy, adrenal hormones are not secreted. Sodium retention is a sign of hyperadrenalism; it does not occur after the adrenals are removed. Potassium excretion is a response to excessive adrenal hormones; after an adrenalectomy, adrenal hormones are decreased until replacement therapy is regulated.

A client had a laproscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. A. Wash the puncture sites with strong soap and hot water daily. B. Call the health care provider if you have a fever of 100o F or more for two days. C. Remove the tape-strips over the puncture sites one week after surgery. D. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage. E. Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the left shoulder.

B. Call the health care provider if you have a fever of 100o F or more for two days. D. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage