Final

1. Which statement made to the nurse by a client most accurately describes self-identification as transgender? A. "Since childhood I have always felt like I was born in the wrong body." B. "I have always been attracted to other women and they are attracted to me." C. "I think women are more amazing and influential and I prefer to be viewed as a woman." D. "I enjoy wearing women's clothes because they are pretty and feel so nice."

1. A A client who identifies self as transgender does not view this as a choice or lifestyle but, rather, an inner sense of being born in the wrong body.

1. For which client does the nurse expect increased production of renin? A. 35-year-old who sustains significant blood loss B. 45-year-old diagnosed with hypertension C. 55-year-old who ingests an excessive amount of fluid D. 65-year-old who gets up two to three times nightly to void

1. A Renin assists in blood pressure control. It is formed and released when there is a decrease in blood flow, blood volume (e.g., blood loss), or blood pressure through the renal arterioles or when too little sodium is present in kidney blood.

1. Which finding does the nurse understand is an early pathologic manifestation when a client is diagnosed with acute gastritis? A. Thickened, reddened mucous membrane with prominent rugae B. Patchy, diffuse inflammation C. H. pylori infection D. Thin, atrophied wall and lining of the stomach

1. A The early pathologic manifestation of acute gastritis is a thickened, reddened mucous membrane with prominent rugae, or folds, in the stomach. Options B, C, and D are signs and symptoms of chronic gastritis.

1. Which body minerals are stored almost exclusively in bones and contribute to bone density? Select all that apply. A. Calcium B. Chloride C. Magnesium D. Phosphorus E. Potassium F. Sodium

1. A, D Bone is the only significant storage site for calcium and phosphorus, although there is some phosphorus in some other body cells for metabolism and energy production. These two minerals are responsible for maintenance of bone density. All other cells store potassium. The major storage site of sodium and chloride is the kidney. Magnesium is present in higher concentrations in muscle cells.

1. Which adult would normally be expected to have the highest total body water volume? A. 25-year-old woman B. 25-year-old man C. 75-year-old woman D. 75-year-old man

1. B Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. Women have more body fat than men, and fat cells contain practically no water. As adults age, their total body water volume decreases because both older men and older women lose muscle mass with aging.

1. What is the priority concept for a client who has heart failure? A. Gas exchange B. Perfusion C. Comfort D. Infection

1. B The priority concept for a client with heart failure (HF) is perfusion. Interrelated concepts include gas exchange and comfort.

1. Which are among the most common reasons for a nurse to administer infusion therapy to a client? Select all that apply. A. Keep a line open for surgery B. Administer medications C. Maintain electrolyte or acid-base balance D. Maintain fluid balance or correct fluid imbalance E. Chemotherapy for cancer clients F. Correct electrolyte or acid-base imbalance

1. B, C, D, F The most common reasons for using infusion therapy with clients are to: maintain fluid balance or correct fluid imbalance; maintain electrolyte or acid-base balance or correct electrolyte or acid-base imbalance; administer medications; and replace blood or blood products.

1. Which are microscopic changes that occur in the brain of a client with Alzheimer disease (AD)? Select all that apply. A. Widening of the cerebral sulci B. Neurofibrillary tangles C. Decreasing size of the brain D. Neuritic plaques E. Narrowing of the gyri F. Vascular degeneration

1. B, D, F While all of these options are changes that occur in the brain with AD, only neurofibrillary tangles, amyloid-rich senile or neuritic plaques, and vascular degeneration are microscopic changes.

1. Which assessment findings will the nurse recognize as modifiable risk factors when planning strategies to prevent harm from progression of a client's osteopenia? Select all that apply. A. Has rheumatoid arthritis B. Mother has osteoporosis C. Is 11 lb (5 kg) underweight for height D. Smokes one pack of cigarettes per day E. Drinks one glass of red wine with dinner nightly F. Takes a calcium supplement containing vitamin D daily

1. C, D Two common modifiable risk factors for osteopenia progressing to osteoporosis are being underweight and cigarette smoking. Although having rheumatoid arthritis and having a parent with osteoporosis are also risk factors, they are not modifiable. Taking a calcium supplement containing vitamin D is a prevention strategy. Excessive alcohol consumption is a risk factor and one glass of wine nightly is not excessive.

1. Which set of energy balance factors leads to body weight loss? A. Energy intake and energy use are balanced. B. Energy use and energy intake are both zero. C. Energy intake exceeds energy use. D. Energy use exceeds energy intake.

1. D Energy balance is the relationship between energy use and energy intake. When energy used is greater than energy taken in or stored, weight loss occurs.

10. Which over-the-counter product will the nurse further explore with a client, for potential impact on kidney function? A. Mouthwash with alcohol B. Vitamin C C. Acetaminophen D. Fiber supplement

10. C The nurse asks for more information because high-dose or long- term use of NSAIDs or acetaminophen can seriously reduce kidney function.

11. Which new-onset assessment findings in a client with Laennec cirrhosis indicates to the nurse that the client may be starting to have delirium tremens (DTs) from alcohol withdrawal? Select all that apply. A. Anxiety B. Tachycardia C. Hypotension D. Hypertension E. Cool, clammy skin F. Psychotic behavior

11. A, B, D, F Alcohol withdrawal occurs sometimes as soon as 6 to 8 hours after stopping alcohol intake after heavy and prolonged use and can lead to DTs. Cognitive, behavioral, and autonomic changes that occur may include acute confusion, anxiety, and psychotic behaviors, such as delusions and hallucinations, along with autonomic changes of tachycardia, elevated blood pressure, and diaphoresis.

11. Which assessment will the nurse use as the most reliable indicator of a client's fluid status? A. Intake and output B. Trends in weight C. Changes in skin turgor D. Presence of dependent edema

11. B Weight change is the most reliable indicator of fluid status. A liter of water weighs 1 kg (2.2 lb). An actual weight gain or loss can account for a daily change of only about a half lb (∼240 g). More than that indicates increased fluid and less than that indicates fluid loss.

12. For a client diagnosed with acute kidney injury (AKI), the nurse considers questions an order for which diagnostic test? A. Ultrasonography B. Kidney-ureter-bladder x-ray (KUB) C. Computed tomography with contrast D. Kidney biopsy

12. C The client's diagnosis is AKI. To complete the CT with contrast, the client will be injected with a contrast dye, which is nephrotoxic, therefore the nurse considers questioning that diagnostic test.

13. Which finding does the nurse assess to determine that a female- to-male (FtM) client prescribed testosterone is having the desired effect? A. Client reports breast tenderness. B. Nurse observes increased body hair. C. Client reports decreased sex drive. D. Nurse observes average sized male penis

13. B Expected changes when a FtM client is taking testosterone therapy include voice deepening, body hair growth (hirsutism) with possibly hairline recession and male pattern baldness, increased muscle mass, increased libido, increased aggression, vaginal dryness, clitoral growth, redistribution of fat, and cessation of menses.

13. Which type of medication does the nurse expect the health care provider to prescribe for a client with acute kidney injury to improve blood flow to the kidneys? A. Loop diuretics B. Phosphate binders C. Calcium channel blockers D. Erythropoietin-stimulating agents

13. C Calcium channel blockers can improve the GFR and blood flow within the kidney. They also help to control blood pressure.

13. Which step will the nurse perform first on a client during assessment of the renal system? A. Listen for a bruit over each renal artery. B. Lightly palpate the abdomen in all four quadrants. C. Percuss from the lower abdomen toward the umbilicus. D. Observe the flank region for asymmetry or discoloration.

13. D With assessment, inspection comes first. The nurse inspects the abdomen and the flank regions with the client in both supine and sitting positions. He or she observes for asymmetry (e.g., swelling) or discoloration (e.g., bruising or redness) in the flank region, especially in the area of the costovertebral angle (CVA). The CVA is located between the lower portion of the 12th rib and the vertebral column. Auscultation for bruits comes next. Auscultation is completed before percussion and palpation because these activities can alter bowel sounds and obscure abdominal vascular sounds. Palpation and percussion are usually completed by the health care provider or nurse practitioner.

15. To which common sites does the nurse expect metastasis when a client has prostate cancer? Select all that apply. A. Liver B. Pancreas C. Lungs D. Lumbar spine E. Kidneys F. Bones of the pelvis

15. A, C, D, F Common sites of metastasis from prostate cancer are the nearby lymph nodes and bones, although it can also metastasize to the lungs or liver. The bones of the pelvis, sacrum, and lumbar spine are most often affected.

15. Which is the initial priority action for the nurse when admitting a client with a cervical spinal cord injury? A. Spinal cord immobilization B. Assessment of client's airway, breathing, and circulation C. Evaluation of pulse, blood pressure, and peripheral perfusion D. Checking bodily sites for hemorrhage

15. B For a client with an SCI, the initial and priority assessment focuses on the client's ABCs (airway, breathing, and circulation). After an airway is established, assess the client's breathing pattern. The client with a cervical SCI is at high risk for respiratory compromise because the cervical spinal nerves (C3-5) innervate the phrenic nerve controlling the diaphragm.

15. With which classes of antidiabetic drugs will the nurse most emphasize to the client with diabetes how to recognize and manage hypoglycemia? A. Alpha-glucosidase inhibitors B. Biguanides C. Insulin D. Incretin mimetics E. Meglitinide analogs F. Second-generation sulfonylureas

15. C, D, E, F Insulin, incretin mimetics, meglitinide analogs, and sulfonylureas all increase blood insulin levels or insulin action and greatly increase the risk for hypoglycemia if the client does not match his or her food intake with peak drug action. Alpha-glucosidase inhibitors and biguanides have different mechanisms of action and do not increase the risk for hypoglycemia when taken alone.

16. Which electrolyte imbalance does the nurse expect when a client is in the early phase of chronic kidney disease (CKD)? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypokalemia

16. B Early in CKD, the nurse expects the client's laboratory values to reveal hyponatremia (sodium depletion) because there are fewer healthy kidney nephrons to reabsorb sodium.

16. Which change in electrolyte values will the nurse expect in a client with acute pancreatitis who reports numbness around the mouth and leg muscle twitching? A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypochloremia

16. C The free or unbound serum calcium level is usually low in clients who have acute pancreatitis as a result of fat necrosis and the inability of the body to use protein-bound calcium.

17. Which priority teaching will the nurse provide to a client who is prescribed bismuth for peptic ulcer disease (PUD)? A. "Take this drug with an aspirin." B. "You may experience dyspepsia between doses." C. "Bismuth may cause your tongue and stool to appear black." D. "Be sure to take this drug before each meal and snack."

17. C The nurse teaches the client that bismuth may cause the stools and/or tongue to turn black. This discoloration is temporary and harmless.

18. Which are signs and symptoms that the nurse will assess in a client with migraine headaches? Select all that apply. A. Nausea B. Throbbing unilateral pain C. Transient loss of consciousness D. Sensitivity to light E. Recurrent episodic headaches F. Sensitivity to sound

18. A, B, D, E, F All of these signs and symptoms occur with migraine headaches except option C, transient loss of consciousness. Photophobia is sensitivity to light and phonophobia is sensitivity to sound. See the box in your text labeled Key Features of Migraine Headaches for additional manifestations of migraines.

18. Which exercise regimen would the nurse teach an older adult is best to meet guidelines for physical fitness to promote heart health? A. Golfing for 4 hours once a week B. Brisk walk for 20 to 30 minutes each day C. Bike ride for 6 hours every Saturday D. Running for 15 minutes twice a week

18. B In the United States the recommended exercise guidelines are: 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week (or a combination of the two) plus completing muscle- strengthening exercises at least 2 days per week. Regular physical activity (not just once a week) promotes cardiovascular fitness and produces beneficial changes in blood pressure and levels of blood lipids and clotting factors.

18. For which condition does the nurse suspect a client with chronic kidney disease (CKD) is attempting to compensate for when respirations increase in rate and depth? A. Hypoxia B. Alkalosis C. Acidosis D. Hypoxemia

18. C As CKD worsens and acid retention increases, increased respiratory action is needed to keep the blood pH normal. The respiratory system adjusts or compensates for the increased blood hydrogen ion levels (acidosis or decreased pH) by increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. This breathing pattern, called Kussmaul respiration, increases with worsening kidney disease.

18. To improve gas exchange, how much supplemental oxygen would the nurse provide a client with HF? A. 2 L/min by nasal canula B. 100% by nonrebreather mask C. Within the range prescribed by the HCP to keep saturation at 90% or more D. 50% by endotracheal tube and mechanical ventilator

18. C Provide the necessary amount of supplemental oxygen within a range prescribed by the cardiac health care provider to maintain oxygen saturation at 90% or greater.

19. Which health problems are most likely to activate the renin-angiotensin-aldosterone system (RAAS)? Select all that apply? A. Shock B. Urinary tract infection C. Constipation D. Dehydration E. Severe asthma F. Hypertension

19. A, D The RAAS system is activated by any condition that causes reduced blood volume, hypotension, or reduced serum sodium levels, such as could happen with shock and dehydration. When activated, RAAS increases sodium and reabsorption to increase blood volume and serum sodium levels. It also increases vasoconstriction to help increase blood pressure. Asthma, urinary tract infection, hypertension, and constipation do not induce symptoms of shock or dehydration.

2. What action by the assisted living facility nurse is most appropriate to prevent influenza spread when a resident client tests positive for influenza A? A. Prepare to administer antibiotics. B. Have the resident eat meals in his or her room. C. Provide oseltamivir to the staff. D. Arrange a follow-up chest x-ray in 2 weeks.

2 B Unless this client develops complications, he or she is most likely going to be managed at the assisted living facility. Influenza is highly contagious. Keeping the client in his or her room rather than going to the dining room and eating with other residents will help prevent infection spread. Antibiotics are not used for influenza. The staff should not, at this time, require oseltamivir unless they have symptoms of influenza. This is not a pandemic influenza and oseltamivir is not used for prophylaxis in this situation. Unless the client develops signs and symptoms of pneumonia, an x-ray is not indicated.

2. What priority question will the nurse be sure to ask a client at risk for acute pyelonephritis? A. "Have you recently been treated for a urinary tract infection?" B. "Are you taking birth control pills as contraception?" C. "Do your have a family history of stroke or myocardial infarction?" D. "Have you ever leaked urine when laughing, jogging, or coughing?"

2. A Acute pyelonephritis is an active bacterial infection, which results from bacterial infection, with or without obstruction or reflux. An important feature is recent cystitis or treatment for urinary tract infection (UTI).

2. Which client will the nurse assess most closely for indications of osteoporosis based on race or ethnicity? A. 40-year-old Chinese-American female B. 50-year-old Irish-American female C. 60-year-old African-American female D. 66-year-old African-American male

2. A Chinese Americans of either gender are most at risk for osteoporosis because of racial differences in bone size and density. Bones are smaller and less dense. The density difference increases the risk for osteoporosis. African Americans have greater bone density than most other races. Although Irish Americans have less bone density than do African Americans, they are taller than and have greater bone density than Chinese Americans.

2. Which technique is best when the nurse assesses an obese client who reports symptoms associated with benign prostatic hyperplasia? A. Instructing the client to urinate, then using the bedside ultrasound bladder scanner B. Applying gentle pressure to the bladder to elicit urgency, then instructing the client to void C. Having the client drink several large glasses of water, then percussing the bladder D. Instructing the client to undress from the waist down, then inspecting and palpating the bladder

2. A Clients with obesity are best assessed with percussion by the health care provider, or bedside ultrasound bladder scanner by the nurse, rather than by inspection or palpation. Instruct the client to urinate before the examination.

2. Which risk factors will the nurse assess for when taking a history of a client suspected of having gastritis? Select all that apply. A. Use of alcohol B. Excessive caffeine intake C. Smoking cigarettes D. Life stressors E. Prescribed steroids F. Ingestion of corrosive substances

2. A, B, C, D, E, F All of these options are potential factors that increase the risk for a client to develop gastritis.

2. Which foods will the nurse expect a client who follows a lacto-ovo vegetarian diet to select as menu items for breakfast? Select all that apply. A. Milk B. Toast C. Cereal D. Sausage E. Tuna fish F. Scrambled eggs

2. A, B, C, F An adult who follows a lacto-ovo vegetarian diet eats a primarily plant-based diet that also includes eggs and dairy products. Meat, poultry, and fish are avoided.

2. What does the nurse expect when a client's parietal cells do not produce enough intrinsic factor? A. Reflux of GI contents B. Poor regulation of metabolism C. Buildup of harmful substances D. Development of pernicious anemia

2. D Parietal cells produce intrinsic factor, a substance that aids in the absorption of vitamin B12. Absence of the intrinsic factor leads to decreased absorption of vitamin B12 and causes pernicious anemia.

20. Which questions will the nurse ask a client suspected of having polycystic kidney disease (PKD)? Select all that apply. A. "Do you have a family history of PKD or kidney disease?" B. "Have you ever had any problems with muscle aches or joint pains?" C. "Do you have any problems with headaches?" D. "Have you had any difficulty with constipation or abdominal discomfort?" E. "Do you have a history of any sexually transmitted infections?" F. "Have you noticed any changes in the color or frequency of urine?"

20. A, C, D, F The nurse gathers essential information when taking a client's history. Explore the family history of a client with suspected or actual PKD and ask whether either parent was known to have PKD or whether there is any family history of kidney disease. Important information to obtain includes the age at which the problem was diagnosed in the parent and any related complications. Ask about pain, abdominal discomfort, constipation, changes in urine color or frequency, hypertension, headaches, and a family history of stroke or sudden death.

20. When a client has an ejection fraction of less than 30%, about which potential treatment does the nurse prepare to educate the client? A. Heart transplant B. Implantable cardioverter/defibrillator C. Ventricular reconstructive procedure D. Implanted mechanical pump

20. B Because these clients are at high risk for sudden cardiac death, clients with an ejection fraction of less than 30% are considered candidates for an implantable cardioverter/defibrillator (ICD).

21. Which intervention will the nurse implement for a client who has a migraine headache with phonophobia?. A. Ensure that the staff knows that the client will need help with ambulation. B. Dim the lights in the client's room and close the curtains. C. Place the client in a quiet room and instruct the staff to minimize noise. D. Increase the amount of ambient light to make it easier for the client to see.

21. C Phonophobia is sensitivity to sound. The nurse would intervene by placing the client in a quiet room and keeping the noise level to a minimum.

22. What diagnostic test does the nurse expect the urologist to prescribe for a client with a urinary tract infection (UTI) who developed signs and symptoms of urosepsis (bacteremia)? A. Blood cultures B. Urine culture C. Culture of urinary meatus D. Repeat urinalysis

22. A The spread of the infection from the urinary tract to the bloodstream is termed bacteremia or urosepsis. Catheter- associated urinary tract infections are the leading cause of urosepsis. To determine which organism is in the bloodstream, blood culture samples are ordered.

22. Which action will the nurse take to prevent harm when a client's total parenteral nutrition (TPN) bag has only 20 mL left in it and the next bag will not be delivered for at least 1 hour? A. Capping the TPN line until the next TPN solution is available B. Infusing 10% dextrose/water until the TPN solution is available C. Preparing to treat the client for hypoglycemia D. Notifying the primary health care provider

22. B The TPN infusion line cannot be capped and must remain patent. The nurse infuses a 10% glucose infusion to keep the line open and prevent changes in blood glucose levels.

22. What complication does the nurse suspect when a client receiving IV antibiotic therapy over the past 3 days develops chills, headache, and an elevated temperature? A. Fluid volume overload B. Allergic reaction to antibiotics C. Phlebitis with infiltration D. Catheter-related bloodstream infection (CRBSI)

22. D With catheter-related bloodstream infection (CRBSI), early symptoms include fever, chills, headache, and general malaise. Later symptoms include tachycardia, hypotension, and decreased urinary output.

23. Which client descriptions of sputum production alert the nurse to the possibility of a current respiratory problem? Select all that apply. A. Totals about 2 ounces daily B. Is streaked with mucous C. Is clear and thin D. Is frothy and pink E. Has a foul odor F. Is colorless

23. B, D, E Sputum is continually produced in all clients. The sputum of a client with no respiratory problem is thin, clear, colorless, has no odor, and is less than 90 mL daily. Excessive pink, frothy sputum is common with pulmonary edema. Bacterial pneumonia often produces rust-colored sputum, and a lung abscess may cause foul-smelling sputum. Clients with chronic bronchitis, especially smokers, have thicker sputum with mucous.

23. How many cigarette pack-years has this client smoked. Smoked half a pack a day for 6 years? A. ½ pack-year B. 1 pack-year C. 2 pack-years D. 3 pack-years

23. D Pack-years are the number of packs of cigarettes per day multiplied by the number of years the client has smoked. ½ x 6 = 3 pack-years.

24. Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill. B. Do not touch these drugs with your bare hands. C. Alternate periods of activity with periods of rest. D. Be sure to take vitamin K supplements with this drug.

24. A All of these drugs cause some degree of immunosuppression and increase the client's risk for infection.

24. What is the nurse's best response when a client who had a vasectomy asks when sexual intercourse can be safely resumed? A. "Your surgeon will discuss the timing and will tell you when it is safe to have sex again." B. "It depends on how much swelling, pain, and bruising you experience after the surgery." C. "Just to be safe, you should probably wait at least 6 months or more before having sex." D. "Sexual intercourse should be avoided for at least 1 week after your surgery."

24. D Heavy lifting, sports, and sexual intercourse should be avoided for at least 1 week. Teach the client and partner to use an alternate form of contraception until a 3-month follow-up. At that time, a semen analysis will be performed to determine if the procedure was effective.

25. Which technique does the nurse use to assess a client's report of paresthesia in the lower extremities? A. Use a Doppler to locate the pedal pulse, the dorsalis pedis pulse, and the popliteal pulse. B. Ask the client to identify sharp and dull sensations using a paper clip and a cotton ball. C. Use a reflex hammer to test for deep tendon reflexes. D. Ask the client to walk across the room and observe for gait and equilibrium.

25. B The nurse asks whether paresthesia (tingling sensation) or numbness is present in the involved leg. Both extremities are checked for sensory perception by using a cotton ball and a paper clip for comparison of light or dull and sharp touch. The client may feel sensation in both legs but may experience a stronger sensation on the unaffected side.

25. What is the nurse's best first action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the client's platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

25. C Bleeding around the IV sites is a strong indicator of clotting problems. Such problems are an indicator of impaired function of the transplanted liver and may be an early sign of transplant rejection. Immediate action is needed to prevent harm in the form of graft loss.

26. What does the nurse suspect when assessment reveals a distended bladder and the client reports passing very small amounts of urine today despite a normal fluid intake and feeling the urge to urinate? A. Urethral stricture B. Polycystic kidney disease C. Hydroureter D. Hydronephrosis

26. A Urethral strictures obstruct urine outflow and may contribute to development of bladder distention, hydroureter, and hydronephrosis.

27. What is the priority action for the nurse and other members of the interprofessional health care team when caring for an older client admitted with hyperglycemic-hyperosmolar state (HHS)? A. Replacing potassium B. Preventing ketoacidosis C. Decreasing blood glucose levels D. Increasing circulating blood volume

27. D The client with HHS is severely dehydrated and at risk for death from decreased cardiac output. The first priority in management of HHS is replacing circulating fluid volume to ensure adequate perfusion. All other concerns, including decreasing blood glucose level, are secondary.

28. Which client will the nurse consider most likely to be a candidate for continuous kidney replacement therapy (CKRT) using venovenous hemofiltration? A. 65-year-old with fluid volume overload B. 55-year-old who needs long-term management C. 45-year-old who is critically ill and unstable D. 35-year-old with a peritoneal infection

28. C Clients who need continuous kidney replacement therapy (CKRT) are hospitalized and are too unstable to tolerate the changes in blood pressure that occur with intermittent conventional hemodialysis. This treatment occurs in an intensive care unit and is continuous over 24 hours.

29. For which client conditions does the nurse expect the possibility of emergent hemodialysis (HD)? Select all that apply. A. Severe uncontrollable hypertension B. Pericarditis C. Symptomatic hyperkalemia with ECG changes D. Myocardial infarction E. Pulmonary edema F. Some drug overdoses

29. A, B, C, E, F Some indications for emergent dialysis include: pulmonary edema; severe uncontrollable hypertension; symptomatic hyperkalemia with ECG changes; other severe electrolyte or acid-base disturbances; some drug overdoses; and pericarditis.

29. What does the nurse suspect when a client who had a bruit on assessment during the previous 2 days does not have a bruit on assessment today? A. The prescribed antiplatelet therapy is working. B. The problem has resolved spontaneously. C. The previous findings may have been an anomaly. D. The occlusion of the blood vessel is now 90%.

29. D Bruits are swishing sounds that may occur from turbulent blood flow in narrowed or atherosclerotic arteries. Assess for the absence or presence of bruits by placing the bell of the stethoscope on the neck over the carotid artery while the client holds his or her breath. Normally there are no sounds if the artery has uninterrupted blood flow. A bruit may develop when the internal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Once the vessel is blocked 90% or greater, the bruit often cannot be heard.

29. What is the priority nursing assessment after a client returns from surgery for an anterior cervical discectomy with fusion (ACDF)? A. Assess for gag reflex and swallowing ability. B. Monitor vital signs and check neurological status. C. Check for bleeding and drainage at the incision site. D. Assess for airway patency and respiratory effort.

29. D The priority for care in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problems with breathing. Swelling from the surgery can narrow the trachea, causing a partial obstruction.

3. Which health problems that are complications of chronic hyperglycemia will the nurse reinforce to the client with diabetes could be delayed or prevented with long-term good glucose control? Select all that apply. A. Amputations B. Blindness C. Chronic kidney disease D. Heart attack E. Erectile dysfunction F. Stroke

3. A, B, C, D, E, F All of these health problems are common complications of diabetes that develop as a result of chronic hyperglycemia. The hyperglycemia causes microvascular and macrovascular changes that reduce perfusion and gas exchange in these tissues resulting in hypoxia, anoxia, ischemia, and buildup of toxic waste products that injure organs and lead to dysfunction. Long-term blood glucose delays or may even prevent these serious complications.

3. Indications of which vitamin deficiency will the nurse be sure to assess for in a client who follows a strict vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D3

3. B A strict vegan diet is plant-based only. All animal sources of protein, such as meat, poultry, fish, seafood, eggs, and dairy products are avoided as are any complex foods that contain these products. Vitamin B12 is highest in red meats.

3. When the nurse interviews a transgender client, which statement is of greatest concern for failure to cope with major life stressors? A. "I smoke two to three packs of cigarettes every day." B. "I've tried to commit suicide four times in my life." C. "When I feel really down, I drink and use marijuana." D. "Last night I went to a bar and picked up a stranger for sex."

3. B For transgender clients, major life stressors, emotional distress, and lack of resources can lead to suicidal ideation or suicide attempts when all other methods of coping have failed. This client requires follow-up with regard to suicide ideation. The health care provider must be notified and a mental health assessment with counselling and follow-up may be needed.

3. Which condition or symptom does the nurse associate with a client who has chronic gastritis? A. Hematemesis B. Pernicious anemia C. Dyspepsia D. Epigastric burning

3. B With chronic gastritis, progressive gastric atrophy from chronic mucosal injury occurs. The function of the parietal (acid- secreting) cells decreases, and the source of intrinsic factor is lost. Intrinsic factor is critical for absorption of vitamin B12. When body stores of vitamin B12 are eventually depleted, pernicious anemia results.

3. What is the nurse's best response when a 65-year-old client with no health problems states that he had a flu shot last year and asks if it is necessary to have it again this year? A. "No, because once you get a flu shot, it lasts for several years and is effective against many different viruses." B. "Yes, because the immunity against the virus wears off, increasing your chances of getting the flu." C. "Yes, because the vaccine guards against a few specific viruses and reduces your chances of acquiring flu and is only effective for 1 year." D. "No, flu shots are only for high-risk clients and you are not considered to be at high risk."

3. C Seasonal influenza can be prevented or its severity reduced when adults receive an annual influenza vaccination containing antigens to the three to four specific viral strains that are most likely to cause illness during that year's influenza season. There are many influenza viruses and their specific prevalences change each year. Thus, annual influenza vaccination is needed.

3. What is the lowest mean arterial pressure (MAP) necessary to perfuse the major organs of the body? A. 90 to 100 mm Hg B. 80 to 90 mm Hg C. 70 to 80 mm Hg D. 60 to 70 mm Hg

3. D A MAP between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs, such as the kidneys and brain. While all of these MAPs will maintain perfusion to the major organs, this question asks for the lowest MAP necessary to maintain major organ perfusion and therefore option D is the best response.

3. Which statement indicates to the nurse that a client who is experiencing frequent episodes of "indigestion" and flatulence may have cholecystitis? A. "My stools are sometimes very dark and tarry looking." B. "Sometimes at night I have bad-tasting fluid in my mouth." C. "Usually about a half hour after I eat, I become sweaty and nauseated." D. "My right arm and shoulder always seem to hurt after I eat fried foods."

3. D Cholecystitis and cholelithiasis can cause referred pain to the right shoulder area, including under the right shoulder blade. Dark, tarry stools are associated with GI bleeding. Bad-tasting fluid or vomitus in the mouth at night is related to gastroesophageal reflux disease. Becoming sweaty and nauseated after a meal is associated with dumping syndrome, not gallbladder disease.

3. Which blood pressure reading does the nurse expect will result in compromised kidney function for a client who sustained major injuries in an automobile accident? A. 160/80 mm Hg B. 140/100 mm Hg C. 80/60 mm Hg D. 68/40 mm Hg

3. D Glomerular filtration rate (GFR) is controlled by blood pressure and blood flow. The kidneys self-regulate their own blood pressure and blood flow, which keeps GFR constant. GFR is controlled by selectively constricting and dilating the afferent and efferent arterioles. When systolic pressure drops below 65 to 70 mm Hg, these self-regulation processes do not maintain GFR.

32. Which side effects of first-generation antihistamines to treat sinusitis does the nurse caution the family of an older client to observe for? Select all that apply. A. Insomnia B. Hypotension C. Confusion D. Dry mouth E. Constipation F. Increased urine output

32. A, C, D, E First-generation antihistamines may not be appropriate drugs for older adults because these clients often have reduced drug clearance resulting in higher risk for confusion and anticholinergic effects such as dry mouth, constipation, difficulty sleeping, and hypertension. The anticholinergic effects can also include urinary retention.

35. Which assessment findings would indicate to the nurse that the client may have hyponatremia? Select all that apply. A. Hyperactive bowel sounds on auscultation B. Acute-onset confusion C. Muscle weakness D. Decreased deep tendon reflexes E. Abdominal cramping F. Nausea

35. A, B, C, D, E, F Low serum sodium levels reduce membrane excitability and result in confusion, muscle weakness, and decreased deep tendon reflexes. GI changes include nausea, increased motility, and cramping.

36. How many grams of carbohydrate (CHO) will the nurse provide to a client who has symptoms of hypoglycemia with a blood glucose level between 69 mg/dL (3.9 mmol/L) and 50 mg/dL (2.8 mmol/L) to correct the problem and prevent harm? A. 5 g B. 10 g C. 15 g D. 30 g

36. C Current recommendations and guidelines for managing hypoglycemia in an alert client follow the 15-15 rule. With this rule, 15 g of CHO are given if the blood glucose level is less than 70 mg/dL (3.9 mmol/L) (or 30 g if less than 50 mg/dL [2.8 mmol/L]) or if the client is experiencing symptoms of hypoglycemia and can swallow safely. If the blood glucose recheck within 15 minutes is still low, the same treatment is given again.

38. Which serum value indicates to the nurse that the client has hypernatremia? A. Potassium 3.9 mEq/L (mmol/L) B. Chloride 103 mEq/L (mmol/L) C. Sodium 149 mEq/L (mmol/L) D. Potassium 4.9 mEq/L (mmol/L)

38. C Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value higher than 145 mEq/L (mmol/L). The other electrolyte values are within their normal ranges.

4. Which assessment finding indicates to the nurse that a client's reticular activating system (RAS) is functioning normally? A. The client awakens from sleep in response to a loud noise. B. The client can move all four extremities. C. The client's respirations are within normal range. D. The client can sense sharp and dull stimuli.

4. A Throughout the brainstem are special cells that constitute the reticular activating system (RAS), which controls awareness and alertness. This tissue awakens a person from sleep when presented with a stimulus such as loud noise or pain or when it is time to awaken.

4. Which signs or symptoms will the nurse assess for in a client who is suspected of having cholecystitis? Select all that apply. A. Anorexia B. Jaundice C. Ascites D. Steatorrhea E. Eructation F. Rebound tenderness

4. A, B, D, E, F Characteristic signs and symptoms of cholecystitis include episodic or vague upper abdominal pain or discomfort that can radiate to the right shoulder, pain triggered by a high-fat or high-volume meal, anorexia, nausea and/or vomiting, dyspepsia, eructation, flatulence, feeling of abdominal fullness, rebound tenderness (Blumberg's sign), and fever. Additional symptoms include jaundice and fatty stools (streatorrhea).

4. What is the nurse's priority concern for an older client with urinary incontinence, who is alert and oriented, but refuses to call for help and has fallen while trying to get to the bathroom alone? A. Managing incontinence B. Initiating fall precautions C. Managing noncompliance D. Accurately measuring urinary output

4. B A common cause of falls in health care facilities is related to client efforts to get out of bed unassisted to use the toilet. The nurse collaborates with all staff members, including assistive personnel (AP), to consistently implement a toileting schedule and prevent incontinence.

4. What action will the advanced practice nurse take after performing a digital rectal examination on a client with benign prostatic hyperplasia (BPH)? A. Instruct the client to remain in a supine position with knees bent. B. Massage the prostate to obtain a fluid sample for possible prostatitis. C. Use a sterile cotton-tipped applicator for a sample from the penis for possible infection. D. Administer pain medication to relieve the discomfort from the examination.

4. B After palpating the prostate gland through a digital rectal examination (DRE), the nurse practitioner may massage the prostate to obtain a fluid sample for examination to rule out prostatitis (inflammation and possible infection of the prostate), a common problem that can occur with BPH.

4. What instructions would the nurse give an assistive personnel (AP) about the proper handling of a client's routine urinalysis specimen? Select all that apply. A. Leave the specimen in the bathroom. B. Ensure the container is tightly covered. C. Place the sample in a sterile container. D. Take the sample to the laboratory within 1 hour. E. Put the sample in a plastic sample bag. F. Refrigerate a sample that cannot be taken to the laboratory right away.

4. B, D, E, F The nurse teaches the AP that urine specimens become more alkaline when left standing unrefrigerated for more than 1 hour, when bacteria are present, or when a specimen is left uncovered. Alkaline urine increases cell breakdown. So, the presence of red blood cells may be missed on analysis. The AP ensures that urine specimens are covered and delivered to the laboratory promptly. A plastic bag protects against contact with urine that may be on the outside the cup. Urine specimen delayed 2 or more hours require refrigeration or other specific storage and transport precautions to ensure the integrity of the urine specimen. This is a routine urinalysis and does not need to be sterile. The sample should not be left in the bathroom.

4. Plasma is part of which body fluid space compartments? Select all that apply. A. The intracellular compartment B. The extracellular compartment C. All fluid within the cells D. Interstitial fluid E. Intravascular fluid F. Fluid within joint capsules

4. B, E, The extracellular fluid includes both the blood (plasma) volume (also known as the intravascular volume) and the interstitial fluid. Although the interstitial fluid comes from the plasma, it is not considered part of it.

4. Which nutrient will the nurse suspect is deficient in a client who has bowing of the bones in both lower limbs? A. Iron B. Protein C. Vitamin C D. Vitamin D

4. D A deficiency of vitamin D can result in osteomalacia, which is softening of the bones. When osteomalacia occurs in weight- bearing bones, such as those in the lower legs, the bones can bend or bow.

4. When would the nurse expect the release of B-type natriuretic peptide (BNP) for a client with heart failure? A. When the client has an enlarged liver B. When a client's ejection fraction is lower than normal C. When a client develops ventricular hypertrophy D. When a client has fluid overload

4. D B-type natriuretic peptide (BNP) is a peptide produced and released by the ventricles when the client has fluid overload as a result of heart failure. BNP levels increase with age and are generally higher in healthy women than in healthy men.

4. For which client does the nurse recommend vaccination with the influenza "super vaccine"? A. 19-year-old living in a college dormitory B. 36-year-old who has type 1 diabetes mellitus C. 50-year-old who just underwent aortic valve replacement D. 75-year old community-dwelling client after hip replacement surgery

4. D For adults aged over 65 years, a new formulation is available, known as a "senior flu shot," which is a higher dose, quadrivalent vaccine designed for more effective protection for adults with age-related reduced immunity.

4. From the acronym LGBTQ, which terms will the nurse understand refer to the sexual orientation of a client? Select all that apply. A. Questioning B. Queer C. Transgender D. Bisexual E. Gay F. Lesbian

4. D, E, F L (lesbian), G (gay), and B (bisexual) refer to specific sexual orientation. However, transgender is nonspecific for sexual orientation and clients may identify as heterosexual, homosexual, both, or neither. Q refers to clients who are queer or questioning (people who do not feel they belong in any other subgroup).

40. Which information from a client's medical history causes the nurse to check for abnormalities of the heart valves? A. Staphylococcal infections of the skin B. Yeast infections of the vagina C. Fungal infections on the toe nails D. Streptococcal infections of the throat

40. D Ask clients about recurrent tonsillitis, streptococcal infections, and rheumatic fever because these conditions may lead to valvular abnormalities of the heart.

41. Which priority teaching would the nurse provide to a client with infective endocarditis who is scheduled for an invasive dental procedure? A. "Be sure to use your nitroglycerin whenever you experience chest pain." B. "Remind your health care provider to provide you with a prescription for prophylactic antibiotics." C. "Get up slowly after taking each dose of your antihypertensive medication." D. "Your health care provider will instruct you to have blood drawn to check your anticoagulation status."

41. B Clients with infective endocarditis must be taught to request a prescription for prophylactic antibiotics whenever any invasive dental or oral procedure is scheduled. This includes clients with a previous history of endocarditis and cardiac transplant or valve recipients.

5. Which activity will the nurse recommend that a client with regional osteoporosis of the vertebrae avoid to prevent harm? Select all that apply. A. Jogging B. Jumping rope C. Riding horses D. Participating in yoga E. Riding a stationary bicycle F. Performing water aerobics

5. A, B, C Clients with regional osteoporosis of the spine (vertebrae) are at risk for harm from vertebral compression fractures. To reduce this risk, clients are advised to avoid activities that jar the spine. Riding a stationary bicycle, performing water aerobics, and participating in yoga are not "jarring" activities.

5. Which nursing assessment findings support a client's diagnosis of multiple sclerosis (MS)? Select all that apply. A. Intention tremors B. Dysmetria C. Dysarthria D. Nystagmus E. Respiratory distress F. Tinnitus

5. A, B, C, D, F All options except E are findings that support a diagnosis of MS. Respiratory distress is generally not a symptom of MS. See the Box labeled Key Features Multiple Sclerosis in your text for additional signs and symptoms of MS.

5. Which hormones are important in promoting bone mass and density in an adult client? Select all that apply. A. Calcitonin B. Estrogen C. Glucocorticoids D. Growth hormone E. Insulin F. Parathyroid hormone G. Testosterone H. Thyroxine

5. A, B, D, E, G, H Except for glucocorticoids and parathyroid hormone, all of the listed hormones play important roles in maintaining bone density and balancing osteoblastic activity with osteoclastic activity for bone health. Glucocorticoids and parathyroid hormone promote bone density loss and do not help maintain healthy bone matrix.

5. Which client findings cause the nurse to suspect the possibility of chronic pyelonephritis? Select all that apply. A. Sudden onset of massive proteinuria B. Inability to conserve sodium C. Decreased urine-concentrating ability and nocturia D. Abscess formation E. Hypertension F. Hyperkalemia and acidosis

5. B, C, E, F The nurse recognizes manifestations that define chronic pyelonephritis from acute by the following characteristics: hypertension; inability to conserve sodium; decreased urine- concentrating ability, resulting in nocturia; and a tendency to develop hyperkalemia and acidosis.

5. When a client admits that he or she sometimes has trouble catching his or her breath, which question would the nurse ask to obtain more information about the client's symptoms? A. "Do you have a history of any medical problems like high blood pressure?" B. "What did your health care provider tell you about your diagnosis?" C. "What was your most strenuous activity during the past week?" D. "How do you feel about being told that you have heart failure?"

5. C Assess activity tolerance by asking whether the client can perform normal ADLs or climb flights of stairs without fatigue or dyspnea. Many clients with heart failure (HF) experience weakness or fatigue with activity or have a feeling of heaviness in their arms or legs. Ask about their ability to perform simultaneous arm and leg work (e.g., walking while carrying a bag of groceries). Such activity may place an unacceptable demand on the failing heart. To gather more data, ask the client to identify his or her most strenuous activity in the past week.

50. Which IV potassium solution can the nurse safely administer to a client with severe hypokalemia? A. KCl 5 mEq in 20 mL NS B. KCl 10 mEq in 100 mL NS C. KCl 15 mEq in 50 mL NS D. KCl 20 mEq in 100 mL NS

50. B Intravenous potassium is a high-alert dangerous drug that can lead to death if administered too rapidly or at a high concentration. It must always be diluted. The maximum allowable concentration of the drug is 1 mEq (mmol) per 10 mL of solution.

50. Which medications will the nurse expect the cardiologist to put on hold before an exercise stress test? A. Acetaminophen and bronchodilator B. Atenolol and diltiazem C. Vitamins and iron D. Colace and aspirin

50. B Usually cardiovascular drugs such as beta blockers (e.g., atenolol) or calcium channel blockers (e.g., cardizem) are withheld on the day of the test to allow the heart rate to increase during the stress portion of the test. The drugs listed in options A, C, and D do not generally affect heart rate.

6. What is the nurse's first action(s) when a client who is receiving IV chemotherapy through a PICC line develops infiltration into the tissue and redness is observed? A. Stop the infusion and disconnect the IV line from the administration set. B. Apply pressure and elevate the site of swelling and redness. C. Aspirate the drug from the intravenous access device. D. Check vital signs, monitor the client, and document the incident.

6. A The IV insertion site should be assessed carefully for early signs of infiltration, including swelling, coolness, tingling, or redness. If any of these symptoms are present, discontinue the drug immediately and notify the infusion therapy team and/or primary health care provider per agency policy when complications like this occur.

62. By which mechanisms does parathyroid hormone (PTH) increase serum calcium levels? Select all that apply. A. Releasing free calcium from the bones B. Increasing calcium excretion in the urine C. Stimulating kidney reabsorption of calcium D. Activating vitamin D E. Increasing calcium absorption in the GI tract F. Pulling calcium out of muscle cells

62. A, C, D, E When more calcium is needed, parathyroid hormone (PTH) is released from the parathyroid glands and increases serum calcium levels by releasing free calcium from bone storage sites, stimulating vitamin D activation to help increase intestinal absorption of dietary calcium, inhibiting kidney calcium excretion, and promoting kidney calcium reabsorption.

7. Which nursing actions will the nurse take to provide safe care and prevent harm for an older client experiencing increased nocturia? Select all that apply. A. Ensure adequate lighting and a hazard-free environment. B. Use caution administering nephrotoxic drugs. C. Ensure the availability of a bedside toilet, bedpan, or urinal if needed. D. Encourage the client to use the toilet, bedpan, or urinal at least every 2 hours. E. Discourage excessive fluid intake for 2 to 4 hours before the client goes to bed. F. Respond as soon as possible to the client's indication of the need to void.

7. A, C, E, F Actions A, C, E, and F are appropriate for preventing harm associated with falls related to frequent nocturia. Option B is an appropriate action for a client with decreased GFR. Option D is an appropriate action for a client with decreased bladder capacity. Option F is appropriate for decreased bladder capacity, but also appropriate for a client with nocturia to prevent falls.

7. Which question will the nurse ask first when a client reports a persistent, nagging cough? A. "Have you been running a fever?" B. "Do you have pain when coughing?" C. "How long has your cough been present?" D. "Do you have a family history of lung cancer?"

7. C A cough is a common symptom with a variety of respiratory problems and some cardiac problems, and must be thoroughly assessed. The first cough assessment questions should be to determine the extent and duration of when it occurs.

8. Which diagnostic procedure does the nurse expect the health care provider to order to test a client with an enlarged bladder, for bladder outlet obstruction? A. Bladder ultrasound scan B. Urodynamic pressure-flow study C. Computed tomography scan D. Transrectal ultrasound

8. B The health care provider orders a urodynamic pressure-flow study to help in determining if there is urine blockage or weakness of the detrusor muscle.

8. Which IV fluid does the nurse expect to administer to a client who is prescribed to receive hypotonic fluids? A. 9% saline B. 3% saline C. 0.9% saline D. 0.45% saline

8. D Isotonic saline is 0.9%. The options of 9% saline and 3% saline are hypertonic. Only 0.45% saline is a hypotonic solution.

8. What priority finding will the nurse assess for when inspecting the hands, face, and eyelids of a client with possible acute glomerulonephritis (GN)? A. Redness B. Rash C. Dryness D. Edema

8. D The nurse assesses a client's face, eyelids, hands, as well as other areas for edema because this is present in most clients with acute GN.

9. Which increased health risks will the nurse monitor for when a transgender client is prescribed estrogen therapy? Select all that apply. A. Elevated blood glucose B. Fluid retention C. Hypotension D. Estrogen-dependent cancer E. Kidney disease F. Venous thromboembolism

9. A, B, D, F Estrogen therapy can cause increased health risks such as increased blood clotting leading to venous thromboembolism (VTE), elevated blood glucose, hypertension, estrogen- dependent cancers, and fluid retention.

9. How will the nurse instruct a client to prepare for a dual x-ray absorptiometry (DXA) scan? A. "Blood and urine specimens will be taken immediately before the test." B. "Leave metallic objects such as jewelry, coins, and belt buckles at home." C. "Be sure to have someone come with you to drive you home after the test." D. "Bring a comfortable loose nightgown without buttons or snaps, and a pair of slippers."

9. B DXA scans are painless and do not require medications or blood and urine specimens. The client remains dressed, but is required to have no metallic objects on them. Metal can interfere with the test.

9. Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "Somogyi phenomenon" to achieve better control? A. "Avoid eating any carbohydrate with your evening meal." B. "Eat a bedtime snack containing equal amounts of protein and carbohydrates." C. "Inject the insulin into your arm rather than into the abdomen around the navel." D. "Take your evening insulin dose right before going to bed instead of at supper time."

9. B The client with "Somogyi phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia caused by the counterregulatory response to nighttime hypoglycemia. Eating a bedtime snack to prevent nighttime hypoglycemia can result in suppression of counterregulatory hormone release. A client with "dawn phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia that results from a nighttime release of adrenal hormones causing blood glucose elevations at about 5 to 6 a.m. It is managed by providing more insulin for the overnight period (e.g., giving the evening dose of intermediate-acting insulin at 10 p.m. instead of with the evening meal). Changing the injection site would not prevent morning hyperglycemia. Not eating any carbohydrate with a meal is more likely to cause severe hypoglycemia during the night and is dangerous.

68. Which system is most important for the nurse to monitor closely for a client who has severe hypomagnesemia? A. Autonomic nervous system B. Gastrointestinal C. Cardiovascular D. Renal/urinary

C. Cardiovascular

"9. What action will the nurse take when, 12 hours after a traditional cholecystectomy, a client's Jackson-Pratt (JP) drain shows serosanguineous drainage stained with bile? A. Placing the client to the left lateral Sims' position B. Clamping the drain intermittently for 30 minutes every hour C. Measuring the drainage and documenting the findings D. Disconnecting the suction device and gently irrigating the drain with sterile saline"

"9. C Serosanguineous drainage stained with bile is expected and normal during the first 24 hours after traditional cholecystectomy. The drain is not to be clamped or irrigated. Placing the client in left lateral Sims' position can be done but is not related to drainage from the JP."

1. Which physiologic actions result from normal insulin secretion? Select all that apply. A. Increased liver storage of glucose as glycogen B. Increased gluconeogenesis C. Increased cellular uptake of blood glucose D. Increased breakdown of lipids (fats) for fuel E. Increased production and release of epinephrine F. Decreased storage of free fatty acids in fat cells G. Decreased blood glucose levels H. Decreased blood cholesterol levels

1. A, C, G, H The main metabolic effects of insulin are to stimulate glucose uptake in skeletal muscle and heart muscle and to suppress liver production of glucose and very-low-density lipoprotein (VLDL). In the liver, insulin promotes the production and storage of glycogen (glycogenesis) at the same time that it inhibits glycogen breakdown into glucose (glycogenolysis). It increases protein and lipid (fat) synthesis and inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). In muscle, insulin promotes protein and glycogen synthesis. In fat cells, it promotes triglyceride storage. Overall, insulin keeps blood glucose levels from becoming too high and helps keep blood lipid levels in the normal range.

1. Which information will the nurse include when providing community education on prevention of seasonal influenza? Select all that apply. A. Adults older than 65 years should get the Prevnar-13 vaccination yearly. B. All adults younger than 49 years should receive a quadrivalent immunization annually. C. Sneeze into a disposable tissue or into your sleeve instead of your hand. D. Avoid large crowds during spring and summer to limit the chance for getting the flu. E. Wash your hands frequently and after blowing your nose, coughing, or sneezing. F. Call your provider for an antiviral prescription within 3 days of getting symptoms.

1. B, C, E Option A is incorrect because Prevnar-13 is a pneumonia vaccine (not for influenza) and is only given once. Option B is correct because this is the injectable form of the influenza vaccine that is recommended for adults aged 50 and younger to receive as an immunization yearly. Option C is correct because this technique is the one recommended by the CDC to limit infection spread. Option D is incorrect because influenza season in North America is in the fall and winter. Option E is correct because this action can limit infection spread. Option F is incorrect because these drugs are effective only if taken within 24 to 48 hours after symptoms begin.

1. Which are the nurse's priority concepts during assessment of a client with a neurologic problem? Select all that apply. A. Fluid and electrolyte balance B. Sensory perception C. Perfusion D. Cognition E. Mobility F. Acid-base balance

1. B, D, E The priority concepts for neurological assessment are: cognition, mobility, and sensory perception. The interrelated concept for this chapter is perfusion.

1. What type of incontinence does the nurse recognize when a 45- year-old female client reports the loss of small amounts of urine during coughing, sneezing, jogging, or lifting? A. Urge incontinence B. Overflow incontinence C. Functional incontinence D. Stress incontinence

1. D The most common type of incontinence in younger women is stress incontinence. Its main feature is the inability to retain urine when laughing, coughing, sneezing, jogging, or lifting. Clients with stress incontinence cannot tighten the urethra enough to overcome the increased bladder pressure caused by contraction of the detrusor muscle.

11. Which signs and symptoms does the nurse expect to assess when a client experiences an upper GI bleed? Select all that apply. A. Decreased blood pressure B. Decreased heart rate C. Dizziness or light-headedness D. Melena (tarry or dark sticky) stools E. Weak peripheral pulses F. Increased hemoglobin and hematocrit levels

11. A, C, D, E See the box labeled Key Features Upper GI Bleeding in your text for a list of what signs and symptoms to expect when this occurs. Option B is not correct because heart rate is increased, and option F is not correct because hemoglobin and hematocrit levels are decreased when upper GI bleeding occurs.

11. Which priority assessment should be addressed next after the emergency department (ED) staff has assessed airway, breathing, and circulation (ABCs) in a client who sustained a head trauma with multiple injuries? A. Check for peripheral sensation. B. Stabilize long bone fractures. C. Rule out cervical spine fracture. D. Determine cerebral artery blockage.

11. C When a client has head trauma and multiple injuries, after assessing the ABCs (airway, breathing, and circulation), one of the first priorities is to rule out cervical spine fracture.

12. Which laboratory result will the nurse monitor to prevent harm when a client on estrogen therapy is also prescribed spironolactone? A. Blood glucose level B. Platelet count C. White blood cell count D. Serum potassium level

12. D Spironolactone is used as an androgen blocker. It is a low-cost potassium-sparing diuretic that also inhibits testosterone secretion and androgen binding to androgen receptors. Periodic laboratory tests to assess for hyperkalemia may be needed especially for clients with renal insufficiency.

13. For which client prescription for urinary incontinence would the nurse be sure to question the health care provider? A. 74-year-old male client with bilateral glaucoma prescribed oxybutynin B. Older female client prescribed a thin application of estrogen vaginal cream daily C. Female client prescribed mirabegron whose blood pressure is 132/80 mm Hg D. Middle-aged male client prescribed imipramine who experiences slight morning dizziness

13. A Oyxbutynin is an anticholinergic drug. The nurse asks whether the client has glaucoma before starting any drugs from this class because anticholinergics can increase intraocular pressure and make glaucoma worse.

14. Which issues regarding diabetes management will the nurse consider delaying to teach about to a client with newly diagnosed type 1 diabetes until after the initial phase? Select all that apply. A. Discussing exactly what causes type 1 diabetes B. Preparing and administering insulin C. Implementing sick-day management rules D. Recognizing indications of hypoglycemia and hyperglycemia E. Explaining the risk for passing on type 1 diabetes to one's children F. Monitoring urine ketone levels

14. A, E, F Responses B, C, and D are "survival skills" and critically important for the client and family to know for safe management of this serious disorder. The other issues are less important for the client to know to prevent immediate harm.

14. Which drugs belong to the estrogen agonist/antagonist class? Select all that apply. A. Alendronate B. denosumab C. estrogen/bazedoxifene D. ibandronate E. raloxifene F. risedronate G. zoledronic acid

14. C, E Alendronate, ibandronate, risedronate, and zoledronic acid all belong to the bisphosphonate class of drugs. Denosumab is a monoclonal antibody. Estrogen/bazedoxifene and raloxifene are from the estrogen agonist/antagonist class of drugs.

15. Which outcome statement indicates to the nurse that the goal of giving a client IV therapy after a diagnostic imaging test with contrast media has been met? A. Lung sounds are clear and there are no signs or symptoms of fluid overload. B. The client has no signs or symptoms of contrast-induced immune response. C. Urine output is 150 mL/hr for 6 hours after the use of the contrast agent. D. Urine output is 0.5mL/kg/hr for 6 hours and the client remains euvolemic.

15. C A common desired outcome for clients undergoing a procedure with contrast medium is a urine output of 150 mL/hr for the first 6 hours after administration of the contrast agent.

16. What findings would the nurse expect when caring for a client who is experiencing spinal shock? A. Stridor, garbled speech, or inability to clear airway B. Bradycardia and decreased urinary output C. Hypotension and a decreased level of consciousness D. Temporary loss of motor, sensory, reflex and autonomic function

16. D Spinal shock occurs immediately as the cord's response to the injury. The client has complete, but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks.

18. For which client complication of diabetes will the nurse expect to administer glucagon intramuscularly? A. Diabetic retinopathy B. Severe hypoglycemia C. Diabetic ketoacidosis (DKA) D. Hyperglycemic-hyperosmolar state (HHS)

18. B Glucagon injections are administered to raise blood glucose levels when severe hypoglycemia is present. This drug breaks down liver glycogen stores into glycogen that is converted into glucose.

18. Which client condition will the nurse recognize as increasing the risk for osteomyelitis of facial bones? A. Chronic sinusitis as a result of persistent allergies B. Poor dental hygiene and periodontal infection C. Untreated pharyngeal streptococcal infection D. Presence of chronic diabetic foot ulcers

18. B Often, osteomyelitis develops as a result of infection in adjacent tissues that spreads directly to nearby bone. These are known as contiguous osteomyelitis infections. Poor dental hygiene and periodontal (gum) infection can be causative factors in contiguous osteomyelitis in facial bones.

19. The nurse reviews a client's laboratory values and discovers a serum potassium level of 3.1 mEq/L. Which gastrointestinal condition could cause this value? A. Malabsorption B. Gastric suctioning C. Acute pancreatitis D. Liver disease

19. B Gastrointestinal causes of decreased potassium include vomiting, gastric suctioning, diarrhea, and drainage from intestinal fistulas.

21. What urinalysis findings does the nurse expect when a client is in the early stage of chronic kidney disease? Select all that apply. A. Proteinuria B. Increased specific gravity C. Red blood cells (RBCs) D. Increased urine osmolarity E. White blood cells (WBCs) F. Glucosuria

21. A, C, E, F In the early stages of CKD, the nurse expects the urinalysis may show protein, glucose, red blood cells (RBCs) and white blood cells (WBCs), and decreased or fixed specific gravity. Urine osmolarity is usually decreased. As CKD progresses, urine output decreases dramatically, and osmolarity then increases.

27. Which finding will the nurse associate with an obstruction in the urinary system specifically associated with hydronephrosis? A. Chills and fever B. Flank asymmetry C. Urge incontinence D. Bladder distention

27. B In hydronephrosis, the kidney enlarges as urine collects in the renal pelvis and kidney tissue. Because the capacity of the renal pelvis is normally 5 to 8 mL, obstruction in the renal pelvis or at the point where the ureter joins the renal pelvis quickly distends the renal pelvis. Since this condition usually affects only one kidney, flank asymmetry is often present due to the enlarged kidney.

28. Which client has an abnormal heart sound? A. S3 in a 54-year-old B. S1 in a 45-year-old C. S2 in a 38-year-old D. S3 in a 25-year-old

28. A An S3 gallop in clients older than 35 years is considered abnormal and represents a decrease in left ventricular compliance. It can be detected as an early sign of heart failure or as a ventricular septal defect. An S3 heart sound is most likely to be a normal finding in those younger than 35 years. S1 and S2 are both normal heart sounds.

30. Which possible imbalance does the nurse suspect when assessment findings on a newly admitted client include pitting dependent edema, engorged neck and hand veins, and headache? A. Dehydration B. Hypervolemia C. Fluid volume deficit D. Hemoconcentration

30. B The client's assessment findings are consistent with hypervolemia (fluid overload) and opposite of dehydration (fluid volume deficit). Hemoconcentration is a manifestation of dehydration, not a type of fluid imbalance.

31. How many milliliters will the nurse record as being lost by a client with pulmonary edema who initially weighed 178 lb and now weighs 161.6 lb? A. 1000 B. 3000 C. 5000 D. 7000

31. D 1 kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 16.6 lb divided by 2.2 = 7000 g (7000 mL).

37. Which assessment findings would cause the nurse to suspect cardiac tamponade in a client? Select all that apply. A. Neck vein distention B. Paradoxical pulse C. Hypertension D. Muffled heart sounds E. Tachycardia F. Petechiae

37. A, B, D, E Findings of cardiac tamponade include: jugular venous (neck vein) distention; paradoxical pulse, also known as pulsus paradoxus; tachycardia; muffled heart sounds; and hypotension (not hypertension).

4. Which health promotion teaching will the nurse stress to healthy adults to prevent harm from acute kidney injury (AKI)? A. Check your blood pressure every day. B. Find out if you have a family history of diabetes. C. Avoid dehydration by drinking 2 to 3 liters of water daily. D. Have annual testing for blood urea nitrogen (BUN), creatinine, protein, and glucose.

4. C Dehydration (severe blood volume depletion) reduces perfusion and can lead to AKI even in adults who have no known kidney problems. The nurse urges all healthy adults to avoid dehydration by drinking 2 to 3 liters of water daily.

44. Which signs or symptoms would the nurse expect when assessing a client with chronic constrictive pericarditis? Select all that apply. A. Exertional fatigue and dyspnea B. Dependent edema C. Crackles and wheezes D. Hepatic engorgement E. Pink, frothy sputum F. Decreased appetite

44. A, B, D Clients with chronic constrictive pericarditis (lasting longer than 3 months) have signs of right-sided HF, including elevated systemic venous pressure with jugular distention, hepatic engorgement, and dependent edema. Exertional fatigue and dyspnea are common.

5. Which assessment finding will the nurse expect in a client with diabetes who has peripheral neuropathy of the motor neurons? A. Muscle weakness B. Orthostatic hypotension C. Absence of feeling in the feet D. Increased risk for myocardial infarction

5. A Neuropathy of motor neurons leads to muscle weakness and increased risk for falls. Neuropathy of sensory neurons leads to loss of sensation in the feet and hands and can cause the client not to feel symptoms when MI occurs but does not increase the risk for having an MI. Cardiac autonomic neuropathy, not motor neuropathy, causes orthostatic hypotension.

6. Which laboratory tests does the nurse expect to be ordered to screen for prostate cancer in a client with benign prostatic hyperplasia (BPH)? Select all that apply. A. Urinalysis and urine culture B. Complete blood count (CBC) C. Prostate-specific antigen (PSA) D. Blood urea nitrogen (BUN) E. Serum acid phosphatase F. Serum creatinine

6. C, E Laboratory tests for cancer screening include PSA (most commonly used to test for early prostate cancer), and serum acid phosphatase (to screen for metastatic prostate cancer). Creatinine and BUN evaluate renal function. CBC looks for evidence of systemic infection or anemia. A urinalysis and urine culture evaluate for systemic infection and if there is blood in the urine, for anemia.

7. With which member of the interprofessional team will the nurse collaborate to improve the symptoms of MS that affect mobility? A. Registered dietician nutritionist B. Orthopedic surgeon C. Physical therapist D. Speech-language therapist

7. C The nurse works in collaboration with physical and occupational therapists to plan an exercise program that includes range-of- motion (ROM) exercises and stretching and strengthening exercises to manage spasticity and tremor.

7. For what priority information will the nurse ask next after a client reports decreased appetite, decreased nutritional intake, and episodes of nausea over the past 2 months? A. Usual bowel pattern B. Baseline blood pressure C. Preferred favorite foods D. Usual weight and weight loss

7. D The next important information the nurse asks about is the client's usual weight and whether he or she has experienced a weight loss (especially unintentional). It is important to inquire about unintentional weight loss because some GI cancers may present in this manner.

8. Which statement by a client to the nurse indicates that treatment for urge incontinence has been successful? A. "I have been using bladder compression and it works." B. "I lose a little urine when I sneeze, but I wear a thin pad." C. "I had a little trouble at first, but now I go to the toilet every 3 hours." D. "I'm doing the exercises, but I think that surgery is my best choice."

8. C For urge urinary incontinence, the best outcome is that the client responds to the urge in a timely manner, gets to toilet between urge and passage of urine, and avoids substances that stimulate the bladder (e.g., caffeine, alcohol).

"8. The nurse is caring for a client who just returned from an extended trip overseas. The client has severe headache, muscle aches, fever, fatigue, sore throat and cough with acute respiratory distress. Which nursing action is appropriate? Select all that apply. A. Ask the client about exposure to anyone who was ill. B. Use only gown and gloves when entering this client's room. C. Prepare to administer isoniazid when the first dose is available. D. Explain that visitors will not be allowed into the care unit. E. Obtain arterial blood gases and monitor oxygen status. F. Obtain sputum cultures for acid-fast bacilli."

"8. A, D, E A is correct. This client has recently traveled overseas and may have been exposed to COVID-19. It is critical to determine whether the client has been in contact with anyone who has symptoms of COVID-19. B is not correct. Although Contact Precautions should be used, Airborne Precautions must also be instituted. C is not correct. Isoniazid is used only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis. D is correct because Covid-19 is highly contagious and strict containment is required. E is correct because any client with acute respiratory distress can have progression to complete respiratory failure. Arterial blood gas results help determine the adequacy of gas exchange and the need for oxygen therapy and/or mechanical ventilation. F is incorrect. This test is only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis."

1. Which signs and symptoms will the nurse expect to find on assessment of a client who is admitted with obstructive jaundice? Select all that apply. A. Pruritus B. Hypertension C. Pale, clay-colored stools D. Dark, coffee-colored urine E. Pink discoloration of sclera F. Bright red bleeding from the gums

1. A, C, D Jaundice is a yellow discoloration of the skin and mucous membranes from excessive bilirubin in these structures and blood. Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee- colored. The obstruction prevents bilirubin from reaching the intestinal system where it is broken down and gives stool its dark brown color. Because the bilirubin does not reach the GI tract, stools are light with a gray or clay color.

1. Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb (9 kg) on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

1. B Postnecrotic cirrhosis of the liver is caused by viral hepatitis, especially hepatitis C, and drugs that are liver toxic, such as acetaminophen. Cirrhosis caused by chronic alcoholism is Laennec cirrhosis. Chronic biliary obstruction can result in biliary cirrhosis. Gallstones are not associated with cirrhosis unless chronic biliary obstruction is also present.

1. Which statement best defines the cardiovascular concept of preload? A. Amount of resistance the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels B. Degree of myocardial fiber stretch at the end of diastole and just before the heart contracts C. The volume of blood ejected each minute by the hear D. Force of blood exerted against the vessel walls

1. B The stretch imposed on the muscle fibers results from the volume contained within the ventricle at the end of diastole. Preload is determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart) (left ventricular end-diastolic [LVED] volume). Option A describes the concept of afterload. Option C describes the concept of cardiac output and Option D is the definition of blood pressure.

1. Which findings will the nurse assess when a client is experiencing problems with urinary elimination caused by acute pyelonephritis? Select all that apply. A. Hypertension B. Pain and burning with urination C. Client reports back, flank, or loin pain D. Urine is cloudy and has a foul odor E. Client produces large amounts of dilute urine F. Urine sample is dark or smoky colored

1. B, C, D, F Options B, C, D, and F are manifestations of acute pyelonephritis. See Key features of Acute Pyelonephritis in your text for additional signs and symptoms. Hypertension occurs with chronic pyelonephritis. Urine will be decreased and have characteristics of infections (e.g., turbidity, foul odor), not dilute.

1. About which pancreatic functions will the nurse teach a client with a gastrointestinal (GI) disorder? Select all that apply. A. Breaking down amino acids B. Producing glucagon from the endocrine part of the organ C. Detoxifying potentially harmful compounds D. Secreting enzymes for digestion from the exocrine part of the organ E. Producing enzymes that digest carbohydrates, fats, and proteins F. Beta cells producing insulin

1. B, D, E, F The nurse teaches the client about two major cellular bodies (exocrine and endocrine) within the pancreas that have separate functions. The exocrine part consists of cells that secrete enzymes needed for digestion of carbohydrates, fats, and proteins (proteases, amylase, and lipase). The endocrine part of the pancreas is made up of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin.

1. Which criteria does the nurse understand are included in the current definition of acute kidney injury (AKI)? Select all that apply. A. Signs and symptoms of fluid overload such as peripheral edema and crackles in the lungs B. Urine volume of less than 0.5 mL/kg/hr for 6 hours C. Presence of polyuria, nocturia, and very dilute pale yellow urine D. Increase in serum creatinine by 0.3 mg/dL (26.2 µmol/L) or more within 48 hours E. Hypotension and tachycardia with progressively decreased amounts of urine F. Increase in serum creatinine to 1.5 times or more from baseline in the previous 7 days

1. B, D, F The most current definition of AKI is an increase in serum creatinine by 0.3 mg/dL (26.2 µmol/L) or more within 48 hours; or an increase in serum creatinine to 1.5 times or more from baseline, which is known or presumed to have occurred in the previous 7 days; or a urine volume of less than 0.5 mL/kg/hr for 6 ho

1. Which symptom does the nurse most likely expect when admitting a client diagnosed with benign prostatic hyperplasia (BPH)? A. Erectile dysfunction B. Pain in the scrotum C. Difficulty passing urine D. Constipation

1. C As the client's prostate gland enlarges, it extends upward into the bladder and inward, causing bladder outlet obstruction. Because of this, the nurse expects the symptom of difficulty in starting and continuing urination.

1. Which description of respiratory physiologic features is correct? A. The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange. B. The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound. C. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung. D. The left lung is responsible for approximately 60% of gas exchange and the right lung is responsible for 60% of pulmonary perfusion.

1. C The right lung is larger and has more diffusing surface and more blood vessels than does the left lung. All lung functions (gas exchange and perfusion) are greater in the right lung, which means that problems in the right lung more severely affect (reduce) gas exchange than do similar problems in the left lung. Surfactant reduces surface tension rather than increases it. Gas exchange does not occur within the tracheobronchial tree because the tissues are too thick for adequate diffusion of gas in either direction.

1. Which statement about the relapsing-remitting type of multiple sclerosis (RRMS) is accurate? A. It involves a steady and gradual neurologic deterioration without remission of symptoms. B. It begins with a relapsing-remitting course and later the symptoms becomes steadily and progressively worse. C. It is characterized by frequent relapses with partial recovery but not a return to baseline. D. It is characterized by symptoms developing and resolving in a few weeks to months, and the client returns to baseline.

1. D Relapsing-remitting type of multiple sclerosis (RRMS) occurs in most cases of MS. The course of the disease may be mild or moderate, depending on the degree of disability. Symptoms develop and resolve in a few weeks to months, and the client returns to baseline. During the relapsing phase, the client reports loss of function and the continuing development of new symptoms. Option A describes primary progressive MS (PPMS); option B describes secondary progressive MS (SPMS); and option C describes progressive-relapsing MS (PRMS).

10. Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

10. A A late finding in clients who have late-stage liver cirrhosis and encephalopathy is asterixis, which is a coarse tremor that is characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

10. What is the most important reason that the nurse asks a client whether he or she is right-handed or left-handed during neurologic assessment? A. The client may be stronger on the dominant side, which is expected. B. The client should be encouraged to strengthen and rely on the dominant side. C. Effects of a neurologic event will be worse if the nondominant side is involved. D. This information is part of all standard databases for older clients.

10. A The nurse asks whether the client is right-handed or left-handed because this information is important for these reasons: the client may be somewhat stronger on the dominant side, which is expected, and the effects of cerebral injury or disease may be more pronounced if the dominant (not nondominant) hemisphere is involved.

10. Which action associated with a habit training bladder program for an older client who is alert but mildly confused will the nurse delegate to the assistive personnel (AP)? A. Remind the client when it is time to use the bathroom and assist him or her on a regular schedule. B. Help the client record all incidents of incontinence that occur in a bladder diary. C. Change the client's incontinence pad or containment briefs every 4 hours. D. Gradually encourage the client's independence and increase the intervals between voidings.

10. A The nurse collaborates with all staff members, including assistive personnel (AP), to consistently implement the toileting schedule for habit training. The scope of practice for an AP includes assisting clients with toileting and reminding them when it is time to use the bathroom. Habit training is undermined when absorbent briefs are used in place of timed toileting. Do not tell clients to "just wet the bed."

10. What results will the nurse expect from a 24-hour urine test for total protein when a client is diagnosed with glomerulonephritis (GN)? A. Protein excretion rate may be increased from 500 mg/24 hr to 3 g/24 hr. B. Protein excretion rate may be decreased from 500 mg/24 hr to 250 mg/24 hr. C. Protein excretion rate will be within normal limits for the client. D. Protein excretion rate will vary from normal to slightly increased.

10. A When a 24-hour urine collection for total protein is obtained, the nurse expects the protein excretion rate for clients with acute GN to be increased from 500 mg/24 hr to 3 g/24 hr.

10. A client has postcholecystectomy syndrome (PCS) with persistent abdominal pain accompanied by vomiting for several weeks after removal of the gallbladder. Which possible causes or complications will the nurse remain alert for in this client? Select all that apply. A. Pseudocyst B. Common bile duct leak C. Dumping syndrome D. Diverticular compression E. Ductal stricture or obstruction F. Sphincter of Oddi dysfunction G. Primary sclerosis cholangitis H. Retained or new gallstones

10. A, B, D, E, F, G, H PCS most commonly indicates possible problems in the biliary tract, such as pseudocyst, common bile duct leak, diverticular compression, ductal stricture or obstruction, sphincter of Oddi dysfunction, primary sclerosis cholangitis, and retained or new gallstones. Dumping syndrome is not part of the problems associated with PCS. Further testing is needed to identify the cause and provide interventions to prevent even more serious complications.

10. Which clients will the nurse recognize to be at risk for developing pneumonia? Select all that apply. A. 72-year-old with chronic confusion B. 66-year-old with influenza C. 55-year-old with atrial fibrillation who is taking an oral anticoagulant D. 40-year-old being mechanically ventilated and is orally colonized with Gram-negative bacteria E. 35-year-old with hyperthyroid disease F. 28-year-old who is extremely malnourished

10. A, B, D, F Clients with chronic confusion are at higher risk for pneumonia because of reduced ability to know when to take precautions to avoid infection. This client's risk is also increased because of age- related reduced immunity and may have a higher risk for aspiration pneumonia. Influenza is a very common cause of pneumonia. Mechanical ventilation greatly increases the risk for ventilator- associated pneumonia as the lower respiratory system is more open with by-passing of some anatomy safe-guards, the mouth may be colonized with organisms that can translocate to the lungs, and oral secretions can be aspirated into the lungs. Anyone who is severely malnourished has an increased risk for infectious pneumonia because of reduced immunity. Neither atrial fibrillation nor anticoagulant therapy increases pneumonia risk. Hyperthyroidism has no direct on risk for any type of pneumonia.

10. Which signs/symptoms in an older client admitted for a medical problem indicate to the nurse the possibility of "failure to thrive?" Select all that apply. A. Weakness B. Exhaustion C. Poor skin turgor D. Reduced hearing E. Stress incontinence F. Slow walking speed G. Low physical activity H. Unintentional weight loss

10. A, B, F, G, H "Failure to thrive" in older clients is a combination of any three of these five symptoms: weakness, slow walking speed, low physical activity, unintentional weight loss, and exhaustion.

10. Which are the goals of nutritional support for a client with acute kidney injury (AKI) when the nurse collaborates with the registered dietitian nutritionist (RDN)? Select all that apply. A. Maintaining or improving nutritional status B. Creating a program for weight loss C. Preserving lean body mass D. Restoring or maintaining fluid balance E. Preserving kidney function F. Preventing end-state kidney disease

10. A, C, D, E Nutrition support goals in AKI are to provide sufficient nutrients to maintain or improve nutrition status, preserve lean body mass, restore or maintain fluid balance, and preserve kidney function.

10. Which criteria will the nurse assess in a client with benign prostatic hyperplasia that indicate the need for a surgical treatment? Select all that apply. A. Hydronephrosis B. Acute urinary tract infection unresponsive to first-line antibiotics C. Hematuria D. Chronic urinary tract infection secondary to residual urine in bladder E. Recurrent kidney stones F. Acute urinary retention due to obstruction

10. A, C, D, F For a client with BPH, some or all of these criteria indicate the need for surgery: acute urinary retention due to obstruction; chronic urinary tract infections secondary to residual urine in the bladder; hematuria; hydronephrosis; and persistent pain with decrease in urine flow.

10. What physical changes will the nurse teach a client to expect when undergoing estrogen therapy for male-to-female (MtF) transition? Select all that apply. A. Decreased testicular size B. Increased libido (sex drive) C. Reduced muscle mass D. Increased erectile function E. Softening of skin F. Increased body hair growth

10. A, C, E The nurse providing care for a client undergoing a MtF transition would teach about these changes: breast tissue development, reduced or absent sperm count and ejaculatory fluid, reduced muscle mass, change in emotions, change in sweat and odor patterns, decreased testicular size, reduced erectile function, decreased libido (sex drive), decreased body hair growth, and softening of skin.

10. Which statements indicate to the nurse that a client has a strong addiction to cigarette smoking. Select all that apply. A. "I smoke a cigarette when I wake up before I make coffee." B. "To reduce my children's exposure, I only smoke outdoors." C. "I used to just 'bum' cigarettes but now I buy a pack daily for myself." D. "I only watch movies on television rather than at a theater because I can smoke at home." E. "Last night I woke up at 2.00 a.m. and 5.00 a.m. to smoke two cigarettes each time." F. "Last year when I had pneumonia, I didn't smoke for 2 weeks but started again when I was well."

10. A, D, E Indicators of strong nicotine dependence includes the need to wake up in the middle of the night to smoke, to find it difficult not to smoke in places where smoking is prohibited (such as movie theaters), having a cigarette within the first 5 to 10 minutes after waking up, and smoking during illness.

10. Which actions will the nurse avoid when a client with Alzheimer disease is agitated? Select all that apply. A. Talking softly and calmly to the client B. Confronting the client C. Attempting to redirect the client D. Reasoning with the client E. Taking offense at what the client says F. Explaining the situation to the client

10. B, D, E, F When a client with AD is agitated, actions to avoid include raising the voice, confronting, arguing, reasoning, taking offense, or explaining. Talking calmly and softly and attempting to redirect the client to a more positive behavior or activity are effective strategies when he or she is agitated.

10. Which is the best action for the nurse to take when a client with MS develops diplopia? A. Obtain a prescription for referral for corrective lenses. B. Teach the client scanning techniques, turning the head from side to side. C. Apply an eye patch alternating it from eye to eye every few hours. D. Use prophylactic bilateral patches to both eyes during the night hours.

10. C An eye patch that is alternated from eye to eye every few hours usually relieves diplopia.

10. Which foods will the nurse suggest to increase calcium and vitamin D intake for a client who is lactose intolerant? A. Fresh apples and pears B. Whole-grain bread and pasta C. Fortified soy or rice products D. Skim milk and fat-free yogurt

10. C Fortified soy and rice products are good sources of calcium and vitamin D. A client who is lactose intolerant would not be able to use dairy products as a calcium source. The other items listed do not contain significant amounts of calcium and vitamin D.

10. What type of bowel sounds will the nurse expect to auscultate when a client reports having diarrhea for the past 2 days? A. Decreased or diminished sounds B. Increased sounds in the left lower quadrant only C. Increased loud and gurgling sounds D. Decreased sounds in the right upper quadrant only

10. C Increased bowel sounds, especially loud, gurgling sounds (borborygmus), result from increased motility of the bowel. These sounds are usually heard when a client has diarrhea, gastroenteritis, or a complete intestinal obstruction (sounds will be heard above the obstruction).

10. Which assessment information obtained from a 60-year-old male client with severe osteoarthritis of the right knee will the nurse consider the greatest contributing factor? A. Is 10 lb (4.5 kg) overweight B. Has ridden a motorcycle for 35 years C. Has worked laying carpet for the past 20 years D. Has a 25 pack-year history of cigarette smoking

10. C Laying carpet requires extensive time in the kneeling position and carpet layers also use their dominant knee to push a device that stretches the carpet and places it under the baseboard. Both actions are repetitive and cause force injuries to the involved joints that can reduce articulating cartilage. Being 10 lb (5 kg) overweight is not usually sufficient in a male to cause osteoarthritis of the knee. A smoking history increases the risk for osteopenia but not arthritis. Riding a motorcycle may cause some musculoskeletal problems, but not osteoarthritis of the knees.

10. What is the nurse's first action when the health care provider prescribes orthostatic blood pressure checks for a client? A. Wait for 1 minute before auscultating blood pressure while the client is sitting. B. Instruct the client to sit on the side of the bed before checking blood pressure. C. Measure the blood pressure after the client has been supine for 3 minutes. D. Tell the client to change positions rapidly between blood pressure checks.

10. C Postural (orthostatic) hypotension occurs when the BP is not adequately maintained while moving from a lying to a sitting or standing position. It is defined as a decrease of more than 20 mm Hg of the systolic pressure or more than 10 mm Hg of the diastolic pressure and a 10% to 20% increase in heart rate. To detect orthostatic changes in BP, first measure the BP when the client is supine. After remaining supine for at least 3 minutes, the client changes position to sitting or standing. Normally systolic pressure drops slightly or remains unchanged as the client rises, whereas diastolic pressure rises slightly. After the position change, wait for at least 1 minute before auscultating BP and counting the radial pulse. The cuff should remain in the proper position on the client's arm. Observe and record any signs or symptoms of dizziness. If the client cannot tolerate the position change, return him or her to the previous position of comfort.

10. For which indication of a fluid balance problem will the nurse assess in an older client at risk for fluid and electrolyte problems? A. Fever B. Elevated blood pressure C. Poor skin turgor D. Mental status changes

10. D Although all of the assessment findings listed may appear with a fluid balance problem, the first indication in older clients is a change in mental status.

10. Which statement by a client with a history of hypertension and heart problems would cause the nurse to suspect development of heart failure? A. "I've had a fever frequently." B. "I noticed a very fine red rash on my chest." C. "I get a pain in my shoulder when I cough." D. "I've had to remove all of my rings for the past month."

10. D Clients may notice that their shoes fit more tightly, or their shoes or socks may leave indentations on their swollen feet. They may have removed their rings because of swelling in their fingers and hands.

10. Where would the nurse insert an IV short peripheral catheter (SPC) in an active client with a prescription for IV therapy? A. Wrist B. Hand C. Antecubital area D. Forearm

10. D Short peripheral catheters are most often inserted into superficial veins of the forearm. In emergent situations, these catheters can also be used in the external jugular vein of the neck. The areas in options A and C are over joints, which would then have to be immobilized. The back of the hand contains little subcutaneous tissue and is easily damaged. Option B, the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition or for active patients receiving infusion therapy in an ambulatory care clinic or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short-term infusion of nonvesicant and nonirritant solutions in young patients.

10. Which client admitted to a surgical unit will the nurse recognize as having a higher risk for having type 2 diabetes? A. 30-year-old Hispanic female runner B. 36-year-old white female who has rheumatoid arthritis C. 40-year-old black male who is 10 lb (4.5 kg) underweight D. 48-year-old obese male American Indian

10. D The type 2 diabetes rate is about 13% among blacks and 12% in the Hispanic population, which is higher than that of non-Hispanic white Americans. At nearly 15.1%, American Indians and Alaska Indians have the highest age-adjusted prevalence of DM among U.S. racial and ethnic groups. The American-Indian client has an increased risk of obesity. The Hispanic female and black male have high activity levels or reduced weight, which decreases the risk.

10. From where does the nurse suspect a client with PUD is bleeding when massive coffee-ground emesis occurs? A. Colon B. Rectum C. Small intestine D. Upper GI system

10. D With massive bleeding, the client vomits bright red or coffee- ground blood (hematemesis). Gastric acid digestion of blood typically results in the coffee-ground appearance. Hematemesis usually indicates bleeding at or above the duodenojejunal junction (e.g., upper GI bleeding).

11. What does the nurse teach an older client with prostate cancer who is scheduled to have a digital rectal examination (DRE) and a prostate-specific antigen (PSA) test? A. The PSA laboratory test is drawn before the DRE. B. The DRE is completed 2 weeks before the PSA. C. The PSA is reviewed first because DRE may not be necessary. D. Both tests can be completed at the client's convenience.

11. A The PSA laboratory test should be drawn before the DRE because this examination can cause an increase in PSA due to prostate irritation.

11. What is the most common symptom that prompts clients to seek medical attention for problems with the kidneys or urinary tract? A. Pain in flank or abdomen, or pain when urinating B. Change in the frequency or amount of urination C. Exposure to one or more nephrotoxic substances D. Change in color, clarity, or odor of the urine

11. A The onset of pain in the flank, in the lower abdomen or pelvic region, or in the perineal area causes concern and usually prompts the client to seek medical care. The nurse asks about the onset, intensity, and duration of the pain; its location; precipitating and relieving factors, and its association with any activity or event. Painful urination also leads clients to seek medical care.

11. Which does the nurse recognize as cardinal symptoms for a client with Parkinson disease (PD)? Select all that apply. A. Tremors B. Muscle rigidity C. Postural instability D. Bradykinesia or akinesia E. Choreiform movements F. Seizure activity

11. A, B, C, D Parkinson disease (PD) is a progressive neurodegenerative disease that is one of the most common neurologic disorders of older adults. It is a debilitating disease affecting mobility and is characterized by four cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability. Huntington disease, a rare hereditary disorder that is characterized by progressive dementia and choreiform movements (uncontrollable rapid, jerky movements) in the limbs, trunk, and facial muscles.

11. Which types of fluid loss are considered "insensible fluid loss?" Select all that apply. A. Sweat B. Salivation C. Urine D. Diarrhea E. Vomit F. Wound drainage

11. A, B, D, E, F Of all these fluid loss routes, the only one that adjusts or is regulated is urine output. The others represent fluid loss that has no regulatory or control mechanisms, also known as insensible.

11. Which mechanisms regulate and mediate blood pressure? Select all that apply. A. Kidneys B. Gastrointestinal system C. Autonomic nervous system D. Respiratory system E. Endocrine system F. Carbon dioxide elimination

11. A, C, E The three mechanisms that regulate and mediate blood pressure: the autonomic nervous system (ANS), which excites or inhibits sympathetic nervous system activity in response to impulses from chemoreceptors and baroreceptors; the kidneys, which sense a change in blood flow and activate the renin-angiotensin- aldosterone mechanism; and the endocrine system, which releases various hormones (e.g., catecholamine, kinins, serotonin, histamine) to stimulate the sympathetic nervous system at the tissue level.

11. Which integrative/complimentary therapies will the nurse recommend to a client with multiple sclerosis? Select all that apply. A. Reflexology B. Herbal therapy C. Massage D. Conservation therapy E. Yoga F. Relaxation and meditation

11. A, C, E, F Clients with MS report that some complementary therapies are successful in decreasing their symptoms. Integrative therapies used by clients with MS include: reflexology; massage; yoga; relaxation and meditation; acupuncture; and aromatherapy. Conservation strategies (balancing periods of rest and activity) are useful for these clients but this is not an integrative therapy.

11. Which respiratory changes does the nurse expect to find in an 82- year-old client who has no indicators of respiratory disease? Select all that apply. A. Exhalation is twice as long as inhalation B. Wheezing on arising every morning C. Decreased force of cough D. Increased anteroposterior diameter E. Shortness of breath at rest F. Softer voice

11. A, C. D, F A respiratory cycle consists of one inhalation followed by one exhalation. The normal respiratory cycle has an exhalation period that is twice as long as inhalation. Vocal cords slacken with age and the voice becomes softer. All muscles of inhalation weaken and lose strength with age, making coughs less forceful. With normal aging, the anteroposterior diameter enlarges. (It is much more exaggerated in obstructive respiratory disorders). Wheezing on arising is not normal at any age. Although older adults may develop some shortness of breath on exertion or exercise, shortness of breath at rest is not a normal age-related finding.

11. Which laboratory result for a client with pneumonia will the cause the nurse to collaborate quickly with the primary health care provider? A. White blood cell (WBC) count of 14,526/mm3 B. Pao2 68 mm Hg C. Paco2 48 mm Hg D. Fasting blood glucose 146 mg/dL

11. B Although all values are abnormal (Paco2 is only slightly elevated), they are expected findings in clients with pneumonia or any other severe infection. The very low Pao2 level indicates severe hypoxemia and great risk for death without immediate intervention.

11. Which action will the nurse avoid to prevent harm for a client with overflow incontinence? A. The Crede method to help initiating the emptying of the bladder B. The Valsalva maneuver when a client has heart disease C. Double voiding using a second attempt to empty the bladder D. Splinting to compress the bladder and move it into a better position

11. B The Valsalva maneuver is contraindicated in clients who have some cardiac problems because it can trigger a vagal response and cause bradycardia.

11. Which nursing assessment has the highest priority for the nurse to perform on a client admitted in severe pain with acute pancreatitis? A. Asking the client to rate the level of pain B. Measuring heart rate, blood pressure, and oxygen saturation C. Auscultating bowel sounds in all four abdominal quadrants D. Determining the amount of alcoholic beverages the client consumes daily

11. B The client with acute pancreatitis is at high risk for death from hemorrhage and shock as a result of necrotic blood vessels destroyed by enzymatic digestion. Although all the above assessments are appropriate, the priority is to determine whether any indications of internal hemorrhage and shock are present.

11. Based on the guidelines from the World Professional Association for Transgender Health (WPATH), which clients meet the criteria for gender-affirming hormonal therapy? Select all that apply. A. 16-year-old who has experienced gender dysphoria since early childhood B. 30-year-old with gender dysphoria and no physical or mental health problems C. 40-year-old who would like to temporarily try being a member of the opposite sex D. 45-year-old with gender dysphoria since grade school and well- controlled hypertension E. 62-year-old with known history of gender dysphoria and symptoms of dementia F. 65-year-old lesbian with history of multiple suicide attempts

11. B, D According to WPATH's most recent Standards of Care (2011), the criteria for gender-affirming hormonal therapy include continuing and well-documented gender dysphoria, client ability to make a fully informed decision and give consent to treatment, client older than 18 years, and well-controlled existing medical or mental health problems.

11. Which interventions will the nurse expect to implement for management of infection as the cause for glomerulonephritis (GN)? Select all that apply. A. Corticosteroids B. Antibiotics C. Cytotoxic drugs D. Personal hygiene E. Fluid restriction F. Handwashing

11. B, D, F Managing infection as a cause of acute GN begins with appropriate antibiotic therapy. Penicillin, erythromycin, or azithromycin is prescribed for GN caused by streptococcal infection. The nurse stresses personal hygiene and basic infection control principles (e.g., handwashing) to prevent spread of the organism. Clients are taught the importance of completing the entire course of the prescribed antibiotic. Corticosteroids and cytotoxic drugs are used for GN that is not caused by infection. Fluid restriction may be used with the complication of fluid overload.

11. For which abnormal laboratory findings will the nurse monitor when providing care for a client with acute pancreatitis? Select all that apply. A. Increased prothrombin time B. Increased serum lipase C. Increased unconjugated bilirubin D. Increased aspartate transaminase E. Increased serum amylase F. Increased serum ammonia

11. B, E Elevations in serum amylase and lipase may indicate acute pancreatitis, a serious inflammation of the pancreas characterized by a sudden onset of abdominal pain, nausea, and vomiting. Serum amylase levels begin to elevate within 24 hours of onset and remain elevated for up to 5 days. The values listed in options A, C, D, and F are more commonly seen with liver disease.

11. Which lifestyle changes will the nurse suggest to a 35-year-old client who has prediabetes to reduce the risk for developing type 2 diabetes? Select all that apply. A. Increasing fluid intake B. Increasing physical activity C. Quitting smoking and vaping D. Eliminating all dietary carbohydrates E. Reducing consumption of empty calories F. Keeping body weight at or slightly below ideal

11. B, E, F The two most important lifestyle changes to reduce the risk for development of type 2 diabetes are increasing activity and maintaining a healthy weight. Part of weight control is reducing consumption of surgery drinks and other sources of "empty" calories that increase overall weight and have minimal nutritional values. Increasing fluid intake and quitting smoking and vaping help prevent complications from diabetes but do not reduce the risk for developing the disorder. Eliminating all dietary carbohydrates is not part of a well-balanced diet, can cause other problems, and is not recommended for prevention of type 2 diabetes.

11. Which MRI report/finding indicates to the nurse that the client has significant generalized bone density loss? A. Red blood cell production is increased above normal. B. Perfusion of the wrist and elbow joints is greater than expected. C. Percentage of bone marrow adipose tissue is higher than expected. D. Osteoblastic activity appears equal to or greater than osteoclastic activity.

11. C Bone marrow adipose tissue (BMAT) or fat is present in higher than expected levels in clients who have bone marrow loss. The other findings listed are not associated with bone marrow loss or osteoporosis.

11. What is the most reliable method of monitoring for fluid gain or loss in a client with heart failure? A. Check for pitting edema in dependent body parts. B. Auscultate the lungs for worsening crackles or wheezes. C. Weigh the client daily at the same time and using the same scale. D. Assess the client's skin turgor and condition of mucous membranes.

11. C Edema is an extremely unreliable sign of HF. Be sure that accurate daily weights are taken to document fluid retention. Assessing weight at the same time of the morning using the same scale is important. Weight is the most reliable indicator of fluid gain and loss! Ask about weight gain. An adult may retain 4 to 7 liters of fluid (10 to 15 lb [4.5 to 6.8 kg]) before pitting edema occurs. Increasing crackles or wheezes can indicate that the client's HF is getting worse but does not indicate weight. Skin turgor and mucous membranes indicate fluid balance but not weight in a client.

11. What would the nurse's first action(s) be when a client's IV site demonstrates slowed flow rate, skin tightness, discomfort at the site (e.g., burning, tenderness), and leakage around the site? A. Apply a cold pack and elevate the extremity. B. Place a sterile dressing over the site if weeping from the tissue occurs. C. Stop the solution and remove the intravenous access. D. Insert a new IV catheter above the site of the old one.

11. C First, stop infusion and remove short peripheral catheter immediately. After this, a sterile dressing can be applied if there is weeping from the tissue. Next, the extremity can be elevated and cold or warm compresses applied. A new catheter should be inserted in the opposite (not the same) extremity. Finally, the nurse would rate the infiltration using the INS Infiltration Scale and document the event.

11. Which additional electrolyte change will the nurse expect to find in a client who has hypercalcemia? A. Hyponatremia B. Hyperkalemia C. Hypochloremia D. Hypophosphatemia

11. D Blood calcium and phosphorus levels exist in a balanced reciprocal relationship that causes one level to rise as the other one decreases. Elevations of serum calcium levels above normal cause a corresponding decrease in serum phosphorus levels. High levels of serum calcium do not change the serum levels of sodium, potassium, or chloride.

11. Which client does the nurse understand has the greatest risk of developing acute kidney injury (AKI)? A. 23-year-old female who was recently treated for a urinary tract infection B. 32-year-old female who is pregnant and has gestational diabetes C. 49-year-old male who is obese and has a history of skin cancer D. 73-year-old male who has hypertension and peripheral vascular disease

11. D Risk factors for AKI include shock, cardiac surgery, hypotension, prolonged mechanical ventilation, and sepsis. Older adults or adults with diabetes, hypertension, peripheral vascular disease, liver disease, or CKD are at higher risk of AKI if hospitalized. The client in option D is an older adult with two important risk factors. Thus, he is at highest risk of AKI development.

12. Which action will the nurse take first when an 80-year-old client with acute pancreatitis has no breath sounds in the left lower lung lobe? A. Apply oxygen. B. Assess the breath sounds on the right. C. Notify the primary health care provider. D. Document the finding as the only action.

12. A Left lower lung effusions, atelectasis, and pneumonia often develop in clients with acute pancreatitis, especially in older adults, and can lead to pulmonary failure and death. The nurse would first apply oxygen and then immediately notify the primary health care provider.

12. Which assessment finding on a client with pneumonia who is receiving IV antibiotics and oxygen by nasal cannula indicates to the nurse that initial goals for this client have been met? A. Client is alert and oriented to person, place, and time. B. Blood pressure is within normal limits and client's baseline. C. Skin behind the ears demonstrates no redness or irritation. D. Urine output has been >30 mL/hr per foley catheter.

12. A One of the first signs and symptoms of pneumonia in an older adult is acute confusion as a result of impaired gas exchange. A client with pneumonia who is alert and oriented to person, place, and time is responding well to appropriate therapy for the disorder. The blood pressure is not an indicator of effective management of pneumonia and neither is urine output. The skin behind the client's ears being intact is important and desirable, but not an outcome indicator for pneumonia management.

12. Which action will the nurse take first to promote adequate intake in a client who is malnourished? A. Asking the client about his or her food preferences B. Providing the client with high-calorie, high-protein food C. Offering frequent snacks or protein shakes between meals D. Obtaining serial weights on a weekly basis to monitor progress

12. A Regardless of a dietary intervention for malnutrition, if the client does not eat the food provided or recommended, malnutrition will continue. Incorporating the client's food preferences into a planned dietary intervention increases the likelihood of the intervention's success.

12. What instructions will the nurse provide to a client with a gastrointestinal problem who is scheduled for an abdominal x-ray? A. "Wear a hospital gown and remove any jewelry or belts." B. "You will have nothing to eat or drink until after the procedure." C. "A nasogastric tube will be placed to decompress your stomach." D. "You will receive a laxative to clear stool out of your bowel."

12. A The nurse teaches the client that no preparation is required except to wear a hospital gown and remove any jewelry or belts, which may interfere with the film.

12. Which precaution is a priority for the nurse to teach a client prescribed dulaglutide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Take this drug right before or with the first bite of a meal. D. Report any genital itching to your diabetes health care provider immediately.

12. A This drug is an incretin mimetic (GLP1-agonist) that works with insulin to prevent hyperglycemia. It is taken as an injection only once per week. If taken more frequently, the client is at risk for an overdose. This drug is not associated with fasciitis of the perineum and does not require total abstinence from alcohol.

12. Which nursing actions are included in the care of a client who had a transurethral resection of the prostate (TURP)? Select all that apply. A. Helping the client out of the bed to the chair as soon as permitted to prevent complications of immobility B. Using normal saline solution for the intermittent bladder irrigant unless otherwise prescribed C. Monitoring and documenting the color, consistency, and amount of urine output D. Providing a safe environment for the client because of temporary changes in mental status E. Assessing the client for reports of severe bladder spasms with decreased urinary output F. Checking the drainage tubing frequently for external obstructions such as kinks, and internal obstructions such as blood clots

12. A, B, C, D, E, F All of these options are appropriate nursing actions when caring for a client after a TURP. See Best Practice for Patient Safety & Quality Care Care of the Patient After Transurethral Resection of the Prostate in your text for additional appropriate nursing care actions to take after a client has a TURP.

12. Which major self-management categories will the nurse include when teaching a client, newly diagnosed with heart failure, who is about to be discharged? Select all that apply. A. Symptoms, what to do when they get worse B. Medications C. Activity D. Heart transplants E. Weight F. Diet

12. A, B, C, E, F One standard and frequently used self-management plan is called MAWDS. The major teaching areas for this plan include: Medications: Take medications as prescribed and do not run out; know the purpose and side effects of each drug; and avoid NSAIDs to prevent sodium and fluid retention. Activity: Stay as active as possible but don't overdo it; know your limits; and be able to carry on a conversation while exercising. Weight: Weigh each day at the same time on the same scale to monitor for fluid retention. Diet: Limit daily sodium intake to 2 to 3 g as prescribed; limit daily fluid intake to 2 liters. Symptoms: Note any new or worsening symptoms and notify the health care provider immediately.

12. When the nurse is providing care for a client with a midline catheter, which key points are true? Select all that apply. A. Midline catheters are inserted in the upper arm, most commonly in the median antecubital vein. B. Midline catheters are used for hydration and for IV drug therapy up to 14 days. C. Strict sterile techniques are used for insertion and for dressing changes for midline catheters. D. Midline catheters can be used for the infusion of vesicant medications. E. All parenteral nutrition formulas may be infused through a midline catheter. F. When using a double-lumen midline catheter, do not administer incompatible drugs.

12. A, B, C, F Options A, B, C, and F are correct statements about midline catheters. Midline catheters should not be used to infuse vesicant solutions. Vesicant solutions can cause severe tissue damage if they escape into the subcutaneous tissue (extravasation). When using a double-lumen midline catheter, do not administer incompatible drugs simultaneously through both lumens because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein.

12. Which laboratory changes will the nurse expect to find with a client who suffered extensive soft-tissue damage from a crush injury of the thighs? Select all that apply. A. Serum potassium 5.2 mEq/L (mmol/L) B. Creatine kinase 280 units/L (345 IU/L) C. Serum calcium 11.5 mg/dL (2.68 mmol/L) D. Alkaline phosphatase 90 units/L (120 IU/L) E. Aspartate aminotransferase 50 units/L (57 IU/L) F. White blood cell (WBC) count 11,000/mm3 (11 × 109/L)

12. A, B, D, E All the laboratory values are elevated. The only ones that are associated with probable skeletal muscle trauma are an elevated serum potassium level (because cells have high levels of potassium, which is released when cells are damaged or destroyed), and the other substances that are present in higher concentrations in skeletal muscle than in the blood, creatine kinase, alkaline phosphatase, and aspartate aminotransferase. Skeletal muscle damage does not directly increase the serum calcium concentration or the white blood cell count.

12. Which assessment techniques are most relevant for the nurse to use when performing a neurologic examination for cognition on a client? Select all that apply. A. Give the client a simple command and observe how he or she reacts. B. Observe the client walking across the room, turning, and walking back. C. Ask the client for his or her name, date of birth, today's date, time, and location. D. Observe how well the client follows a topic or attends to an activity. E. Show the client a familiar object and ask him or her to state its name and purpose. F. Note whether the client responds rapidly and relevantly to questions.

12. A, C, D, E, F Cognition is the complex integration of mental processes and intellectual function for the purposes of reasoning, learning, memory, and personality. All of these responses are appropriate except B. The nurse uses response B to assess client mobility. See the box labeled Best Practice for Patient Safety and Quality care (QSEN) - Assessment of Cognition in your text for additional methods of assessing cognition.

12. Which complication does the nurse suspect when a client with PUD suddenly develops sharp epigastric pain that spreads over the entire abdomen? A. Gastric erosion B. Perforation C. Hemorrhage D. Gastric cancer

12. B Gastric and duodenal ulcers can perforate and bleed. Perforation occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away. The stomach or duodenal contents can then leak into the peritoneal cavity. Sudden, sharp pain begins in the mid-epigastric region and spreads over the entire abdomen.

12. Which exercise will the nurse suggest for the client with kyphosis to improve lung capacity? A. Swimming and yoga B. Deep breathing and pectoral stretching C. Range of shoulder and hip movements D. Walking or jogging 30 minutes three times weekly

12. B Kyphosis reduces chest expansion and lung capacity. Exercises that can specifically improve lung capacity include abdominal tightening, deep breathing, and pectoral stretching.

12. Which precaution to prevent harm is most important for the nurse to teach a client who is newly prescribed to take varenicline? A. Avoid crowds and people who are ill because your immunity is reduced while on this drug. B. Immediately report any change in thought process or suicide ideation because this drug can alter behavior. C. Be sure to remain in an upright position for an hour after taking the drug to avoid esophageal reflux and ulceration. D. Do not smoke cigarettes or use nicotine in any form while on this drug because the risk for heart attack or stroke is increased.

12. B This drug has psychotropic properties and can increase feelings of self-harm or suicide ideation. It does not contain nicotine and can be used at the same time as nicotine to gradually reduce the urge to smoke. Varenicline does not induce esophageal irritation or ulcers nor does it reduce immunity.

12. Which client factors affect the amount and distribution of body fluids? Select all that apply. A. Race B. Age C. Gender D. Height E. Body fat F. Muscle mass

12. B, C, E, F Total body water in adults varies by age, gender, degree of muscle mass, and percent of body fat. Water makes up about 55% to 60% of total weight for younger adults and 50% to 55% of total weight for older adults. Women of all ages usually have a lower percentage of body water than do men of the same ages because of greater muscle mass. Fat cells contain little or no water. The higher the percentage of body fat, the lower the percentage of total body water. Neither race nor height affect total body water.

12. Which statement best describes hyperflexion as a cause of a client's spinal cord injury? A. Hyperflexion occurs most often in vehicle collisions in which the vehicle is struck from behind or during falls when the client's chin is struck. B. Hyperflexion is a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck. C. Hyperflexion results from diving accidents, falls on the buttocks, or a jump in which a person lands on the feet. D. Hyperflexion results from injuries that are caused by turning the head beyond the normal range.

12. B. Hyperflexion is a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck. Option A describes hyperextension; option C describes axial loading or vertical compression; and option D describes excessive rotation.

12. What is the nurse's priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NPO B. Notifying the primary health care provider immediately C. Assessing for abdominal rigidity and taking the client's temperature D. Applying a heating blanket and raising the head of the bed to a 45-degree angle

12. C Increasing abdominal pain and the presence of chills in a client who has ascites indicate possible spontaneous bacterial peritonitis. The nurse would perform a complete abdominal assessment and assess for a temperature elevation before notifying the primary health care provider.

12. When a client is hypovolemic, which tissue reacts and sends fewer impulses to the CNS? A. Baroreceptors B. Central chemoreceptors C. Stretch receptors D. Kidney receptors

12. C Stretch receptors in the vena cava and the right atrium are sensitive to pressure or volume changes. When a client is hypovolemic, stretch receptors in the blood vessels sense a reduced volume or pressure and send fewer impulses to the CNS. This reaction stimulates the sympathetic nervous system to increase the heart rate and constrict the peripheral blood vessels. Impulses from these baroreceptors inhibit the vasomotor center which results in a drop in BP. Central chemoreceptors in the respiratory center of the brain are also stimulated by hypercapnia (an increase in partial pressure of arterial carbon dioxide [Paco2]) and acidosis. The kidneys retain sodium and water so BP tends to rise because of fluid retention and activation of the renin-angiotensin-aldosterone mechanism.

12. Which problem or complication does the nurse suspect when a client with chronic kidney disease develops anorexia, nausea and vomiting, muscle cramping, and pruritus? A. Client has oliguria B. Client has anuria C. Client has uremia D. Client has azotemia

12. C Uremia is the buildup of nitrogenous waste products in the blood from inadequate elimination as a result of kidney failure. Symptoms include anorexia, nausea and vomiting, muscle cramps, pruritus (itching), fatigue, and lethargy. Anuria is failure of kidneys to produce urine; oliguria is the production of abnormally small amounts of urine; and azotemia is the buildup of nitrogenous waste products in the blood.

12. When a client with glomerulonephritis has a urine output over the past 24 hours of 1050 mL, how much fluid will the nurse allow the client during the next 24-hour period? A. 1050 to 1150 mL B. 1250 to 1350 mL C. 1450 to 1550 mL D. 1550 to 1650 mL

12. D For clients with fluid overload, hypertension, and edema, diuretics and sodium and water restrictions are prescribed. The usual fluid allowance is equal to the previous 24-hour urine output plus 500 to 600 mL. In this case the client would be allowed 1050 mL plus 500 to 600 mL which equals 1550 to 1650 mL for the next 24 hours.

12. What priority information will the nurse teach a client and family about self-catheterization for the long-term problem of incomplete bladder emptying? A. Use sterile technique especially if the catheterization will be done by a family member. B. Use a large-lumen catheter with good lubrication for rapid emptying of the bladder. C. Catheterize yourself after you are incontinent or when your bladder feels distended. D. Perform careful handwashing and cleaning of the catheter to prevent risk for infection.

12. D The nurse focuses on these important points when teaching the intermittent self-catheterization technique: proper handwashing and cleaning of the catheter to reduce the risk for infection; a small lumen and good lubrication of the catheter prevent urethral trauma; and a regular schedule for bladder emptying prevents distention and mucosal trauma. Clients must be able to understand instructions and have the manual dexterity to manipulate the catheter. Caregivers or family members in the home can also be taught to perform intermittent catheterization using clean (rather than sterile) technique with good outcomes.

12. What priority information does the nurse include when teaching a client with Parkinson disease (PD) about the prescribed drug selegiline, a selective monoamine oxidase type B (MAO-B) inhibitor? A. Take the drug with meals. B. Avoid driving or operating heavy machinery. C. Take the medication daily at bedtime. D. Avoid eating aged cheese or cured meats.

12. D The nurse would teach clients taking MAOIs about the need to avoid foods, beverages, and drugs that contain tyramine, such as cheese and aged, smoked, or cured foods and sausage. Remind them to also avoid red wine and beer to prevent severe headache and life-threatening hypertension. Clients are taught to continue these restrictions for 14 days after the drug is discontinued.

13. Which criteria must the nurse follow before using a newly established peripherally inserted central catheter (PICC) to start IV therapy for a client? A. Wait for the results of a chest x-ray indicating that the tip resides in the lower superior vena cava (SVC). B. Check the client's chart to ensure that sterile technique is used for insertion to reduce the risk for catheter-related bloodstream infection (CRBSI). C. Review the purpose of the PICC line and check the pH or osmolality of fluids to be infused through the line. D. Check patency of the PICC line by flushing with 20 mL of sterile normal saline.

13. A Before the PICC line can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique. Sterile technique is used with all IV insertions. The PICC line is placed in a vein with high flow that can handle hyperosmolar fluids and those in various pH ranges. Flushing the catheter should be done before each use to assess patency of the catheter and after each use to ensure that occlusion from blood that backflows into the lumen does not occur.

13. How will the nurse interpret the physical therapist's report that a client has 70 degrees of flexion based on goniometry measurement on the left knee? A. Flexion is reduced B. Flexion is increased C. Extension is unaffected D. Range of motion is normal

13. A The minimum normal knee joint flexion is 90 degrees. Therefore, this client's range of motion in the left knee is reduced. There is not enough information in the question to draw a conclusion about the extension of the left knee.

13. What is the nurse's best first action when a client with a gastric ulcer is found lying in the knee-chest (fetal) position with a rigid, tender, and painful abdomen? A. Notify the primary health care provider. B. Administer opioid pain medication. C. Reposition the client supine. D. Measure the abdominal circumference.

13. A When the client's abdomen is tender, rigid, and board-like, this is likely an infection (peritonitis). The client often assumes a "fetal" position to decrease the tension on the abdominal muscles. He or she can become severely ill within hours. Bacterial septicemia and hypovolemic shock can follow. Peristalsis diminishes, and paralytic ileus develops. Peptic ulcer perforation is a surgical emergency and can be life threatening. The nurse's best first action is to notify the primary health care provider or the Rapid Response Team (RRT).

13. Which actions will the nurse take to enhance an older client's desire to eat? Select all that apply. A. Assisting the client to make menu selections and substitutions to match his or her food preferences B. Removing any items from sight that reduce appetite such as emesis basins, urinals, and bedpans C. Eliminating distractions, such as turning down the volume of the television D. Offering the client the opportunity to toilet before the meal arrives E. Opening cartons and condiment packages for the client F. Bringing the client's medications to take with the meal G. Ensuring the food served is at appropriate temperature H. Asking all of the client's visitors to leave

13. A, B, C, D, E, G Although it is not possible to increase a client's appetite, actions that make the client more comfortable, reduce unpleasant thoughts, and make food more appetizing can improve a client's interest or desire to eat. These include toileting before meals, removing objects that evoke unpleasant thoughts, providing food that the client likes at the right temperatures, making it easier for the client to access food items on the tray, and avoiding interruptions with medication administration. Visitors do not have to leave and may, in fact, make the dining experience more pleasant. Visitors are only asked to leave if they hamper a client's desire to eat.

13. Which assessment findings will the nurse expect in a client with late-stage liver cirrhosis whose total serum albumin level is low? Select all that apply. A. Ascites B. Hypotension C. Hyperkalemia D. Hyponatremia E. Dependent edema F. Decreased serum ammonia levels

13. A, B, D, E Serum albumin maintains plasma oncotic pressure and sodium levels in the normal range. When albumin levels are low, plasma volume decreases as fluid leaks into the abdomen and dependent areas, forming ascites and dependent edema. Sodium follows the albumin, making serum sodium levels low. The decreased plasma volume results in hypotension.

13. Which symptoms will the nurse expect to find on assessment when a client with chronic glomerulonephritis (GN) develops uremia? Select all that apply. A. Ataxia B. Slurred speech C. Neck vein distention D. Asterixis E. Crackles in lung bases F. Itching

13. A, B, D, F Uremic symptoms include slurred speech, ataxia, tremors, or asterixis (flapping tremor of the fingers or the inability to maintain a fixed posture with the arms extended and wrists hyperextended). Skin symptoms of uremia include a yellowish color, texture changes, bruises, rashes, or eruptions. Itching and areas of dryness or excoriation from scratching are often present.

13. Which serum laboratory values will the nurse expect to be elevated in a client who has acute pancreatitis? Select all that apply. A. Amylase B. Bilirubin C. Calcium D. Lipase E. Magnesium F. Glucose

13. A, B, D, F With acute pancreatitis, the pancreatic enzymes amylase and lipase are elevated. Bilirubin also is usually elevated as a result of biliary dysfunction or obstruction. Blood glucose levels are often elevated because pancreatic secretion of insulin is reduced. Most often, magnesium and calcium levels are decreased.

13. Which cardiovascular assessment changes would the nurse expect in an older client? Select all that apply. A. Presence of murmurs B. Atrial dysrhythmias C. Fewer premature ventricular contractions D. Very short QT interval on ECG E. Increased dizziness F. Positive orthostatic blood pressure

13. A, B, E, F Calcification of heart valves can cause murmurs. Pacemaker cells decrease in number which can lead to atrial dysrhythmias and increased (not fewer) premature ventricular contractions. The size of the left ventricle increases which can lead to widened QRS complexes and longer (not shorter) QT intervals. Baroreceptors become less sensitive which can lead to positive orthostatic blood pressure and dizziness as well as fainting.

13. Which questions will the nurse be sure to ask EMS when an unconscious client with a cervical spinal cord injury (SCI) is brought into the emergency department? Select all that apply. A. What was the location and position of the client immediately after the injury? B. Has the family been notified for permission to begin treatment? C. What symptoms occurred immediately after the injury and what changes have occurred since then? D. What type of immobilization equipment was used at the site and were there problems with transport? E. What treatments were given at the site of injury and during transport? F. Does the client have a history of any respiratory problems or difficulties?

13. A, C, D, E, F All of these questions are pertinent to the immediate treatment of the client except option B. While the family must be notified as soon as possible, this is an emergency situation and life- preserving treatment must not be delayed.

13. Which findings must be reported to the health care provider immediately when the nurse assesses several clients using the Glasgow Coma Scale (GCS)? Select all that apply. A. A client's GCS decreases by 3 points B. A client arouses with supraorbital pressure C. A client has fixed nonreactive pupils D. A client has extreme flexion of the upper extremities E. A client asks for pain medication often before the drug is due F. A client is suddenly unable to recall where he or she is now

13. A, C, D, F The Glasgow Coma Scale (GCS) is a tool used in many acute care settings to establish baseline data for these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and should be communicated to the primary health care provider immediately. Other findings requiring urgent communication with the primary health care provider include a new finding of abnormal flexion or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint or dilated nonreactive pupils; and sudden or subtle changes in mental status. A change in level of consciousness is the earliest sign of neurologic deterioration. Communicate early recognition of neurologic changes to the Rapid Response Team or primary health care provider to prevent complications and preserve CNS function.

13. Which potential problems does the nurse assess for when caring for a client whose urine output is less than what is needed as the obligatory urine output? Select all that apply. A. Lethal electrolyte imbalances B. Alkalosis C. Urine becomes diluted D. Toxic buildup of nitrogen E. Increased infection risk F. Acidosis

13. A, D, F The kidney is the main way excess waste products and electrolytes are eliminated from the body. It must cause a 500 to 600 mL output daily for adequate elimination of these products daily. When these products are retained, the consequences include lethal levels of electrolytes, toxic buildup of nitrogen, and retention of hydrogen ions causing acidosis.

13. When the client asks the nurse about the best method of diagnosing heart failure, what teaching would the nurse provide? A. Radionuclide studies B. Echocardiography C. Multigated acquisition (MUGA) scan D. Pulmonary artery catheter

13. B Echocardiography is considered the best tool in diagnosing heart failure. Radionuclide studies (thallium imaging or technetium pyrophosphate scanning) can also indicate the presence and some causes of HF. Multigated acquisition (MUGA) scans, also called multigated blood pool scans, provide information about left ventricular ejection fraction and velocity, which are typically low in clients with HF. Placement of a pulmonary artery catheter is done in an intensive care unit. This catheter can provide direct measures of pressures in the heart and cardiac output.

13. Which dietary changes will the nurse in collaboration with the registered dietitian nutritionist reinforce to the client who has osteoporosis to treat the disorder. Select all that apply. A. Increasing fiber B. Limiting caffeinated beverages C. Increasing leafy green vegetables D. Increasing low-fat dairy products E. Reducing high carbohydrate-containing fruit F. Eliminating eggs and other animal-sourced proteins

13. B, D The specific dietary treatment for osteoporosis is the same as prevention. This focuses on increasing intake of calcium and vitamin D (dairy products) and reducing dietary intake of substances that can reduce blood levels of the mineral and vitamin (i.e., caffeine). Eggs and other proteins are needed to maintain good bone health, as are fruits and vegetables.

13. What is the nurse's first priority when providing care for a client after an esophagogastroduodenoscopy (EGD)? A. Monitoring the client's vital signs every 15 minutes B. Auscultating the client's breath sounds for crackles C. Keeping the client NPO until the gag reflex returns D. Recording accurate intake and output

13. C After an EGD, the nurse's priority of care is to prevent aspiration. The client is kept NPO until the gag reflex returns (usually in 30 to 60 minutes) because an absent gag reflex increases the risk for aspiration. Clients must not be offered fluids or food by mouth until the gag reflex is intact!

13. Which serum electrolyte level is most important for the nurse to monitor closely to prevent harm in a client who has hyperglycemia? A. Sodium B. Chloride C. Potassium D. Magnesium

13. C Although all electrolytes can change as a result of hyperglycemia, potassium changes with either hyperkalemia or hypokalemia cause excitable membrane alterations that can be life threatening, especially in cardiac conduction and skeletal muscle contraction. The nurse must evaluate serum potassium levels most closely to prevent harm.

13. Which functional assessment is a priority when the nurse assesses a client with Parkinson disease and notes masklike face? A. Ability to sense pain in the facial area B. Ability to hear normal voice tones C. Ability to chew and swallow D. Ability to see in a dim lighted environment

13. C Changes in facial expression or a masklike face with wide-open, fixed, staring eyes is caused by rigidity of the facial muscles. In late-stage PD, this rigidity can lead to difficulties in chewing and swallowing, particularly if the pharyngeal muscles are involved. As a result, the client may have inadequate nutrition and uncontrolled drooling may occur.

13. Which factor will the nurse recognize as increasing a client's risk for developing community-acquired pneumonia (CAP)? A. Obtaining an influenza vaccination in November rather than September B. Having received a pneumococcal vaccination C. Using tobacco and alcohol often and regularly D. Living alone and preparing own meals

13. C Chronic tobacco use (especially cigarette smoking) is associated with an increased risk for community-acquired pneumonia by reducing immunity within the pulmonary system. It also increases the inflammatory response with more secretions that provide a nutrient environment for microorganisms. Chronic alcohol consumption also reduces general immunity and may lead to malnutrition, another pneumonia risk factor. Although being immunized against influenza later in the fall, protection against influenza should be sufficient within 3 weeks. Receiving a pneumococcal vaccination reduces pneumonia risk. Living alone and preparing his or own meals does not increase a person's risk for infection or pneumonia.

13. What type of assessment information does the nurse expect to gather when asking a client who has a respiratory problem whether the symptoms are worse at work or at home? A. Exposure to respiratory infections B. Presence of inherited predisposition C. Possible particulate matter exposure D. Possible continuation of a childhood respiratory problem

13. C In using the I-PREPARE model to determine whether a respiratory problem is possibly caused by particulate matter exposure (PME), the nurse investigates all aspects of a client's work history for exposure to industrial dusts, fumes, or chemicals. Occupations with higher risk for exposures include bakers, coal miners, stone masons, cotton handlers, woodworkers, welders, potters, plastic and rubber manufacturers, printers, farm workers, those working in grain elevators or flour mills, and steel foundry workers. A key indicator of PME is when breathing difficulties are less severe when away from the work environment. Answers to this question do not determine whether the problem is inherited, a continuation of a childhood disorder, or infectious in nature.

13. Which client does the nurse recognize has the highest risk for development of prostate cancer? A. 45-year-old Asian American with a history of benign prostatic hyperplasia B. 55-year-old Hispanic American who practices poor dietary intake C. 65-year-old Caucasian American with two cousins who developed prostate cancer D. 75-year-old African American whose father and brother developed prostate cancer

13. D The risk of prostate cancer increases for men who have a first- degree relative (father, brother, son) with the disease, and for African-American men.

14. When the nurse reviews laboratory values for a client with chronic glomerulonephritis, and the serum phosphorus level is 5.3 mg/dL, which other change does the nurse expect to see? A. Serum calcium level is low normal or slightly below normal B. Serum potassium level below the normal range C. Elevated serum sodium levels related to dehydration D. Elevated chloride levels related to elevated sodium

14. A The client's phosphorus level is elevated, so the nurse expects the client's calcium level to below normal, or slightly below normal. This occurs because calcium and phosphorus exist in the blood in a balanced reciprocal relationship. Whenever one electrolyte is elevated, the other is decreased.

14. What is the nurse's priority action when the health care provider orders IV fluids at a rate of 1 mL/kg/hr for 12 hours prior to a CT scan with contrast media for a client who weighs 152 lbs? A. Set the IV pump to deliver fluid at 69 mL/hr. B. Set the IV pump to deliver fluid at 152 mL/hr. C. Call the health care provider for clarification of the order. D. Ask the radiologist for clarification of the order.

14. A The nurse calculates the client's weight in kilograms (152 lb divided by 2.2 = 69 kg). Then the nurse sets the IV pump to run at 69 mL/hr.

14. When the nurse provides care for a client with chronic kidney failure, what assessments will be made that support a finding of fluid overload? Select all that apply. A. Weigh the client and compare to baseline. B. Compare current blood pressure to baseline. C. Measure for residual urine with a bladder scanner. D. Auscultate the lung fields to determine if fluid is present. E. Check for pedal and periorbital swelling. F. Obtain a sterile urine specimen by catheterization.

14. A, B, D, E To assess for fluid overload, the nurse looks at the skin and tissues which may show edema associated with kidney disease, especially in the pedal (foot), pretibial (shin), and sacral tissues and around the eyes (periorbital). A stethoscope is used to listen to the lungs to determine whether fluid is present. The client is weighed and blood pressure measured as a baseline for later comparisons. A client with chronic kidney failure does not make much urine, thus checking for residual urine with a bladder scanner is not necessary. A sterile sample is not needed unless infection is suspected.

14. Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an esophagogastroduodenoscopy (EGD)? Select all that apply. A. Measuring oxygen saturation B. Checking for leakage from the site C. Assessing for return of the gag reflex D. Monitoring heart rate and blood pressure E. Auscultating bowel sounds in all four quadrants F. Comparing weight with that obtained before the procedure

14. A, C, D A client with cirrhosis and ascites is at risk for bleeding and hemorrhage as a result of reduced blood clotting factor synthesis. The endoscope placement for an EGD can irritate or rupture any varices in the esophagus, stomach, or duodenum and lead to hemorrhage. The client must be closely monitored for indications of bleeding and hemorrhage by examining for changes in oxygen saturation, heart rate, and blood pressure. In addition, the procedure is performed under local anesthesia or light sedation and the client's gag reflex is affected.

14. Which early symptoms indicate to the nurse that a client's HF is getting worse and pulmonary edema is developing? Select all that apply. A. Crackles in the lung bases B. Frothy, blood-tinged sputum C. Dyspnea at rest D. Cyanosis E. Disorientation F. Level of crackles rises higher in the lungs

14. A, C, E Assess for and report early symptoms, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion, especially in older clients. Later, the level of the fluid progresses from the bases to higher levels in the lungs as the condition worsens. The client in acute pulmonary edema is typically extremely anxious, tachycardic, and struggling for air. As pulmonary edema becomes more severe, he or she may have a moist cough productive of frothy, blood-tinged sputum; and his or her skin may be cold, clammy, or cyanotic.

14. Which assessment factors for a 62-year-old client would the nurse recognize as modifiable risk factors for heart disease? Select all that apply. A. History of smoking B. Age C. Obesity D. Ethnic background E. Sedentary lifestyle F. Gender

14. A, C, E Modifiable risk factors are personal lifestyle habits, including cigarette smoking, physical inactivity, obesity, and psychological variables. Nonmodifiable (uncontrollable) risk factors include the client's age, gender, ethnic origin, and a family history of cardiovascular disease.

14. Which simple, noninvasive tests will the nurse expect to be ordered to detect H. pylori in a client with PUD? Select all that apply. A. Serologic testing for antibodies B. Abdominal ultrasound C. Urea breath test D. Computerized tomography scan E. Stool antigen test F. Magnetic resonance imaging

14. A, C, E There are three simple, noninvasive tests to detect H. pylori in the client's blood, breath, or stool. Although the breath and stool tests are considered more accurate, serologic testing for H. pylori antibodies is the most common method used to confirm H. pylori infection.

14. When the SpO2 of a client with very dark skin reads 91%, which additional assessments will the nurse perform to determine the client's gas exchange adequacy? Select all that apply. A. Examine the color of oral mucosa. B. Ask the client to rate his or her dyspnea. C. Reapply the pulse oximeter to the earlobe. D. Use capnography to assess end-tidal CO2 levels. E. Examine the color of the sclera closest to the iris. F. Compare the temperature of the right foot to that of the left.

14. A, D The color of the oral mucous membranes is related to blood oxygenation rather than skin pigmentation and can be used to determine whether the client has any degree of cyanosis. Measurement of capnography for end-tidal CO2 levels is a very sensitive indicator of gas exchange adequacy. If this measure is normal, gas exchange is adequate even when pulse oximetry is low. Dyspnea is a subjective sensation and does not accurately indicate adequacy of gas exchange. The earlobe is also pigmented and moving the sensor to the earlobe is not likely to result in an accurate result. The color of the sclera is not related to blood flow and oxygenation. This area is the one used to assess for jaundice, not gas exchange. Foot temperature is not used to assess gas exchange adequacy.

14. For which client is it appropriate for the nurse to teach intermittent self-catheterization? A. 18-year-old client with a severe head injury B. 25-year-old male client with paraplegia C. 48-year-old female client with stress incontinence D. 70-year-old client who wears absorbent briefs

14. B Clients for whom intermittent catheterization or other alternatives to indwelling catheters are considered include those with spinal cord injuries or conditions. The client who performs this procedure must be able and willing to learn, as well as have the dexterity to complete it safely.

14. Which statement by a client to a nurse indicates the need for additional teaching regarding care of a PICC line? A. "My PICC line has a lumen size 4 French so blood samples can be drawn from it." B. "I will be able to rejoin my soccer team as long as I protect the PICC with padding." C. "My PICC line will work for IV antibiotics even up to 14 days." D. "I will be careful to use sterile technique when I change the dressing."

14. B Option B indicates that the client needs additional teaching about the PICC line. While clients will be able to perform their usual activities of daily living (ADLs), they should avoid excessive physical activity (e.g., playing soccer) because of the increased risk for catheter dislodgment and possible lumen occlusion. Options A, C, and D indicate understanding of care for PICC lines.

14. Which clients will the nurse recognize as having a higher risk for development of acute pancreatitis? Select all that apply. A. 26-year-old woman who is a marathon runner B. 34-year-old man with Stage II HIV disease C. 40-year-old woman who has had cholelithiasis for 3 years D. 56-year-old man who drinks alcohol heavily and is underweight E. 62-year-old woman with gastroesophageal reflux disease F. 70-year-old man who has type 2 diabetes

14. B, C, D Although the cause of acute pancreatitis is often unknown, risk factors include viral infection with HIV, long-term cholelithiasis that can lead to obstruction, and alcoholism. Being thin and active is not directly associated with pancreatitis. Neither gastroesophageal reflux disease nor type 2 diabetes increase the risk for acute pancreatitis.

14. Which nursing actions are included in the preoperative care of a male-to-female (MtF) client who will undergo a vaginoplasty? Select all that apply. A. Give nothing by mouth for 24 hours prior to surgery. B. Administer an enema and laxatives as prescribed. C. Instruct the client to ambulate because positioning for surgery will be prolonged. D. Monitor for and report hematocrit and hemoglobin level results. E. Administer preoperative antimicrobials to minimize infection. F. Monitor and record the drainage from the Jackson-Pratt drain.

14. B, D, E Preoperative care for a MtF client having a vaginoplasty includes a bowel preparation which may be started 24 hours before surgery, and may include a clear liquid diet, laxatives, and sodium phosphate/saline enemas. Increased fluids are recommended until the client goes to bed the night before surgery because the bowel preparation can be very dehydrating. Antimicrobials are typically given on the day of surgery to minimize the risk for infection. Adequate hemoglobin and hematocrit (H&H) levels are especially important because some blood is lost during surgery. Jackson-Pratt drainage is monitored postoperatively.

14. At what rate does the nurse set the infusion pump for a client with a spinal cord injury (SCI) to receive the prescribed 500 mL of dextran over 4 hours? A. 75 mL/hr B. 100 mL/hr C. 125 mL/hr D. 150 mL/hr

14. C 500 mL/4 hr = 125 mL/hr

14. Which assessment findings will the nurse expect in a client with chronic a vitamin D deficiency? A. Swollen, bleeding gums B. Reddened and dry conjunctiva C. Osteomalacia, bone pain, and rickets D. Enlargement of the liver and spleen

14. C Activated vitamin D is needed to absorb and use calcium, an element that contributes to bone density. When a client is chronically deficient in vitamin D, bones become soft (osteomalacia), bend (rickets), and bone pain increases.

14. Which diagnostic procedure does the nurse expect will be ordered by the health care provider to view a client's liver, gallbladder, bile ducts, and pancreas for identification of the location of an obstruction? A. Upper gastrointestinal radiographic series B. Percutaneous transhepatic cholangiography C. Endoscopic retrograde cholangiopancreatography D. Esophagogastroduodenoscopy

14. C Endoscopic retrograde cholangiopancreatography (ERCP) includes visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and location of obstruction. After a cannula is inserted into the common bile duct, a radiopaque dye is instilled, and several x-ray images are obtained. The health care provider may perform a papillotomy (a small incision in the sphincter around the ampulla of Vater) to remove gallstones. If a biliary duct stricture is found, plastic or metal stents may be inserted to keep the ducts open. Biopsies of tissue are also frequently taken during this test.

14. Which laboratory test suggests to the nurse that a client with prostate cancer has metastasis to the bone? A. Decreased alpha-fetoprotein B. Increased blood urea nitrogen (BUN) C. Elevated serum alkaline phosphatase D. Decreased serum creatinine

14. C The laboratory test result that suggests metastasis of prostate cancer to the bones is elevated serum alkaline phosphatase levels. These clients also have severe pain.

14. What is the priority nursing concern for a client with Parkinson disease (PD) with right-sided trembling and weakness, as well as dizziness when moving from sitting to standing? A. Decreased ability to perform activities of daily living B. Feelings of isolation and loneliness C. Safety related to possible injury due to falls D. Poor nutritional and fluid intake

14. C The nurse's priority concern for this client with PD is related to safety. The client has right-sided trembling and weakness, as well as experiencing dizziness when first moving from a sitting to a standing position, all of which increases the risk for injuries due to falls.

14. With which client does the nurse remain most alert for an electrolyte imbalance? A. 49-year-old with intermittent asthma who also uses an albuterol inhaler PRN B. 60-year old with a sprained wrist who also takes acetaminophen for pain C. 72-year-old with diabetes mellitus who also takes a diuretic daily D. 80-year-old anemia who also take an iron supplement

14. C This client has three risk factors for an electrolyte imbalance: older adult, endocrine disorder, and takes a diuretic daily, which alters fluid and electrolyte excretion. Although the 80- year-old has an increased risk because of age, he or she has no other specific risk factors listed.

14. Which client assessment findings alert the nurse to the possibility of uncomplicated community-acquired pneumonia (CAP)? Select all that apply. A. Abdominal pain B. Back pain C. Chest discomfort D. Dyspnea E. Increased sputum production F. Fever

14. C, D, E, F Common uncomplicated community-acquired pneumonia signs and symptoms include chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. Abdominal pain is not associated with pneumonia. Back pain is only present when pneumonia is complicated by pleural inflammation.

14. Which action will the nurse perform next when an obese client's popliteal pulse on one side cannot be palpated? A. Palpating the popliteal pulse on the opposite side B. Attempting to assess the pedal pulse on the same side C. Notifying the primary health care provider immediately D. Using a Doppler to assess blood flow in that popliteal space

14. D The popliteal pulse may be difficult to palpate in an obese client. The next best action is to assess this pulse using a Doppler device. Although other assessment findings on that limb, such as checking for a pedal pulse, can help determine whether general blood flow is adequate, it does not establish whether or not there is a problem in that specific artery.

14. What is the nurse's first priority action when assessing a client and finding unilateral loss of motor function and sensation? A. Apply oxygen at 2 L per nasal cannula. B. Order a stat computed tomography scan. C. Place the client in semi-Fowler position. D. Immediately notify the health care provider.

14. D When the nurse discovers a sudden unilateral (one side of the body) loss in motor function and sensation, it is an emergency situation requiring a stroke center and staff with expertise to diagnose and intervene during a stroke or "brain attack." Immediately notifying the health care provider will get the client evaluated by stroke experts and rapid treatment. Oxygen and semi-Fowler position may be of value, but the highest priority is notification of the health care provider and the stroke expert team who will likely order a CT scan and provide rapid treatment.

15. What nutritional deficiency does the nurse suspect when a client reports recent onset of alopecia? A. Zinc B. Vitamin A C. Riboflavin D. Vitamin C

15. A Hair loss is one of the first indicators of a zinc deficiency.

15. In which situations will the nurse appropriately insert a urinary catheter into a client? Select all that apply. A. Acute urinary retention or bladder obstruction B. Accurate measurement of urine volume in critically ill clients C. To manage clients who are incontinent D. To assist in healing of open sacral wounds in incontinent clients E. To provide comfort at end of life F. Perioperatively for gynecological surgeries

15. A, B, D, E, F All of these situations are appropriate for insertion of a urinary catheter except for option C, the management of incontinence. There are many other strategies and interventions that can be used successfully to treat incontinence. Remember that the longer a urinary catheter is in place, the more risk for the client to develop a urinary tract infection (UTI).

15. Which major components and precautions of the catheter-related bloodstream infection (CRBSI) prevention bundle must the specially trained nurse follow when inserting a PICC line into a client? Select all that apply. A. Measuring upper arm circumference as a baseline before insertion B. Betadine skin antisepsis C. Proper aseptic hand hygiene D. Maximal barrier precautions on insertion E. Optimal catheter site selection F. Daily review of line necessity with prompt removal of unnecessary lines

15. A, C, D, E, F All options are appropriate and part of the catheter-related bloodstream infection (CRBSI) prevention bundle, except option B which should be chlorhexidine skin antisepsis (not betadine).

15. Which teaching points will the nurse include when instructing a client about preparation for a colonoscopy? Select all that apply. A. "Avoid taking aspirin, NSAIDs, or anticoagulants for several days before the test." B. "Drink lots of red, orange, or purple beverages the day before the test." C. "Do not eat or drink for 4 to 5 hours before the test." D. "After the bowel-cleansing solutions, you may develop constipation for 1 to 2 days." E. "Drink only clear liquids the day before the colonoscopy." F. "An IV will be placed to give medication to help you relax during the procedure."

15. A, C, E, F Clients are instructed to avoid aspirin, anticoagulants, and antiplatelet drugs for several days before the procedure. The health care provider will prescribe the specific method of preparation of the bowel which begins the night before the procedure. Drinkable solutions can be chilled to improve taste. Teach the client to have a clear liquid diet the day before the scheduled colonoscopy. The nurse instructs him or her to avoid red, orange, or purple (grape) beverages or gelatin. The client should be NPO for several hours before the procedure, based on the health care provider's instructions. Watery diarrhea usually begins about an hour after starting the bowel preparation process. In some cases, the client may also require laxatives, suppositories (e.g., bisacodyl), or one or more small-volume cleansing enemas. Intravenous access is necessary for the administration of moderate sedation. The health care provider prescribes drugs to aid in relaxation during the procedure.

15. Which actions will the nurse take to help relieve the severe pain in a client with acute pancreatitis? Select all that apply. A. Maintaining the client on NPO status B. Administering oral NSAIDs around the clock C. Inserting a nasogastric (NG) tube to low suction D. Providing opioids by patient-controlled analgesia E. Administering pancreatic enzyme replacement therapy F. Assisting the client to a side-lying position with knees drawn up to the chest

15. A, D, F Pain can be reduced by preventing pancreatic stimulation by keeping the client NPO. Opioids are needed for severe pain and are best provided by PCA. Clients may obtain some pain relief from a side-lying position with the knees drawn closely to the chest. NSAIDs are not used and pancreatic enzyme replacement therapy would only make the pancreatitis worse at this time. NG tube placement is reserved for only those clients who have continuous vomiting or biliary obstruction.

15. Which interventions would the nurse expect to include in the care of a client with pulmonary edema caused by HF? Select all that apply. A. Sodium restriction B. Fluid restriction C. Administration of potassium supplement D. Position client in semi-Fowler or high-Fowler E. Weekly weight monitoring F. Administration of loop diuretics

15. A, D, F Reducing sodium and water retention will decrease the workload of the heart. The primary health care provider may restrict sodium intake in an attempt to decrease fluid retention. Weigh the client daily. Remember that 1 kg of weight gain or loss equals 1 liter of retained or lost fluid. The same scale should be used every morning before breakfast for the most accurate assessment of weight. Loop diuretics such as furosemide, torsemide, and bumetanide are most effective for treating fluid volume overload. If the client has dyspnea, place in a high-Fowler position with pillows under each arm to maximize chest expansion and improve gas exchange. Potassium supplements may be needed for potassium replacement, but it does not improve pulmonary edema.

15. What sound does the nurse expect to hear when listening over the renal artery of a client who has renal artery stenosis? A. Quiet, pulsating sound B. Swishing sound C. Occasional gurgling D. Faint wheezing

15. B A bruit is an audible swishing sound produced when the volume of blood or the diameter of the blood vessel changes. It often occurs with blood flow through a narrowed vessel, as in renal artery stenosis.

15. Which drugs will the nurse expect to administer to a client with PUD, caused by an H. pylori infection, who is prescribed PPI-triple therapy? A. A proton pump inhibitor, two antibiotics, and bismuth B. A proton pump inhibitor and two antibiotics C. An opioid drug, proton pump inhibitor, and an antibiotic D. An H2 histamine blocker, an antibiotic, and a proton pump inhibitor

15. B A common drug regimen for H. Pylori infection is PPI-triple therapy, which includes a proton pump inhibitor (PPI), such as lansoprazole, plus two antibiotics such as metronidazole and tetracycline or clarithromycin and amoxicillin for 10 to 14 days.

15. Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary health care provider? A. Sodium 133 mEq/L (mmol/L) B. Potassium 6.4 mEq/L (mmol/L) C. Chloride 101 mEq/L (mmol/L) D. Calcium 8.9 mg/dL (2.2 mmol/L)

15. B Although the sodium and calcium levels are slightly low, they do not pose a significant risk at this time. The serum potassium level is well above normal, which may be related to the spironolactone therapy because it causes sodium excretion and potassium retention, and must be reported to the primary health care provider immediately. The serum chloride level is normal.

15. For which client does the nurse avoid harm by not performing a sharp and dull sensory for pain assessment? A. Client with pulses that are not palpable in the distal extremities B. Client who is prescribed anticoagulant therapy and bruises easily C. Client who is sensitive to pain and temperature changes D. Client who is unable to move the affected or injured side

15. B Before testing for pain using the dull and sharp method, the nurse must check to determine whether the client is on anticoagulant therapy. If so, the nurse avoids any testing with a sharp object because it can cause bleeding.

15. To prevent harm, which prescribed drug would the nurse question for an older client with Parkinson disease (PD)? A. Bromocriptine mesylate B. Benztropine C. Amantadine D. Levodopa-carbidopa

15. B For severe motor symptoms such as tremors and rigidity, one of the older anticholinergic drugs may be prescribed, but they are rarely used as primary drugs of choice for PD. Examples are benztropine, trihexyphenidyl HCl, and procyclidine. These drugs should be avoided in older adults because they can cause acute confusion, urinary retention, constipation, dry mouth, and blurred vision. The nurse would be sure to clarify a prescription for this drug written for an older adult with PD.

15. Which actions will the nurse delegate to the assistive personnel (AP) for appropriate care of a client with acute glomerulonephritis? A. Teaching how to collect a 24-hour urine specimen B. Weighing the client every morning with the same scale C. Assessing for changes in the urine sample D. Evaluating the client's ability to safely get to the bathroom

15. B The scope of practice for an AP includes assisting with activities of daily living, weighing the client, assisting to the bathroom and other ambulation. The nurse instructs the AP to weigh the client every morning at the same time, wearing the same amount of clothes, and using the same scale. Teaching, assessing, and evaluating are higher level skills performed by the professional RN.

15. Which questions would the nurse ask to assess a client's nicotine dependence? Select all that apply. A. "What brand of cigarettes do you smoke?" B. "Do you smoke even when you are ill?" C. "How soon after you wake up in the morning do you smoke?" D. "What happened the last time you tried to quit smoking?" E. "Do you wake up in the middle of the night to smoke?" F. "Do you find it difficult not to smoke in places where smoking is prohibited?"

15. B, C, E, F Determine nicotine dependence by asking questions such as: How soon after you wake up in the morning do you smoke?; Do you wake up in the middle of the night to smoke?; Do you find it difficult not to smoke in places where smoking is prohibited?; and Do you smoke even when you are ill?

15. Which activity does the nurse ask a client to perform when assessing range of motion (ROM) in the hand? A. Gripping the nurse's hand as hard as possible B. Rapidly rotating the hand from palm up to palm down C. Apposing each finger to thumb and then making a fist D. Waving the hand from side to side as though waving goodbye

15. C A quick way to assess range of motion in the hand is by asking the client to perform two separate maneuvers. One is making a fist. The other is bringing each fingertip separately to appose the thumb. Gripping is a way to assess strength but not ROM. Waving and rotating the hand palm up and palm down assesses some ROM of the wrist but not of the fingers.

15. Which priority action will the nurse take to help prevent the complication of pneumonia for a client who is postoperative from extensive abdominal surgery? A. Monitoring chest x-rays and WBC counts for early signs of infection B. Monitoring lung sounds every shift and encouraging fluids C. Teaching coughing, deep-breathing exercises, and use of incentive spirometry D. Encouraging hand hygiene among all caregivers, clients, and visitors

15. C All actions listed are helpful for pneumonia prevention. However, the most common cause of pneumonia after abdominal surgery is decreased mobility causing atelectasis and pulmonary fluid stasis. This noninfectious type of pneumonia can be prevented by having the postoperative client cough, turn, move about as much as possible, and perform deep-breathing exercises, such as the use of incentive spirometry.

15. Which client report indicates to the nurse that one of the most serious complications of vaginoplasty has occurred? A. Burning sensation during urination B. Urinary incontinence when sneezing C. Leakage of stool from the vagina D. Tenderness and bruising of the labia

15. C One of the worst complications is a vaginal-rectal fistula, which is caused by rectal perforation during surgery. The nurse teaches a client to report any leakage of stool into the vagina immediately to their surgeon.

15. How will the nurse document the respiratory assessment findings on auscultation that are heard as squeaky, musical continuous sounds when the client inhales and exhales? A. Fine crackles B. Coarse crackles C. Wheezes D. Rhonchi

15. C Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Fine crackles are heard as popping, discontinuous high-pitched sounds at the end of inhalation. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.

15. Which instruction is most appropriate for the nurse to teach a client prescribed to take alendronate 10 mg daily? A. "Be sure to rotate injection sites every week." B. "Be sure to take the drug 1 hour before or at least 2 hours after a meal." C. "Remain in the upright position for at least 30 minutes after taking the drug." D. "Report any headaches you experience to your primary health care provider immediately."

15. C This drug, along with all others in the bisphosphonate class, greatly increases the risk for esophagitis, esophageal ulcers, and gastric ulcers. The drug must be taken with food and not on an empty stomach. Having the client remain in the upright position after taking the drug helps prevent stomach contents from refluxing back into the esophagus and irritating it.

15. Which electrolyte change does the nurse expect to see in a client who produces excessive amounts of aldosterone? A. Low serum sodium level B. High serum potassium level C. Low serum calcium level D. High serum sodium level

15. D Aldosterone increases sodium and water reabsorption in the kidney. Higher than normal levels of this hormone usually result in high serum sodium levels.

16. Which instruction would the nurse give the assistive personnel (AP) who is helping a client with HF and excessive aldosterone secretion? A. Restrict the client's fluids to 2 L/day and keep accurate intake and output. B. Severely restrict fluids to 500 mL of fluid plus the client's urine output from the past 24 hours. C. Give the client as much water as he or she wants to prevent dehydration. D. Frequently offer the client ice chips and moistened mouth swabs and limit fluids to 1 L/day.

16. A Clients with excessive aldosterone secretion may experience thirst and drink 3 to 5 liters of fluid each day. As a result, their fluid intake may need to be limited to a more normal 2 L/day. Supervise assistive personnel (AP) to ensure that they limit the prescribed intake and accurately record intake and output.

16. With which interprofessional health care member will the nurse collaborate to assess a client's strength? A. Physical therapist B. Orthopedic surgeon C. Skin care specialist nurse D. Neurology technician

16. A The nurse collaborates with the physical therapist to test the client's strength. When testing strength against resistance, ask the client to resist the examiner's bending or straightening of the arm, hand, leg, or foot being tested. A five-point rating scale is commonly used. Always evaluate and compare strength on each side. Compare previous results with current findings and report all decreases to the primary health care provider. An orthopedic surgeon is not needed to assist in strength testing and nor is a skin care specialist.

16. Which actions will the nurse include when providing care for a client after a colonoscopy procedure? Select all that apply. A. Checking vital signs every 15 to 30 minutes until the client is alert B. Keeping client in left lateral position to promote passing of flatus C. Assessing for signs and symptoms of bowel perforation, including severe abdominal pain and guarding D. Preventing the client from taking anything by mouth until sedation wears off E. Keeping the top side rails up until the client is alert F. Holding the client 6 to 8 hours before allowing him or her to drive home

16. A, B, C, D, E All of these options must be included in the care provided to the client after colonoscopy except option F. If the procedure is performed in an ambulatory care setting, another person must drive the client home because of the action of IV drugs given to help with relaxation during the procedure.

16. Which actions will the nurse implement to minimize catheter- associated urinary tract infections (CAUTI) on a client care unit? Select all that apply. A. Leaving urinary catheters in place only as long as needed B. Using sterile equipment in the acute care setting when inserting a urinary catheter C. Maintaining a closed system by ensuring that catheter tubing connections are sealed securely D. Emptying the bag regularly, using a separate, clean container for each client E. Ensuring that the drainage spigot does not come into contact with nonsterile surfaces F. Securing the catheter to the client's thigh (women) or lower abdomen (men)

16. A, B, C, D, E, F All of these options are appropriate actions for the nurse to implement to prevent the occurrence of CAUTIs. For additional suggestions, see Best Practice for Patient Safety & Quality Care Minimizing Catheter-Associated Urinary Tract Infections (CAUTI) in your text.

16. Which priority actions will the nurse take to manage a client's active upper GI bleeding? Select all that apply. A. Administering oxygen B. Starting two large-bore IV lines C. Infusing 0.9% normal saline solution as prescribed D. Collecting a urine sample for urinalysis E. Inserting a nasogastric tube (NGT) F. Monitoring serum electrolytes

16. A, B, C, E The nurse understands that a client with an active GI bleed has a life-threatening emergency and needs supportive therapy to prevent hypovolemic shock and possible death. The priority for care of this client is to maintain airway, breathing, and circulation (ABCs). Collecting urine for urinalysis is not a priority at this time, nor is monitoring serum electrolytes. Options A, B, C, and E are appropriate actions for this emergency situation. See the section in your text entitled Emergency: Upper GI Bleeding for more information.

16. After a transrectal ultrasound with biopsy for prostate cancer, what instructions will the nurse provide the client? Select all that apply. A. Report fever, chills, bloody urine, and any difficulty voiding. B. The biopsy will diagnose if you have prostate cancer. C. Drink plenty of fluids during the first 24 hours. D. Expect to see bright red bleeding at first. E. Report any pink color in the urine to the health care provider. F. Avoid strenuous physical activity.

16. A, B, C, F After a transrectal ultrasound with biopsy, the nurse teaches a client to report fever, chills, bloody urine, and any difficulty voiding. He is advised to avoid strenuous physical activity and to drink plenty of fluids, especially in the first 24 hours after the procedure. The nurse teaches that a small amount of bleeding turning the urine pink is expected during this time. Bright red bleeding should be reported to the health care provider immediately. The biopsy provides an accurate diagnosis for prostate cancer.

16. Which specific signs and symptoms does the nurse expect to see in an 80-year-old client admitted with bacterial pneumonia? Select all that apply. A. Confusion B. Decreased oxygen saturation C. Productive cough D. Weakness and fatigue E. Elevated white blood cell (WBC) count F. Fever

16. A, B, D The older adult with pneumonia has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and an elevated WBC count are often absent initially because of the older client's reduced immune and inflammatory responses (the WBC count may not be elevated until the infection is severe). The older client often does not cough with pneumonia, but hypoxemia is often present.

16. Which actions will the nurse expect when a client with Parkinson disease (PD) develops drug toxicity or tolerance? Select all that apply. A. A reduction in drug dosage B. Complete cessation of all drugs used to treat PD symptoms C. A change of drug or in the frequency of administration D. A drug holiday (particularly with levodopa therapy) E. Prescription of additional drugs to help relieve symptoms associated with the disease F. Implementation of exercise therapy to maintain functional abilities

16. A, C, D, E When drug tolerance is reached, the drug's effects do not last as long. The treatment of PD drug toxicity or tolerance includes: a reduction in drug dosage; a change of drug or in the frequency of administration; and a drug holiday (particularly with levodopa therapy). During a drug holiday, which can last up to 10 days, the client receives no drug therapy for PD and the nurse would carefully monitor the client for symptoms of PD and document assessment findings. Many clients are on additional drugs to help relieve symptoms associated with the disease (e.g., muscle spasms may be relieved by baclofen, drooling can be minimized by sublingual atropine sulfate, and insomnia may require a sleeping aid such as zolpidem tartrate).

16. Which aspects will the nurse include when assessing the neurovascular status of a client's right limb after diagnostic arthroscopy 1 hour ago? Select all that apply. A. Presence of pain B. Gait and balance C. Distal pulses D. Capillary refill E. Sensation F. Skin temperature

16. A, C, D, E, F After arthroscopy for either diagnostic or surgical intervention purposes, the nurse assesses the neurovascular status on a regular basis to prevent harm from poor circulation in the extremity or any possible nerve damage. Assessment includes monitoring distal pulses, warmth, color, capillary refill, pain, movement, and sensation of the affected extremity. Neurovascular assessment does not include gait and balance.

16. Which serum electrolyte finding on a newly admitted client does the nurse report immediately to the health care provider? Select all that apply. A. Potassium 2.8 mEq/L (mmol/L) B. Sodium 143 mEq/L (mmol/L ) C. Calcium 9.9 mg/dL (2.59 mmol/L) D. Chloride 101 mEq/L (mmol/L) E. Chloride 98 mEq/L (mmol/L) F. Magnesium 1.2 mEq/L (0.7 mmol/L)

16. A, F The serum potassium and serum magnesium levels are both lower than normal (potassium = 3.5 to 5.0 mEq/L or mmol/L; magnesium = 1.8 to 2.6 mEq/L or 0.74 to 1.07 mmol/L). Low levels of these electrolytes can have profound effects on heart function. All other electrolytes listed are within the normal range.

16. For which client with osteoporosis will the nurse question the primary health care provider's prescription for calcium and vitamin D supplementation? A. 40-year-old with diabetes mellitus B. 50-year-old with urinary stones C. 55-year-old with esophageal ulcers D. 65-year-old with venous thromboembolism

16. B Increasing serum calcium levels can exacerbate the development of urinary stones in a client who has a history of stone formation.

16. Which assessment finding in a client with long-standing diabetes will the nurse interpret as an early sign of diabetic nephropathy? A. Positive urine red blood cells B. Microalbuminuria C. Positive urine glucose D. Positive urine white blood cells

16. B Microalbuminuria is the most common and reliable indicator of diabetic nephropathy. Red blood cells and white blood cells in the urine are indicators of urinary tract infection and not specific to nephropathy. Presence of glucose in the urine is more of an indication of hyperglycemia and not of the early stages of diabetic nephropathy.

16. Which statement by a client to the nurse indicates an understanding of cigarette usage related to cardiovascular risks? A. "I don't smoke as much as I used to and I'm down to half a pack a day." B. "I need to be completely cigarette free for at least 3 years." C. "I started smoking a few years ago but I plan to quit in a year or two." D. "I smoke to relax like when I go out with friends or when I drink."

16. B Three to four years after a client has stopped smoking, his or her CVD risk appears to be similar to that of a person who has never smoked. The client is still smoking in the other responses and is still at risk for CVD.

16. Which information will the nurse include when teaching a client who had a vaginoplasty about self-care management? Select all that apply. A. Do not take baths (submerged in water) for 8 months after surgery. B. Avoid tobacco or smoking for at least a month after surgery to promote healing. C. Carefully follow the prescribed individualized dilator protocol. D. Do not have sexual intercourse until at least 3 months after surgery. E. Avoid swimming or bike riding for 3 weeks. F. Take acetaminophen as prescribed for pain control at home.

16. B, C, D, F See the box titled Best Practice for Patient Safety & Quality Care Postoperative Teaching for Clients Who Have a Vaginoplasty in your text for a list of postoperative teaching that the nurse must include for a client who has a vaginoplasty. Option A is not correct because the client should not take a bath for 8 weeks postoperatively, and option E is not correct because swimming and bike riding should be avoided for 3 months.

16. Which techniques will the nurse instruct the family who will be caring for an 88-year-old female client who has severe osteoarthritis, muscle weakness, and dementia to use to improve nutrition and prevent harm? Select all that apply. A. "Be sure to keep her in bed while eating to prevent her from becoming over tired." B. "Let her feed herself as much as possible even if she uses her fingers." C. "Always include some foods that you know she likes for every meal." D. "Withhold her pain medications before meals to prevent nausea." E. "If she doesn't finish a meal in 20 minutes, take the food away." F. "During meals, be sure she has her glasses and hearing aid on."

16. B, C, F Clients are more likely to eat when they enjoy the experience and have some control over the process. Clients are encouraged to feed themselves whenever it is possible and to eat food that they like. Wearing prescribed glasses and hearing aids increase sensory perception, which can help hold the client's interest in eating. Having the client up in a chair for meals, rather than in bed, improves movement through the GI tract, reduces the risk for aspiration, and helps keep the client awake. Clients are more likely to eat if they are not in pain. Giving prescribed pain medication an hour to 30 minutes before meals can increase the comfort. The family is instructed to let the client eat at her own pace. Hurrying the client can result in an increased risk for aspiration, as well as make the experience less pleasant.

16. Which findings noted during assessment of a client who reports a respiratory problem will the nurse document as abnormal? Select all that apply. A. Moveable trachea B. Use of pursed-lip breathing C. Intercostal space two finger-breadths wide D. Flat percussive sound in the upper center chest E. No breath sounds heard below the diaphragm F. Rough scratching sounds over the right lower lobe

16. B, C, F The trachea should be midline and slightly moveable. Pursed-lip breathing is abnormal and generally used only in clients who have obstructive disease with air trapping. The space between the ribs (intercostal space) should be only one finger-breadth wide. A flat percussive sound is expected in the upper center chest because the sternum is located there. No breath sounds are heard below the diaphragm because the lungs are located above the diaphragm. Rough scratching sounds heard over the right lower lobe are an abnormal sound known as a pleural friction rub.

16. Which is the best technique for the nurse to use when assessing a client for bladder distention? A. Use one hand to gently depress the bladder as the client takes a deep breath, then percuss as the client slowly exhales. B. Place one hand under the client's back and palpate with the other hand over the bladder, percussing the lower abdomen until tympanic sounds are no longer heard. C. Gently palpate the outline of the bladder and percuss the lower abdomen toward the umbilicus until dull sounds are no longer produced. D. Locate the symphysis pubis, gently palpate for outline of the bladder, then auscultate for bowel sounds in the lower abdomen.

16. C A distended bladder sounds dull when percussed. After gently palpating to determine the outline of the distended bladder, the nurse begins percussion on the lower abdomen and continues in the direction of the umbilicus until dull sounds are no longer produced. If the nurse suspects bladder distention, a portable bladder scanner is used to determine the amount of retained urine.

16. Which health problem does the nurse suspect when a client with decreased kidney function has increased proteinuria, decreased serum albumin, lipids in blood and urine, increased aPTT and INR, facial edema, and hypertension? A. Glomerulonephritis B. Pyelonephritis C. Nephrotic syndrome D. Chronic kidney failure

16. C Signs and symptoms of nephrotic syndrome (NS) include sudden onset of: massive proteinuria; hypoalbuminemia; edema (especially facial and periorbital); lipiduria; hyperlipidemia; delayed clotting or increased bleeding with higher-than-normal values for serum activated partial thromboplastin time (aPTT) coagulation or international normalized ratio for prothrombin (INR, PT); and reduced kidney function with elevated blood urea nitrogen (BUN) and serum creatinine and decreased glomerular filtration rate (GFR).

16. Which actions will the nurse perform when preparing a client for paracentesis? Select all that apply. A. Obtaining informed consent B. Maintaining the client on NPO status C. Asking the client to void before the procedure D. Placing the client in the flat supine position E. Weighing the client before the procedure F. Assessing the respiratory rate and blood pressure

16. C, E, F Vital signs, including weight, are taken before the procedure to use as a baseline for changes after the procedure. Weight is important because it can help determine the volume of fluid removed (clients are expected to weigh less after a paracentesis). Having the client void before procedure helps prevent injury to the bladder. The health care provider performing the paracentesis is responsible for obtaining informed consent, not the nurse. The client does not need to be NPO before the procedure. The client is positioned with the head of the bed elevated.

16. Which technique is recommended by the Infusion Nurses Society (INS) for the nurse to maintain a PICC line for a client receiving IV antibiotic therapy every 4 hours? A. Flush the catheter with 10 mL heparinized saline after each dose of antibiotic. B. Flush the catheter every 12 hours using a 5-mL syringe. C. Avoid flushing the catheter with heparinized saline more than twice a week. D. Use 10 mL of sterile saline to flush before and after each dose of antibiotic.

16. D The INS recommends that PICC lines not actively in use be flushed with 5 mL of heparin (10 units/mL) in a 10-mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. Use 10 mL of sterile saline to flush before and after medication administration; 20 mL of sterile saline to flush after drawing blood. Always use 10-mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk for rupturing the catheter.

17. With which client condition will the nurse remain most alert for insensible water loss? A. Continuous GI suctioning B. Deep respirations C. Receiving oxygen therapy D. Hypothermia

17. A Continuous gastric suctioning removes fluid before it is absorbed into the body, which decreases fluid intake by the oral route. This ongoing fluid loss, if not measured as replaced by another route, can result in a fluid volume deficit.

17. When the nurse reviews the laboratory results and finds that a client with chronic kidney disease (CKD) has a serum potassium level of 8 mEq/L (mmol/L), which assessment will be completed before notifying the health care provider? A. Cardiac rhythm B. Respiratory rate and depth C. Tremors of the hands D. Change in urine appearance

17. A Normal potassium level is within 3.5 to 5 mEq/L (mmol/L). With CKD, high potassium (K+) levels can develop quickly, reaching 7 to 8 mEq/L (mmol/L) or greater. Life-threatening changes in cardiac rate and rhythm result from K+ elevation because of abnormal depolarization and repolarization.

17. Which chest x-ray finding will the nurse expect to see for a client suspected to have pneumonia? A. Patchy areas of increased density B. "Ground-glass" appearance of the lung C. Mediastinal widening D. Large hyperinflated airways

17. A The classic chest x-ray findings for a client with pneumonia is patchy areas of increased density in the involved lung areas. A "ground-glass" appearance is associated with acute respiratory distress syndrome. Mediastinal widening is associated with inhalation anthrax. Large, hyperinflated lungs occur with chronic obstructive pulmonary disease.

17. What is the nurse's best response when a client who is scheduled for an ultrasound to identify whether osteomyelitis is present states that she is afraid of the pain the procedure will cause? A. "This procedure does not involve needles or incisions and is usually painless." B. "There would only be pain with this procedure if you don't remain perfectly still." C. "A small amount of numbing medicine will be applied to the skin before the procedure." D. "The same medication your dentist uses will be injected 10 minutes before the needle is inserted."

17. A Ultrasonography is noninvasive and involves rolling a probe on the skin over the area to be imaged. Ultrasound jelly is applied to the skin over the site to be examined to reduce the friction of the probe and make movement smoother. Although clients report a cold sensation, pain is not expected, and no special preparation necessary.

17. What are the priority nursing actions related to caring for an older adult client with HF who is prescribed digoxin? Select all that apply. A. Monitor the ECG strip for early signs of toxicity such as bradycardia. B. Auscultate the apical pulse heart rate and rhythm for a full minute before administering the drug. C. Observe for signs of toxicity, which are often nonspecific such as anorexia, fatigue, and blurred vision. D. Report any changes in heart rate or rhythm to the health care provider. E. Monitor serum digoxin and potassium levels. F. Check the health care provider's prescription for parameters to hold the drug.

17. A, B, C, D, E, F All of these responses are appropriate to the care of an older adult with heart failure who has been prescribed digoxin. Often the cardiac health care provider will have the nurses hold a client's digoxin dose if the heart rate is less than 50 to 60 beats/min.

17. Which equipment and actions will the nurse use to assess a female client's urethra prior to inserting a urinary catheter? Select all that apply. A. Ensure a good light source is available. B. Record any discharge from the meatus. C. Assess for lesions or rashes and record. D. Remind the client to wipe from back to front. E. Ask about discomfort with urination. F. Wear well-fitting gloves during the assessment.

17. A, B, C, E, F Using a good light source and wearing gloves, the nurse inspects the urethra by examining the meatus and the tissues around it. Any unusual discharge such as blood, mucus, or pus is noted and recorded. The skin and mucous membranes of surrounding tissues are inspected. The nurse records the presence of lesions, rashes, or other abnormalities of the labia or vaginal opening. Urethral irritation is suspected when the client reports discomfort with urination. The nurse uses this opportunity to remind female clients to clean the perineum by wiping from front to back (not back to front). The client is taught that the front-to-back technique keeps organisms in stool from coming close to the urethra and decreases the risk for infection.

17. With which signs and symptoms will the nurse teach a client to take action to prevent harm as indicators of mild hypoglycemia? Select all that apply. A. Headache B. Weakness C. Cold, clammy skin D. Irritability E. Pallor F. Tachycardia

17. A, B, D The earliest signs and symptoms of mild hypoglycemia are associated with changes in neurologic functioning including headache, sensation of hunger, irritability, and weakness. The other symptoms listed are present when hypoglycemia becomes more severe.

17. Which tasks will the nurse delegate to the assistive personnel (AP) when caring for a client with stage 3 moderate Parkinson disease? Select all that apply. A. Assist client to the bathroom. B. Record accurate intake and output. C. Teach the client about safety precautions. D. Assist client with activities of daily living as needed. E. Assess client's gait and posture. F. Check and record client's vital signs every 4 hours.

17. A, B, D, F To correctly respond to this question, the nurse must be familiar with the AP's scope of practice which includes assisting clients with ambulation, activities of daily living, recording intake and output, and checking as well as recording vital signs. Assessment and teaching for clients requires the additional training and skills of a professional RN.

17. Which nursing and collaborative actions are implemented by the nurse when caring for a client with nephrotic syndrome (NS)? Select all that apply. A. Administration of mild diuretics B. Fluid restrictions C. Frequent assessment of hydration status D. Administration of angiotensin-converting enzyme inhibitors E. Collection of urine sample for culture F. Assessment for periorbital swelling

17. A, C, D, F Angiotensin-converting enzyme inhibitors (ACEIs) can decrease protein loss in the urine and lower blood pressure for clients with NS. Mild diuretics and sodium restriction may be needed to control edema (facial and periorbital) and hypertension. The nurse assesses the client's hydration status because vascular dehydration is common.

17. Which clients will the nurse expect to be prescribed total enteral nutrition (TEN) to help attain or maintain an adequate nutrition status? Select all that apply. A. 28-year-old who remains comatose 10 days after a head injury B. 38-year-old with esophageal strictures and an intestinal blockage C. 48-year-old who eats all meals but remains 22 lb (10 kg) underweight D. 58-year-old who has lung cancer and cachexia E. 68-year-old with no teeth or dentures F. 78-year-old who cannot swallow after a stroke

17. A, C, D, F As long as the stomach and lower GI system are functioning, clients can receive TEN to provide all or part of their nutritional needs regardless of their level of consciousness, if they are unable to meet these needs by eating (clients in options C and F). The client with an intestinal blockage should be NPO and may require parenteral nutrition. The client who has no teeth or dentures can use liquids, semisolids, soft foods, and chopped or minced foods that require no chewing. The client with lung cancer and cachexia can receive TEN if he or she chooses to do so.

17. Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? Select all that apply. A. Decreased confusion B. Increased urine output C. Musty odor to the breath D. Two to three soft stools daily E. Lower serum bilirubin levels F. Lower serum ammonia levels

17. A, D, F Lactulose helps reduce encephalopathy by increasing stools, which causes the loss of some nitrogen-producing bacteria in the intestinal tract. This loss reduces ammonia levels and helps decrease confusion. Lactulose does not affect serum bilirubin levels or increase urine output. A musty odor of the breath (fetor hepaticus) is an indication of worsening encephalopathy.

17. Which complication in a client with acute necrotizing pancreatitis who develops a temperature spike to 104°F (40°C) will the nurse suspect? A. Pancreatic pseudocyst B. Pancreatic abscess C. Chronic pancreatitis D. Pancreatic cancer

17. B A sudden temperature elevation in a client with acute necrotizing pancreatitis is a strong indicator of pancreatic abscess that develops as a secondary bacterial infection with suppuration and pus formation of the necrotic pancreatic tissue. This condition can lead to sepsis and multiple organ dysfunction syndrome (MODS).

17. What is the nurse's best action when assessing a client after open radical prostatectomy and finding scrotal and penile swelling? A. Notify the health care provider and monitor for inability to urinate. B. Elevate the scrotum and penis, then apply ice to the area intermittently. C. Assist the client to increase mobility by using early ambulation. D. Observe the urethral meatus for redness, discharge, and abnormal output.

17. B After open radical prostatectomy, when the nurse assesses and finds swelling of the scrotum and penis, the best action is to elevate the scrotum and penis and apply ice to the area intermittently for the first 24 to 48 hours. The cause of this swelling is from the disrupted pelvic lymph flow.

17. Which client does the nurse monitor carefully because of high risk for developing a complicated urinary tract infection (UTI)? A. 26-year-old male who is sexually active but consistently uses condoms B. 28-year-old male who has a neurogenic bladder due to a spinal cord injury C. 35-year-old woman who has had three full-term deliveries and one miscarriage D. 53-year-old woman who has some menstrual irregularities

17. B Neurogenic bladder is among the factors that contribute to a diagnosis of complicated UTI.

17. What is the best term for the nurse to use when documenting a client's paralysis of both lower extremities? A. Paraparesis B. Paraplegia C. Quadriparesis D. Quadriplegia

17. B The term for bilateral lower extremity paralysis is paraplegia. Paraparesis is weakness of the lower extremities. Paraplegia and paraparesis are seen in lower thoracic and lumbosacral injuries or lesions. Tetraplegia (also called quadriplegia) is paralysis of all four extremities. Quadriparesis refers to weakness involving all four extremities. Quadriplegia and quadriparesis are seen with cervical cord and upper thoracic injury.

17. With which client will the nurse expect to find a "barrel chest" on respiratory assessment? A. 22-year-old with mild, intermittent asthma B. 28-year-old with cystic fibrosis C. 55-year-old with chronic emphysema D. 60-year-old with bilateral pneumonia

17. C A barrel chest occurs when air trapping and increased residual volume is severe and long-standing, such as in chronic emphysema. Neither pneumonia nor cystic fibrosis cause air trapping. Although asthma can result in air trapping, this does not happen with mild disease occurring intermittently. Although the anteroposterior chest diameter does increase somewhat as a result of normal aging, it does not increase to the point that it is equal to or greater than the lateral chest diameter.

17. What is the nurse's best response when a client who has been treated for 4 weeks for osteomyelitis asks why the disease is so difficult to cure? A. "Bones have a poor blood supply and are located so deep in the body that it is hard for antibiotics to reach them." B. "There are no early symptoms of osteomyelitis, so by the time it is detected the infection is widespread." C. "After a bone abscess forms, it gets covered with a new layer of bone that is difficult for drugs to penetrate." D. "The most common organisms that cause osteomyelitis are usually drug-resistant."

17. C Bone infections can easily damage bone tissue leading to tissue necrosis and abscess formation. Because bone is a dynamic tissue and attempts to heal itself, osteoblasts often lay new bone tissue over the infected tissue making it difficult for drug therapy to penetrate into the infected bone. Although some organisms may be drug-resistant, even when the organism is sensitive to the antibiotic, the real problem is drug penetration. Higher doses and longer duration of drug therapy are needed to eradicate the infection and prevent complications such as chronic osteomyelitis and sepsis.

17. Which client condition influences the nurse's choice of right versus left forearm placement when a short peripheral catheter (SPC) needs placement? A. Myocardial infarction with pain radiating down the left arm B. Pneumothorax with a chest tube on the right side C. Regular renal dialysis with a shunt on the left forearm D. Right hip fracture with immobilization and traction in place

17. C Mastectomy, axillary lymph node dissection, lymphedema, paralysis of the upper extremity, and the presence of dialysis grafts or fistulas alter the normal pattern of blood flow through the arm. Using veins in the extremity affected by one of these conditions requires a primary health care provider's order.

17. Which reaction indicates to the nurse that a client has a cerebral or brainstem reason for muscle weakness when asked to close his or her eyes and hold arms perpendicular to the body with palms up for 15 to 30 seconds? A. Arms, wrists, and fingers are flexed with internal rotation B. Abnormal movement with rigidity and extension of the arms C. Arm on client's weak side drifts with the palm turning inward D. Dorsiflexion of the thumb and spreading of the other fingers

17. C To assess cerebral motor or brainstem integrity, the nurse asks the client to close his or her eyes and hold the arms perpendicular to the body with the palms up for 15 to 30 seconds. If there is a cerebral or brainstem reason for muscle weakness, the arm on the weak side will start to fall, or "drift," with the palm pronating (turning inward). This is called a pronator drift.

17. For which gastrointestinal diagnostic test does the nurse teach a client to expect mild gas pain, flatulence, and a small amount of bleeding after the procedure if a biopsy was obtained? A. Endoscopic retrograde cholangiopancreatography B. Esophagogastroduodenoscopy C. Barium swallow D. Proctosigmoidoscopy

17. D The nurse informs the client that after proctosigmoidoscopy, mild gas pain and flatulence may be experienced from air instilled into the rectum during the examination. If a biopsy was obtained, a small amount of bleeding may be observed. The client is instructed to report excessive bleeding to the health care provider immediately.

17. What is the priority medical-surgical concept when the nurse is assessing a client with cardiovascular disease (CVD)? A. Acid-base balance B. Fluid and electrolyte balance C. Gas exchange D. Perfusion

17. D The priority concept when assessing for cardiovascular disease is perfusion. The interrelated concept for this chapter is fluid and electrolyte balance. Gas exchange and acid-base balance are more pertinent to respiratory and renal illnesses.

18. Which arterial blood gas (ABG) values from an 86-year-old client does the nurse consider to be normal? A. pH 7.32, PaO2 94 mm Hg, PaCO2 42 mm Hg B. pH 7.35, PaO2 90 mm Hg, PaCO2 52 mm Hg C. pH 7.45, PaO2 88 mm Hg, PaCO2 48 mm Hg D. pH 7.47, PaO2 98 mm Hg, PaCO2 30 mm Hg

18. A Adults over 60 years of age usually have a slightly lower than normal pH and slightly lower PaO2 levels (slightly acidotic). PaCO2 levels are not affected by increasing age alone. Normal arterial pH is 7.35-7.45.

18. Which precaution is most important for the nurse to instruct a client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol. B. Maintain one-floor living to prevent excessive fatigue. C. Use cool baths to reduce the sensation of itching. D. Report any change in cognition to the health care provider.

18. A Although all of the listed precautions are important, the most important is the avoidance of acetaminophen and alcohol. These substances are toxic to the liver and will worsen the client's liver disease.

18. What is the nurse's priority assessment when a client is given IV midazolam hydrochloride before a colonoscopy? A. Monitoring the rate and depth of respirations B. Auscultating for bowel sounds in all four quadrants C. Monitoring the client for cardiac dysrhythmias D. Suctioning secretions as needed to prevent aspiration

18. A Midazolam is commonly used for sedation with procedures such as colonoscopy. These drugs can depress the rate and depth of respirations. Thus, the nurse's priority assessment is checking the client's rate and depth of respirations. If the client's respiratory rate is below 10 breaths/min or the exhaled carbon dioxide level falls below 20%, the nurse uses a stimulus such as a sternal rub to encourage deeper and faster respirations.

18. When assessing sensation, why does the nurse make a clinical judgment decision to forgo assessing pain sensation for a client with Guillain-Barré syndrome (GBS)? A. The client's temperature sensation is intact. B. Sensory function assessment is routinely completed at 4-hour intervals. C. Only clients with spinal trauma require completion of this assessment. D. Clients with GBS are often too confused to respond appropriately.

18. A Pain and temperature sensation are transmitted by the same nerve endings. Therefore, if one sensation is tested and found to be intact, it can safely be assumed that the other is intact. Testing temperature sensation can usually be accomplished using a cold reflex hammer and the warm touch of the hand.

18. What is the priority action the nurse will take for a client admitted with nephrotic syndrome (NS) who has proteinuria, hypertension, lipidemia, and facial edema? A. Monitoring client's fluid volume and hydration status B. Consulting with registered dietician nutritionist about adequate intake C. Using clean and sterile techniques to prevent infections D. Teaching the client about and preparing for a renal biopsy

18. A The nurse's priority action is to assess the client's fluid volume and hydration status. Assessing the client's hydration status is essential because vascular dehydration is common. If plasma volume is depleted, kidney problems worsen.

18. What factors will the nurse recognize as contributors to a client diagnosis of complicated urinary tract infection (UTI)? Select all that apply. A. Pregnancy B. Obstruction C. Diabetes D. Pulmonary infection E. Chronic kidney disease F. Decreased immunity

18. A, B, C, E, F Some factors and conditions that contribute to a diagnosis of complicated UTI are pregnancy, male gender, obstruction, diabetes, neurogenic bladder, chronic kidney disease, and reduced immunity. Pulmonary infection does not contribute to complicated UTI diagnosis.

18. Which new-onset symptoms indicate to the nurse that a client with spinal cord injury (SCI) is experiencing autonomic dysreflexia (AD)? Select all that apply. A. Sudden hypertension with bradycardia B. Flaccid paralysis C. Blurred vision D. Tachypnea E. Profuse sweating of face, neck, and shoulders F. Severe throbbing headache

18. A, C, E, F Signs and symptoms of autonomic dysreflexia include: sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia; profuse sweating above the level of lesion, especially in the face, neck, and shoulders; goose bumps above or possibly below the level of the lesion; flushing of the skin above the level of the lesion, especially in the face, neck, and shoulders; blurred vision; spots in the client's visual field; nasal congestion; onset of severe, throbbing headache; flushing about the level of the lesion with pale skin below the level of the lesion; and a feeling of apprehension. See the box labeled Key Features Autonomic Dysreflexia in your text.

18. Which is the priority action for the nurse to perform when caring for a patient who just had a needle bone biopsy under local anesthesia? A. Administering pain medication B. Assessing for bleeding C. Checking the gag reflex D. Assessing the distal pulse

18. B Bone is very vascular and can bleed excessively after a biopsy. Although pain management is also important, the medication can be administered after first assessing whether excessive bleeding is present. The gag reflex is not affected by local anesthesia. Pulses distal to the biopsy area are not likely to be affected by the procedure. They should be assessed but not as the first or priority action.

18. What is the nurse's priority action when attempting to insert a short peripheral catheter (SPC) and the client reports a feeling of "pins and needles"? A. Ask the client to wiggle the fingers to stimulate circulation. B. Stop immediately, remove the catheter, and choose a new site. C. Change to a short-winged butterfly needle. D. Pause the procedure and gently massage the fingers.

18. B Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.

18. What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of antidiuretic hormone (ADH) is extremely low? A. Decreased blood volume; decreased blood osmolarity B. Decreased blood volume; increased blood osmolarity C. Increased blood volume; decreased blood osmolarity D. Increased blood volume; increased blood osmolarity

18. B The normal action of ADH is making kidney nephrons more permeable to water and increasing water reabsorption that is returned to the blood. With less ADH available, the client excretes more water in the urine leading to decreased blood volume and the osmolarity of the blood is increased.

18. Which common serum tumor markers does the nurse expect will be ordered to confirm a client's suspected diagnosis of testicular cancer? Select all that apply. A. Early prostate cancer antigen (EPCA-2) B. Lactate dehydrogenase (LDH) C. Alpha-fetoprotein (AFP) D. Beta human chorionic gonadotropin (hCG) E. BRCA1 mutation F. Glutathione S-transferase (GST P1)

18. B, C, D Common serum tumor markers that are used when formulating a diagnosis of testicular cancer are: alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). Early prostate cancer antigen (EPCA-2) may be a serum marker for prostate cancer. Glutathione S- transferase (GST P1) mutation increases the risk for prostate cancer. BRCA1 mutation increases a woman's risk for breast cancer.

18. For which reasons will the nurse insert a large-bore nasogastric tube (NGT) in a client with active upper GI bleeding or possible obstruction? Select all that apply. A. To provide nutritional supplements B. To determine the presence or absence of blood in the stomach C. To assess the rate of bleeding D. To administer medications E. To prevent gastric dilation F. To administer gastric lavage

18. B, C, E, F Upper GI bleeding or obstruction often requires the primary health care provider or nurse to insert a large-bore NGT in order to: determine the presence or absence of blood in the stomach, assess the rate of bleeding, prevent gastric dilation, and administer gastric lavage.

18. Which is the most effective action for the nurse to take to assess adequate bowel function in a client with acute pancreatitis who is at risk for the development of paralytic (adynamic) ileus? A. Observing contents of the nasogastric drainage B. Listening for bowel sounds in all four abdominal quadrants C. Asking the client if he or she has passed flatus or had a stool D. Interpreting the report of a CT scan of the abdomen with contrast medium

18. C The best indicator of bowel function and adequate motility is the actual passage of flatus or stool. Bowel sounds may still be present in the presence of an adynamic ileus. A CT scan is static and does not indicate motility. Gastric contents cannot indicate bowel motility.

18. What question does the nurse ask to help interpret the result when a healthy adult client's urinalysis reveals a protein level of 0.9 mg/dL? A. "Have you ever been treated for a urinary tract infection?" B. "Are you sexually active and if so, do you use condoms?" C. "Do you have a family history of cardiac or biliary disease?" D. "Have you recently performed any strenuous exercise?"

18. D A random finding of proteinuria (usually albumin in the urine) followed by a series of negative (normal) findings does not imply kidney disease. Normal value for protein in the urine is 0- 8 mg/dL. The nurse asks the client about recent strenuous exercise because urinary protein levels may be increased with exercise. Other causes of increased protein level include stress, infection, and glomerular disorders.

18. What is the nurse's best action to prevent harm for a client who is receiving enteral feedings by nasogastric (NG) tube when stomach contents cannot be aspirated and the client is coughing continuously? A. Notify the primary health care provider to request an order for a chest x-ray. B. Use a piston-style syringe and gentle pressure to instill 30 mL of water. C. Reposition the client on his or her right side and apply oxygen. D. Remove the tube.

18. D If the position of the NG tube is in doubt or questionable, remove the tube. The fact that the client is continuously coughing is an indication that the tube may no longer be in the esophagus. Although a chest x-ray could establish tube placement, removal is warranted to prevent respiratory distress.

18. For which client with pneumonia and hypoxemia will the nurse avoid the use of oxygen therapy? Select all that apply. A. 28-year-old with community-acquired pneumonia B. 38-year-old with fractured ribs C. 48-year-old with type 2 diabetes mellitus D. 58-year-old client with metastatic breast cancer E. 68-year-old with chronic obstructive pulmonary disease F. 78-year-old with acute confusion

18. None of the above All clients with pneumonia who have hypoxemia require oxygen therapy, even the client who has chronic obstructive pulmonary disease.

19. Which assessment findings will the nurse expect in a client who is admitted with acute osteomyelitis of the left lower leg? A. Temperature greater than 101°F, swelling, tenderness, erythema, and warmth in the area B. Ulceration resulting with sinus tract formation, localized pain, and drainage C. Aching pain, poorly described, deep, and worsened by pressure and weight bearing D. Shortening of the extremity with pain during weight bearing or palpation

19. A The most common symptom of acute osteomyelitis is pain. Fever, usually with temperature greater than 101° F (38.3° C) also is present. As the area around the infected bone swells, tenderness on palpation occurs. Erythema (redness) and heat may also be present.

19. Which American Heart Association guidelines would the nurse teach a client to fight obesity and improve cardiovascular health? Select all that apply. A. Don't consume more calories than you can use in a day B. Consume foods that contain vitamins, minerals, and fiber. C. Choose foods that are healthy and low in calories. D. Avoid gas-producing vegetables such as cabbage or broccoli. E. Eat vegetables, fruit and whole-grain foods. F. For calcium, choose whole milk dairy products.

19. A, B, C, E The American Heart Association provides guidelines to combat obesity and improve cardiac health, including ingesting more nutrient-rich foods that have vitamins, minerals, fiber, and other nutrients but are low in calories. To get the necessary nutrients, teach clients to choose foods such as vegetables, fruits, unrefined whole-grain products, and fat-free (not whole milk) dairy products most often. Also teach clients to not eat more calories than they can burn every day. Vegetables such as cabbage and broccoli are good sources of nutrients.

19. Which are potential benefits of a client receiving the drug digoxin? A. Reduced heart rate B. Increased contractility C. Venous vasodilation D. Slowed conduction through the AV node E. Inhibition of sympathetic activity with enhanced parasympathetic activity F. Enhanced renal excretion of sodium and water

19. A, B, D, E The potential benefits of digoxin include: increased contractility; reduced heart rate (HR); slowing of conduction through the atrioventricular node; and inhibition of sympathetic activity while enhancing parasympathetic activity. Diuretics (especially loop and thiazide) enhance excretion of water and sodium. Nitrates are venous vasodilators.

19. Which actions will the nurse take when caring for a client with a spinal cord injury who is experiencing autonomic dysreflexia? Select all that apply. A. Raise the head of the bed. B. Check the client's bladder for distention. C. Place a condom catheter on male clients as necessary. D. Give nifedipine or nitrate as prescribed. E. Monitor blood pressure every 10 to 15 minutes. F. Check the client for fecal impaction.

19. A, B, D, E, F All of these actions are appropriate to the care of a client with SCI who has autonomic dysreflexia except option C. If the client requires a catheter, a urinary catheter would be placed, not a condom catheter. See the box labeled Best Practice for Patient Safety & Quality Care Emergency Care of the Patient Experiencing Autonomic Dysreflexia: Immediate Interventions in your text for additional appropriate actions.

19. Which stimuli are recommended for the nurse to apply when a client has not responded to a loud voice or gentle shaking during Glasgow Coma Scale (GSC) assessment? Select all that apply. A. Supraorbital pressure by placing a thumb under the orbital rim in the middle of the eyebrow and pushing upward B. Alternating sharp pin prick with cotton ball on several spots over the hands and feet C. Trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the angle of the shoulder and neck muscle D. Mandibular pressure to the jaw by using the index and middle fingers to pinch the lower jaw E. Sternal rub by making a fist and rubbing/twisting the knuckles against the sternum F. Continuous application of pain for 45 seconds to determine if the client will withdraw from the pain

19. A, C, D, E If a client does not respond to a loud voice or shaking during GCS assessment, the nurse could apply one of these methods: supraorbital pressure by placing a thumb under the orbital rim in the middle of the eyebrow and pushing upward; trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the angle of the shoulder and neck muscle; mandibular pressure to the jaw by using the index and middle fingers to pinch the lower jaw; or sternal (breastbone) rub by making a fist and rubbing/twisting the knuckles against the sternum. If the client does not respond after 20 to 30 seconds, stop applying the painful stimulus.

19. Which actions will the nurse take to prevent harm when caring for a client receiving continuous enteral tube feeding? Select all that apply. A. Checking the residual volume at least every 6 hours B. Changing the feeding bag and tubing every 12 hours C. Keeping the head of the bed elevated at least 30 degrees D. Using clean technique when changing the feeding system E. Discarding unused open enteral products after 24 hours F. Warming the enteral products before infusion

19. A, C, D, E Residual volume must be assessed at least every 6 hours to prevent reflux and aspiration, as well as other complications. Keeping the head of the bed elevated to at least 30 degrees also helps prevent reflux and aspiration. Clean technique is required to prevent GI infection, as is discarding any unused enteral products that have been open for 24 hours. The feeding bag and tubing are changed every 24 to 48 hours as needed and in accordance with agency policy. Warming of the enteral product is not required or recommended.

19. Which laboratory values will the nurse monitor as specific indicators of a client's kidney function? Select all that apply. A. Creatinine B. Blood urea nitrogen (BUN) C. Cystatin-C D. Blood osmolarity E. BUN/creatinine ratio F. White blood cell count

19. A, C, D, E Serum creatinine is produced when muscle and other proteins are broken down. Because protein breakdown is usually constant, the serum creatinine level is a good indicator of kidney function. Cystatin-C measures glomerular filtration rate. Increased levels can be considered a predictor of chronic renal disease. Blood osmolarity is a measure of the overall concentration of particles in the blood and is a good indicator of hydration status. The kidneys excrete or reabsorb water to keep blood osmolarity in the range of 280 to 300 mOsm/kg (mmol/kg). When both the BUN and serum creatinine levels increase at the same rate, the BUN/creatinine ratio remains normal. However, elevations of both serum creatinine and BUN levels suggest kidney dysfunction. Blood urea nitrogen (BUN) measures the effectiveness of kidney excretion of urea nitrogen, a by-product of protein breakdown in the liver. Other factors influence the BUN level, and an elevation does not always mean that kidney disease is present. WBC level provides more useful information about infection.

19. When providing discharge teaching, for which symptoms will the nurse teach a client with peptic ulcer disease (PUD) to seek immediate medical attention? Select all that apply. A. Bloody or black stools B. Dyspepsia or reflux C. Bloody vomit or vomit that looks like coffee grounds D. Odynophagia with nausea E. Sharp, sudden, persistent, and severe epigastric or abdominal pain F. Loss of appetite with dysphagia

19. A, C, E The nurse teaches a client with PUD to seek immediate medical attention for these symptoms: sharp, sudden, persistent, and severe epigastric or abdominal pain; bloody or black stools; or bloody vomit or vomit that looks like coffee grounds.

19. For clients with which types of hepatitis will the nurse teach about prevention of infection spread through the oral-fecal contamination route? Select all that apply. A. Hepatitis A (HAV) B. Hepatitis B (HBV) C. Hepatitis C (HCV) D. Hepatitis D (HDV) E. Hepatitis E (HEV) F. Toxic hepatitis

19. A, E HAV and HEV are spread by the oral-fecal route from contaminated food and water sources. HBV, HCV, and HDV are spread primarily by the parenteral route although sexual contact can also result in infection spread. Toxic hepatitis is not infectious and is caused by exposure to hepatotoxic chemicals.

19. Which statement made by the client with type 1 diabetes during nutritional counseling indicates to the nurse that he or she correctly understands his or her nutritional needs? A. "If I completely eliminate carbohydrates from my diet, I will not need to take insulin." B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." C. "My intake of protein in terms of grams and calories should be the same as my intake of carbohydrate." D. "My intake of unsaturated fats in terms of grams and calories should be the same as my intake of protein."

19. B Carbohydrates are the main fuel for human cells, especially neurons, and the substance most commonly used to make ATP. The dietary recommendations for clients who have diabetes is that, although the percentage of total calories needed is determined for each client, the diet should never contain less than 130 g of carbohydrate per day. Protein intake should range between 15% and 30% of total caloric intake per day.

19. How will the nurse categorize a client's level of dyspnea who reports no shortness of breath (SOB) at rest, fair to moderate SOB with activity, some SOB while dressing, and has to stop to catch his breath when going up a flight of stairs? A. Class II B. Class III C. Class IV D. Class V

19. B Clients with class III dyspnea report that shortness of breath commonly occurs during usual activities such as showering or dressing, but the patient can manage without assistance from others (although the client may consider asking for help because self-care is too time-consuming). Dyspnea is not present at rest and client can walk for more than a city block at own pace but cannot keep up with others of own age. Usually clients must stop to catch their breath partway up a flight of stairs.

19. Which action will the nurse consider the highest priority when caring for a client who is currently experiencing a migraine headache? A. Avoiding environmental triggers of migraine headaches B. Providing pain management for client C. Assessing the client for visual symptoms D. Detecting a pre-migraine aura

19. B The priority for care of the client having migraines is pain management. This outcome may be achieved by abortive and preventive therapy. Drug therapy, trigger management, and complementary and integrative therapies are the major approaches to managing pain.

19. Which factors promote long-term adherence to the prescribed antihypertensive drug therapy for a client diagnosed with nephrosclerosis? Select all that apply. A. Monthly reminders B. Once-a-day dosing C. Written drug information D. Low cost E. Minimal side effects F. Eliminating diet restrictions

19. B, D, E Although many antihypertensive drugs may lower blood pressure, the client's response is important in ensuring long-term adherence to the prescribed therapy. Factors that promote adherence include once-a-day dosing, low cost, and minimal side effects.

19. Which additional client condition(s) or factor(s) will the nurse recognize as increasing the risk for ventilator-associated pneumonia (VAP)? Select all that apply. A. History of alcohol use and cigarette smoking B. Presence of feeding tube C. Unplanned weight loss D. IV therapy with normal saline E. Tooth loss and mouth sores F. Bacterial colonization of the airway

19. B, E, F A feeding tube prevents full closure of the epiglottis making aspiration into the airway easier when an endotracheal tube is also in place. Colonization of any part of the airway with bacteria allows direct translocation into the lower respiratory tract and lungs. The presence of tooth loss and mouth sores adds additional loss of barrier function and increases microorganism presence in the oral cavity, a major cause of VAP. Although alcohol use and cigarette smoking increase the risk for infectious pneumonia, they do not generally increase the risk for VAP. Weight loss alone does not increase the risk for VAP.

19. Which type of equipment decreases the risk of disconnection or leakage when a nurse attaches an administration set to a client's central venous catheter? A. Slip lock connector B. Extension set C. Luer-Lok connector D. Needleless connector

19. C A Luer-Lok connection has an end with a threaded collar that requires twisting onto the corresponding threads of the catheter hub. All connections, including extension sets, should have a Luer-Lok design to ensure that the set remains firmly connected. A slip lock has a male end that slips into the female catheter hub but does not have the threaded collar. An extension set lengthens the tubing but does not protect against disconnection or leakage. A needleless connection protects against needlesticks but does not stop disconnection or leakage.

19. Which circumstance is cause for the nurse's greatest concern when several clients in the long-term facility have developed urinary tract infections (UTIs)? A. Residents are not drinking enough fluids with meals and snacks. B. Assistive personnel (AP) are not assisting with toileting in a timely manner. C. A large percentage of residents have indwelling urinary catheters. D. Many residents have dementia and functional incontinence.

19. C The major concern is that many clients in the facility have indwelling urinary catheters. Ensuring that urinary catheters are used appropriately and discontinued as early as possible is essential. Catheters must not be left in place for staff convenience. Indwelling catheters are a major factor for the number of catheter-associated urinary tract infections (CAUTI).

19. What does the nurse practitioner suspect when performing an examination on a young male client and finding a testicular lump that is hard and painless? A. Prostate cancer B. Epididymitis C. Testicular cancer D. Erectile dysfunction

19. C The most common finding in a client with testicular cancer is a painless, hard swelling or enlargement of the testicle. A health care provider palpates the testes for lumps and swelling that are often not visible.

19. Which statements about eating habits and diet therapy indicate to the nurse that the client recovering from acute pancreatitis understands the recommendations made in collaboration with the registered dietitian nutritionist? Select all that apply. A. "Now I can go back to my usual three meals a day." B. "Replacing carbohydrates with protein will speed my recovery." C. "Although they do not contain fat, I will avoid chocolate and caffeine." D. "If vomiting or diarrhea occur, I will call my primary health care provider." E. "I can't wait to have some good, spicy Mexican food after all this hospital food." F. "I am planning on joining Alcoholics Anonymous and giving up drinking altogether."

19. C, D, F Recommendations for diet therapy during recovery from acute pancreatitis includes small, frequent, moderate- to high- carbohydrate, high-protein, low-fat meals with bland, nonspicy food; avoidance of alcohol; and avoidance of GI stimulants such as caffeine-containing food (tea, coffee, cola, and chocolate). If clients start to have nausea, vomiting, or diarrhea after eating, he or she is instructed to notify the primary health care provider.

19. Which instruction will the nurse give an assistive personnel (AP) to prevent harm when providing care to a client who has osteodystrophy? A. Assist the client with feeding for all meals. B. Gently wash the client's skin with a mild soap and rinse well. C. Assist the client with ambulation to the toilet every 2 hours. D. Use a lift sheet when moving or lifting the client.

19. D Clients with osteodystrophy have thin, fragile bones that are at risk for fractures with even slight trauma. When lifting or moving a client with fragile bones, the AP is instructed to use a lift sheet rather than pulling the client.

2. Which type of neuron is the nurse assessing when asking a client to lift one leg and then the other? A. Motor B. Sensory C. Afferent D. Synaptic knob

2. A Some neurons are motor (causing purposeful physical movement or mobility). Sensory neurons result in the ability to perceive stimulation through the sensory organs. Afferent neurons send impulses toward the central nervous system (CNS) and away from the peripheral nervous system (PNS). Synaptic knobs are the enlarged distal ends of each axon.

2. Which activities would be performed by infusion nurses for clients requiring infusion therapy? Select all that apply. A. Provide education about infusion therapy for staff, families, and clients. B. Monitor client outcomes with infusion therapy. C. Develop evidence-based policies and procedures. D. Consult on product selection and purchasing decisions. E. Develop new products for more effective infusion therapy. F. Insert and maintain peripheral, midline, and central venous catheters.

2. A, B, C, D, F Infusion nurses may perform any or all of these activities: develop evidence-based policies and procedures; insert and maintain various types of peripheral, midline, and central venous catheters and subcutaneous and intraosseous accesses; monitor client outcomes of infusion therapy; educate staff, clients, and families regarding infusion therapy; consult on product selection and purchasing decisions; provide therapies such as blood withdrawal, therapeutic phlebotomy, hypodermoclysis, intraosseous infusions, and administration of medications.

2. Which questions will the nurse ask a client, with increased fatigue and stiffness in the extremities, that will assess whether the symptoms may be associated with multiple sclerosis (MS)? Select all that apply. A. "Has anyone in your family been diagnosed with multiple sclerosis? B. "Have your symptoms gotten worse over time?" C. "Are you having trouble breathing with slight exertion?" D. "Which factors seem to make your symptoms worse?" E. "Have your symptoms come and gone over time?" F. "Are you having headaches that occur with stress?"

2. A, B, D, E A complete history is essential for the diagnosis of MS. The nurse asks the client about a history of vision, mobility, and sensory perception changes, all of which are early indicators of MS. Symptoms are often vague and nonspecific in the early stages of the disease and may disappear for months or years before returning. Ask about the progression of symptoms. Pay particular attention to whether they are intermittent or are becoming progressively worse. Document the date (month and year) when the client first noticed these changes. Ask about factors that aggravate the symptoms, such as fatigue, stress, overexertion, temperature extremes, or a hot shower or bath. Ask the client and the family about any personality or behavioral changes that have occurred (e.g., euphoria [very elated mood], poor judgment, attention loss). Also, ask whether there is a family history of MS or autoimmune disease.

2. For which causes will the nurse monitor clients for development of intrarenal (intrinsic) acute kidney injury (AKI)? Select all that apply. A. Glomerulonephritis B. Bladder cancer C. Exposure to nephrotoxins D. Embolism in renal blood vessels E. Severe dehydration F. Kidney stones

2. A, C, D Examples of disorders causing intrinsic renal AKI include allergic disorders, embolism or thrombosis of the renal vessels, and nephrotoxic agents. Severe dehydration causes prerenal failure. Bladder cancer and kidney stones cause postrenal failure. For additional causes, see Table 63.4 Diseases and Conditions That Contribute to Acute Kidney Injury in your text.

2. Which statements about the structure of the heart are accurate? Select all that apply. A. The heart normally pumps about 5 L of blood per minute. B. A muscular wall called the septum separates only the ventricles of the heart. C. The pericardium is a covering that protects the heart. D. The left ventricle pumps deoxygenated blood to the lungs. E. The right ventricle pumps blood into the aorta and systemic arterial system. F. Coronary artery blood flow occurs primarily during diastole.

2. A, C, F Options A, C, and F are accurate. The septum separates the atria and the ventricles. The right ventricle pumps deoxygenated blood to the pulmonary artery and lungs, while the left ventricle pumps blood to the aorta and the systemic arterial system.

2. What is the priority or most relevant medical-surgical concept for the nurse when performing an assessment of a client's respiratory system? A. Perfusion B. Gas exchange C. Acid-base balance D. Cellular regulation

2. B Although all four concepts are associated with the respiratory system, the main function of the respiratory system is gas exchange. The other three concepts are dependent on gas exchange for proper activity.

2. How will the nurse interpret the risk for osteoporosis in a client whose T-score is -3? A. Osteopenia is present. B. Osteoporosis is present. C. Risk for osteopenia is increased. D. Score is normal and does not indicate a risk for osteoporosis.

2. B The T-score represents the standard deviations above or below the average bone marrow density (BDM) for young healthy adults. A T-score of -1 to -2.5 indicates osteopenia. A T-score lower than -2.5 (-3) indicates osteoporosis.

2. Which substances will the nurse consider an abnormal finding in a client's routine urine sample? Select all that apply. A. Electrolytes B. Red blood cells C. Proteins D. Water E. Albumin F. Creatinine

2. B, C, E Large particles, such as blood cells, albumin, and other proteins, are too large to filter through the glomerular capillary walls. Therefore, these substances are not normally present in the excreted final urine.

2. What question will the nurse ask first when a client's medical record states that he has gender dysphoria? A. "Do you think of yourself as male or female?" B. "Are you seeking interventions for sex reassignment?" C. "How do you prefer to be addressed?" D. "What issues of sexuality would you like to talk about?"

2. C A client with gender dysphoria experiences emotional or psychological distress caused by an incongruence between one's natal (birth) sex and gender identity. The most appropriate question for the nurse to ask is how the client prefers to be addressed.

2. Which action by a client with Alzheimer disease and documented by the nurse demonstrates the finding of apraxia? A. Client is unable to understand or follow a simple command. B. Client sustains a burn from a heating pad without realizing it. C. Client pushes food on his or her plate with eye glasses. D. Client is unable to find words when asked the name of his or her pet dog.

2. C Apraxia is the inability to use words or objects correctly. In this case the client is attempting to use eye glasses for eating food. Inability to understand or follow simple commands is aphasia. Agnosia is the loss of sensory comprehension so a client may be burned without realizing that it occurs. Anomia is the inability to find words, as when the client is unable to find the word to name his or her pet.

2. Which client will the nurse recognize as having the most risk factors for cholelithiasis? A. 25-year-old white female athlete who is 10 lb (4.5 kg) underweight and had an appendicitis 2 months ago B. 35-year-old African-American male who is 10 lb (4.5 kg) overweight and is hypertensive C. 50-year-old Mexican-American female who has three children and takes hormone replacement therapy D. 60-year-old Asian-American male who had coronary artery bypass graft surgery 4 weeks ago

2. C Cholelithiasis has a higher incidence among Mexican-Americans, especially women who have had multiple pregnancies, and among those who are taking estrogen/progesterone hormone replacement therapy.

2. What is the nurse's best response when a client who has type 1 diabetes asks why he shouldn't try to keep his blood glucose level as close to zero (0) as possible? A. "That would only frustrate you because there are many ways your body prevents your blood glucose level from going below 50 mg/L (2.8 mmol/L)." B. "You would have to eat absolutely no carbohydrates to accomplish this and just about all food contains some carbohydrates." C. "Glucose is an important nutrient, especially for your brain, and you cannot live if your blood glucose level gets too low." D. "Maintaining such a low glucose level would require a lot of very expensive drugs and not reduce the complications."

2. C Glucose is a critical nutrient for all cells and tissues. Although chronically high blood glucose levels cause many serious problems, low blood glucose levels can rapidly (within minutes) lead to neuron injury and death. Therefore, the desired outcome of diabetes management is to keep blood glucose levels in the range of 60 to 100 mg/dL (3.3 to 5.6 mmol/L) to support brain function and prevent death.

2. What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

2. C In compensated cirrhosis, the liver is scarred with physical changes and cellular regulation is impaired, but the organ can still perform essential functions, including maintaining normal liver enzyme levels without causing major symptoms. In decompensated cirrhosis, liver function is impaired with obvious signs and symptoms of liver failure, including elevated liver enzymes.

2. When a client develops heart failure, what initial compensatory mechanism of the heart does the nurse expect to occur that will maintain cardiac output (CO)? A. Parasympathetic stimulation B. Ventricular hypertrophy C. Sympathetic stimulation D. Renin-angiotensin activation system

2. C In heart failure (HF), stimulation of the sympathetic nervous system (e.g., increasing catecholamines) as a result of tissue hypoxia represents the most immediate compensatory mechanism. This results in an immediate increase in cardiac output. Later compensatory mechanisms include activation of renin-angiotensin system and myocardial hypertrophy.

2. Which is the nurse's best action for an ambulatory obese older client with incontinence and dementia? A. Teach the client about strategies for weight reduction. B. Assist the client to apply estrogen cream. C. Provide the client assistance with toileting every 2 hours. D. Perform intermittent catheterization on the client.

2. C The client has dementia and is cognitively impaired, which leads to functional incontinence. Habit training (scheduled toileting) is a type of bladder training that is successful in reducing incontinence in cognitively impaired clients. To use habit training, caregivers help the client void at specific times (e.g., every 2 hours on the even hours). The goal is to get the client to the toilet before incontinence occurs. The nurse could assign this assistance to an LPN/LVN or delegate it to the assistive personnel (AP).

2. Which body fluid compartment is considered the "third space?" A. Extracellular fluid B. Intracellular fluid C. Interstitial fluid D. Blood (plasma)

2. C The extracellular fluid includes both the blood (plasma) volume and the interstitial fluid. Another term for the interstitial fluid is the third space, which is between the cells rather than inside the cells or in the blood (plasma).

20. What is the best action for a nurse to take to prevent harm when a client with diabetes, who just received a premeal dose of regular insulin, is picked up by transportation to the radiation department for a scheduled x-ray before she has a chance to eat her lunch? A. Calling the radiation department and rescheduling the x-ray B. Sending the client's lunch with her to the radiation department C. Administering glucagon by the intramuscular route immediately D. Reminding the transporter that this client must be seen first in the radiation department

20. A A client who receives premeal regular insulin and then does not eat the meal is at high risk for severe hypoglycemia. The best action is to not let the client go to the radiation department without eating. The nurse will reschedule the client's x-ray for a time after she has eaten. Sending the client's meal with her does not ensure sufficient intake to prevent hypoglycemia. The transporter has no responsibility in this matter. Giving glucagon is not a good option because the client's blood glucose level may not have decreased yet. Also, after glucagon is administered, the client requires close monitoring and would still not be able to have an x-ray at this time.

20. Which client is the nurse most likely to teach about placement of a tunneled central venous catheter? A. Client in wheelchair to receive IV antibiotics for 16 weeks B. Client with trauma from a motor vehicle crash C. Client in need of fluid replacement for dehydration D. Client with acute renal failure and decreased urine output

20. A Tunneled catheters are used primarily when the need for infusion therapy is frequent and long term. Tunneled catheters are chosen when several weeks or months of infusion therapy are needed and a PICC is not a good choice (e.g., wheelchair bound, paraplegic).

20. Which actions and precautions will the nurse educate a client with chronic pancreatitis about when starting pancreatic enzyme replacement therapy (PERT)? Select all that apply. A. Do not crush or chew the capsules. B. Take these drugs with all meals and snacks. C. Sit in an upright position for at least 30 minutes after taking the drug. D. Wear sunscreen and protective clothing outdoors to prevent severe sunburn. E. Check your stools for amount and presence of fat to assess whether the drugs are working. F. If you are too nauseated to eat or to take the drug, go to an emergency department for an injectable form of the drug.

20. A, B, E PERT is used to assist in the digestion of foods. Thus, it must be taken orally only whenever the client eats a meal or snack. Capsules are not to be opened, crushed, or chewed for maximum benefit. The amount of fat in the stools, as well as the amount and consistency of stools are used to evaluate PERT effectiveness. It is not necessary to remain upright, and the drug does not cause or increase photosensitivity.

20. Which instructions will the nurse teach a client after an open retroperitoneal lymph node dissection (RPLND) for testicular cancer? Select all that apply. A. Do not lift anything that weighs over 15 lbs. B. Limit intake of fluids to 1000 to 1200 mL per day. C. Do not drive a car until the health care provider allows it. D. Perform monthly testicular self-examination on the remaining testicle. E. Report fever, drainage, or increasing tenderness around the incision. F. Avoid climbing stairs during the first week after surgery.

20. A, C, D, E The nurse teaches the client the following instructions after RPLND: do not lift anything over 15 lb (6.8 kg), avoid stair climbing, and do not drive a car for several weeks. Notify the surgeon immediately if chills, fever, vomiting, increasing incisional pain, drainage, or dehiscence of the incision occurs. Perform monthly testicular self-examination (TSE) on the remaining testis. The client should not limit fluid intake to 1000 to 1200 mL per day.

20. Which drugs will the nurse expect the health care provider to prescribe for a client with mild migraine headaches? Select all that apply. A. Acetaminophen B. Eletriptan C. Naproxen D. Cafergot E. Metoclopramide F. Isometheptene combination

20. A, C, E Drugs commonly prescribed for mild migraines include acetaminophen, NSAIDs (e.g., naproxen, ibuprofen), NSAIDs combined with caffeine (e.g., OTC acetaminophen with aspirin and caffeine), and antiemetics for nausea. Metoclopramide may be administered with NSAIDs to promote gastric emptying and decrease vomiting. For more severe migraines, drugs such as triptan preparations, ergotamine derivatives, and isometheptene combinations are needed.

20. Which food will the nurse recommend a client avoid when he or she reports fear of stomach cancer? A. Foods that cause reflux B. Pickled or processed foods C. Large, heavy meals D. Spicy foods that cause gas

20. B Stomach cancer seems to be positively correlated with eating excessive pickled foods, nitrates from processed foods, and salt added to food. The ingestion of these foods over a long period can lead to atrophic gastritis, which is a precancerous condition.

20. For which emergency procedure does the nurse prepare when a client with chronic kidney disease develops chest pain, tachycardia, low-grade fever, friction rub, and muffled heart tones? A. Hemodialysis B. Removal of pericardial fluid C. Cardioversion D. Endotracheal intubation

20. B The client's signs and symptoms suggest pericarditis which often occurs in CKD and can cause tamponade. Treatment of tamponade, which is a medical emergency, requires immediate removal of pericardial fluid (pericardiocentesis) by placement of a needle, catheter, or drainage tube into the pericardium.

20. Which gastrointestinal condition does the nurse suspect a client is at increased risk for, when she reports emotional distress about her family situation and whether she will be able to return to work? A. Hiatal hernia B. Exacerbation of irritable bowel syndrome C. Nausea accompanied by vomiting and diarrhea D. Esophageal ulcers

20. B The nurse must ask a client about experiencing stressful events because stress has been associated with the development or exacerbation (flare-up) of irritable bowel syndrome (IBS).

20. Which changes in signs and symptoms in a client with bacterial pneumonia does the nurse report to the primary health care provider as indicators of possible empyema? Select all that apply. A. Increased production of thick yellow sputum B. Reduced chest wall motion on one side C. Decreased breath sounds D. Flat percussion E. Persistent fever F. Wheezing

20. B, C, D, E Pulmonary empyema is a collection of pus in the pleural space (not in the lungs) most commonly caused by pneumonia or another pulmonary infection. Its manifestations include reduced chest wall motion, reduced or absent or fremitus, flat percussion, and decreased breath sounds. The client has either a persistent fever despite antibiotic therapy or recurrence of fever. Although empyema fluid is thick, purulent, and foul-smelling, the client cannot cough it up because it is in the pleural space and not in the lungs. Wheezing does not occur because the fluid is not in the airways.

20. Which triad of symptoms would the nurse assess for in a woman at risk for cardiovascular disease? Select all that apply. A. Severe chest pain B. Feeling of abdominal fullness C. Chronic fatigue despite adequate rest D. Extremity pain E. Dyspnea or inability to catch her breath F. Intermittent claudication

20. B, C, E Some clients, especially women, do not experience pain in the chest but, instead, feel discomfort or indigestion. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feelings of an "inability to catch my breath" (dyspnea) are also common in heart disease.

20. Which questions will the nurse ask a client with a blood urea nitrogen (BUN) of 26 mg/dL to identify non-renal factors that may contribute to this laboratory result? Select all that apply. A. "Have you been trying to lose weight with severe calorie restrictions?" B. "Have you noticed any blood in your stool or vomited any blood?" C. "Have you been on a high-protein diet or been drinking high- protein drinks?" D. "Did you drink a lot of extra fluid before the blood sample was drawn?" E. "Are you taking or have you recently taken any steroid medications?" F. "Have you recently experienced any physical or emotional stress?"

20. B, C, E, F An increased BUN level may indicate liver or kidney disease, dehydration or decreased kidney perfusion, a high-protein diet, infection, stress, steroid use, Gl bleeding, or other situations in which blood is in body tissues. The nurse asks questions about these non-kidney factors that can cause increases in BUN.

20. Which are the most common signs and symptoms of urinary tract infection that the nurse will recognize when assessing a client? Select all that apply. A. Nocturia B. Frequency C. Hematuria D. Urgency E. Suprapubic tenderness F. Dysuria

20. B, D, F Frequency, urgency, and dysuria are the most common symptoms of a urinary tract infection (UTI), but other symptoms may be present. See Key Features of UTI in your text for additional symptoms that may also be noted when a client has a UTI.

20. What is the nurse's best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary health care provider about receiving the hepatitis A vaccine."

20. C Receiving immunoglobulin with a high concentration of antihepatitis A antibodies within 2 weeks of exposure can prevent an exposed person from developing the infection. Receiving the vaccination at this time takes too long to develop sufficient immunity to prevent an infection from this exposure.

20. Which observation indicates to the nurse that a quadriplegic client's spouse understands teaching about performance of assistive coughing (quad cough)? A. The spouse assists the client into a wheelchair and coaches deep coughing. B. The spouse places hands on the client's lateral chest and pushes inward on exhalation. C. The spouse places hands below the client's diaphragm and pushes upward with exhalation. D. The spouse assists the client into high-Fowler position and encourage taking a number of deep breaths.

20. C The client is taught by the nurse to coordinate his or her cough effort with an assistant. The spouse, or other assistant, places his or her hands on the upper abdomen over the diaphragm and below the ribs. The client takes a breath and coughs during expiration (exhalation). The assistant locks his or her elbows and pushes inward and upward as the client coughs. This technique is called assisted coughing, quad cough, or cough assist. Repeating the coordinated effort, with rest periods as needed, until the airway is clear is important.

20. What would be the priority concern when the nurse asks a client to stand with arms at the sides, feet and knees close together, and eyes open, then close his or her eyes and maintain position; and the nurse notes client swaying only when the eyes are closed? A. Difficulty with performance of activities of daily living B. Potential for brainstem injury C. Possible falls related to lack of awareness of body position D. Functional incontinence due to difficulty with ambulation

20. C The nurse is checking for equilibrium with this assessment. The client is asked to stand with arms at the sides, feet and knees close together, and eyes open. The nurse checks for swaying and then ask the client to close his or her eyes and maintain position. The examiner should be close enough to prevent falling if the client cannot stay erect. If the client sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is likely related to proprioception (awareness of body position). If the client sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin.

20. With which client will the nurse remain most alert for indications of acute hematogenous osteomyelitis? A. 30-year-old male with a leg fracture and external skeletal pins B. 50-year-old female in an ICU with pneumonia C. 65-year-old female with MRSA infection D. 72-year-old male with a catheter-related urinary tract infection

20. D Acute hematogenous infection results from bacteremia, underlying disease, or nonpenetrating trauma. Urinary tract infections, particularly in older men, tend to spread to the lower vertebrae.

20. Which client assessment finding does the nurse recognize as an immediate gas exchange and perfusion problem? A. Pursed-lip breathing B. Clubbed fingers C. Barrel chest D. Cyanosis

20. D Finger clubbing and a barrel chest take many months to years of inadequate gas exchange to develop. Pursed-lip breathing is a learned behavior to compensate for loss of elastic recoil. Only cyanosis reflects an immediate decrease in gas exchange and/or perfusion.

20. Which complication does the nurse suspect when a client in a starvation state receiving enteral feedings has shallow respirations, weakness, acute confusion, and oozing from the IV site? A. Sepsis B. Aspiration C. Hypoglycemia D. Refeeding syndrome

20. D Refeeding syndrome is a life-threatening complication of aggressive enteral feeding in a severely malnourished client that is caused by fluid and electrolyte shifts. This condition can lead to heart failure, muscle breakdown, seizures, and hemolysis. Main electrolyte imbalances are hypokalemia and hypophosphatemia. The hypokalemia causes shallow respiration, as does heart failure. Bleeding around the IV site can be caused by the accompanying hemolysis and poor clotting.

20. Which electrolyte plays the largest role in maintaining blood osmolarity? A. Calcium B. Chloride C. Potassium D. Sodium

20. D Sodium is the electrolyte with the highest concentration in the blood. This high concentration keeps more of the chloride ions in the blood. As a result, sodium keeps the blood osmolarity within the normal range. Both calcium and potassium have low blood levels.

21. Which priority information will the nurse gather from a client who is seeking a prescription for sildenafil for erectile dysfunction? A. Medication prescription for nitrate drugs B. Presence of nocturnal or morning erections C. Use of any illicit drugs or substances D. Dietary consumption of proteins each day

21. A The nurse asks the client whether he takes nitrates. Men who are prescribed nitrates must avoid PDE5 inhibitors (e.g., sildenafil) because the vasodilation effects can cause a profound hypotension and reduce blood flow to vital organs.

21. Which actions are most effective for nurses and other health care workers to prevent occupational transmission of viral hepatitis? Select all that apply. A. Washing hands before and after contact with all clients B. Using needleless systems for parenteral therapy C. Using Standard Precautions with all clients regardless of age or sexual orientation D. Obtaining an immunoglobulin injection after exposure to hepatitis A E. Being fully vaccinated with the hepatitis B vaccine F. Wearing gloves during direct contact with all clients

21. A, B, C, D, E With the exception of F, all actions are effective in preventing or reducing transmission of infectious hepatitis among health care workers as a result of occupational exposure (see the Best Practices for Patient Safety and Quality Care: Prevention of Viral Hepatitis in Health Care Workers box). Wearing gloves during direct contact with all clients may give a false sense of security and does not prevent transmission if gloves are contaminated and then come into contact with another person. Gloves are not needed for all client contact.

21. Which priority instructions will the nurse teach the client and family to prevent harm from urinary tract infections (UTIs) after discharge? Select all that apply. A. Drink fluids liberally, as much as 2 to 3 liters daily if not contraindicated by health problems. B. Be sure to get enough sleep, rest, and nutrition daily to maintain immunologic health. C. Do not routinely delay urination because the flow of urine can help remove bacteria that may be colonizing the urethra or bladder. D. For both men and women, gently wash the perineal area before intercourse. E. For women, be sure to douche before and after sexual intercourse. F. If spermicides are used, consider changing to another method of contraception.

21. A, B, C, D, F The nurse teaches all of these options to prevent a UTI, except option E. Women must be taught to avoid using irritating substances such as douches, scented lubricants for intercourse, bubble bath, tight-fitting underwear, and scented toilet tissue.

21. Which nursing actions are implemented when caring for a client with an implanted port? Select all that apply. A. Before giving a drug through the port, always check for a blood return. B. De-access the port using a 5-mL syringe and 5 mL of heparin 5 units/mL. C. Before puncturing a port, palpate the port and locate the septum. D. Use a noncoring needle to access the implanted port. E. Flush the implanted port at least once monthly between courses of therapy. F. Use a topical anesthetic cream to decrease the pain of accessing the port.

21. A, C, D, E, F All options are appropriate for the care of an implanted port except option B. The INS recommendation for locking or de- accessing a port is the use of a 10-mL syringe with either heparin 10 units/mL or preservative-free 0.9% normal saline.

21. Which response on blood glucose level does the nurse expect to find in a client with diabetes who is now receiving corticosteroid therapy for an acute inflammation? A. Hypoglycemia B. Hyperglycemia C. Ketoacidosis D. No specific change

21. B Corticosteroids increase blood glucose levels in a variety of ways, including increased release of liver glycogen and desensitizing the insulin receptor to insulin, which reduces cellular uptake of glucose from the blood.

21. What early sign would the nurse expect when a client is suspected of autosomal dominant polycystic kidney disease (ADPKD)? A. Headache B. Nocturia C. Pruritus D. Facial edema

21. B Nocturia (the need to urinate excessively at night) is an early symptom and occurs because of decreased urine-concentrating ability when a client develops PKD.

21. The electrolyte magnesium is responsible for which functions? Select all that apply. A. Formation of hydrochloric acid B. Carbohydrate metabolism C. Contraction of skeletal muscle D. Regulation of intracellular osmolarity E. Vitamin activation F. Blood coagulation

21. B, C, E, F Magnesium is important for skeletal muscle contraction, carbohydrate metabolism, generation of energy stores, vitamin activation, blood coagulation, and cell growth. Adequate amounts of intracellular magnesium are particularly essential for the health and maintenance of cardiac muscle.

21. Which clients will the nurse recognize as at higher risk for having active tuberculosis (TB) in North America? Select all that apply. A. 22-year-old college student sharing a room in a dormitory B. 28-year-old man with HIV-III (AIDS) C. 48-year-old homemaker who volunteers at a soup kitchen D. 55-year-old homeless man with alcoholism who stays weekly in a shelter E. 60-year-old migrant farm worker from Mexico F. 68-year-old man incarcerated for 20 years

21. B, D, E, F Many people are exposed to the TB organism and do not develop active disease if they are otherwise healthy and immunocompetent. The college student living in a dormitory and the homemaker working in a soup kitchen are not at high risk. The man with HIV-III is severely immunocompromised despite his age, as is the client who is homeless and suffers from alcoholism. Poor immigrants from less affluent countries, such as Mexico, and those who live in crowded areas such as long-term care facilities, prisons, homeless shelters, and mental health facilities, are at high risk for developing active TB.

21. What procedural teaching will the nurse provide for a client scheduled for an abdominal CT scan with contrast? Select all that apply. A. The test will take about 30 to 45 minutes. B. An IV line will be placed for injection of the contrast. C. You may experience loud and gurgling sounds from your belly. D. The CT technician may ask you to hold your breath while images are taken. E. You may feel warm and flushed, and may experience a metallic taste with the injection. F. If you are claustrophobic, you can be given a mild sedative before the procedure.

21. B, D, E, F The nurse instructs the client that an IV access is required for injection of the contrast medium. Advise the client that he or she may feel warm and flushed, or experience a metallic taste, on or after the injection. A client who has claustrophobia may require a mild sedative to tolerate the study. The CT technician will instruct the client to lie still and to hold his or her breath when asked, as a series of images are taken. The test takes about 10 minutes and the client is not likely to experience gurgling bowel sounds.

21. Which signs and symptoms does the nurse expect to assess when a client has early gastric cancer? Select all that apply. A. Nausea and vomiting B. Feeling of fullness C. Weakness and fatigue D. Epigastric, back, or retrosternal pain E. Palpable gastric mass F. Abdominal discomfort initially relieved with antacids

21. B, D, F Although clients with early gastric cancer may be asymptomatic, dyspepsia and abdominal discomfort are the most common symptoms. A feeling of fullness and epigastric, back, or retrosternal pain are also early symptoms. Nausea and vomiting, weakness and fatigue, and a palpable gastric mass are late symptoms of gastric cancer.

21. Which cranial nerve does the nurse suspect is involved when a client reports severe, intermittent facial pain? A. Cranial nerve I B. Cranial nerve III C. Cranial nerve V D. Cranial nerve VII

21. C If the client reports severe, intermittent facial pain, he or she may have trigeminal neuralgia. Trigeminal neuralgia is a persistently painful and debilitating disorder that involves the trigeminal cranial nerve (V). Cranial nerve I is olfactory; cranial nerve III is oculomotor; and cranial nerve VII is facial.

21. A client is being evaluated for bone pain in the lower extremity. Which laboratory result indicates to the nurse a possible malignant bone tumor? A. Low vitamin D level B. Decreased serum calcium level C. Elevated serum alkaline phosphatase D. Decreased erythrocyte sedimentation rate

21. C Most often, the presence of a malignant bone tumor causes an elevated serum alkaline phosphatase (ALP) levels, regardless of specific tumor type. Elevation of this enzyme results from the body's attempt to form new bone by increasing osteoblastic activity.

21. What is the nurse's best response to a client who says he is afraid to have pulmonary function testing (PFTs) because it may reveal that he has lung cancer? A. "This test can establish whether lung cancer is present at a very early stage when the disease is more curable." B. "Because this test is noninvasive, it is less likely to cause you pain or increase your risk for infection." C. "These tests only determine whether your breathing is normal and cannot diagnose lung cancer." D. "There is nothing to fear because a local anesthetic is used."

21. C PFTs are noninvasive, which makes them painless and without risk for infection; however, they cannot diagnose lung cancer. The fear of a lung cancer diagnosis is this client's concern, not fear of pain or discomfort.

21. Which assessment will the nurse complete before notifying the health care provider about an older client's blood osmolarity result of 313 mOsm/L? A. Checking lungs for respiratory status B. Assessing for any discomfort or pain C. Looking for signs of dehydration D. Smelling urine for odor and looking for particles

21. C The normal range for blood osmolarity is 280 to 300 mOsm/kg (mmol/kg). When blood osmolarity increases, vasopressin is released. Vasopressin increases the permeability of the distal tubules to water. The nurse assesses the client for signs of dehydration from water loss.

21. Which electrolyte imbalance will the nurse assess for most frequently in a client who is receiving total parenteral nutrition with a solution that contains both glucose and insulin? A. Hypochloremia B. Hyperchloremia C. Hypokalemia D. Hyperkalemia

21. C The presence of insulin in the TPN solution activates the sodium- potassium ATPase pump on cell membranes and moves potassium from the extracellular fluid across the membranes into the cells, resulting in hypokalemia. Because the potassium is not present in the blood in high concentrations, any movement out of the blood can result in hypokalemia and serious physiologic changes.

21. Which statement about the peripheral vascular system is accurate? A. The velocity of blood flow depends on the diameter of the blood vessel lumen. B. The parasympathetic nervous system has the largest effect on blood flow to organs. C. Veins have valves that direct blood flow to the heart and prevent backflow. D. Blood flow decreases and blood tends to clot as the viscosity decreases.

21. C Veins in the superficial and deep venous systems (except the smallest and the largest veins) have valves that direct blood flow back to the heart and prevent backflow. Skeletal muscles in the extremities provide a force that helps push the venous blood forward. Veins have the ability to accommodate large shifts in volume with minimal changes in venous pressure.

21. Which client will the nurse recognize as having the highest risk for pancreatic cancer? A. 27-year-old man who is underweight and has opioid use disorder B. 35-year-old woman who is overweight and uses oral contraceptives C. 50-year-old woman who has ductal breast cancer and receiving radiotherapy D. 60-year old man who smokes two packs of cigarettes daily and has liver cirrhosis

21. D Although the exact cause of pancreatic cancer is not known, the older man who smokes and has liver cirrhosis has four risk factors.

21. When a client with heart failure walks 200 feet down the hall and develops a feeling of heaviness in the legs, how does the nurse interpret this finding? A. The client is building endurance. B. The activity is appropriate. C. The client could walk farther. D. The activity is too stressful.

21. D Many clients with heart failure (HF) experience weakness or fatigue with activity or have a feeling of heaviness in their arms or legs while walking for a distance. Such activity may place an unacceptable demand on the failing heart.

21. What is the nurse's best first action when a client with a spinal cord injury suddenly develops an SpO2 of 92% with stridor, bradycardia with decreased urine output, and a systolic blood pressure of 84 mm Hg? A. Apply oxygen at 2 L per nasal cannula. B. Place a large-bore IV access. C. Insert a urinary catheter. D. Notify the Rapid Response Team.

21. D The client with acute spinal cord injury would be monitored at least hourly for indications of neurogenic shock including: pulse oximetry (Spo2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability to clear airway); symptomatic bradycardia, including reduced level of consciousness and deceased urine output; and hypotension with systolic blood pressure (SBP) <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg. When symptoms of neurogenic shock occur, the priority action is to notify the Rapid Response Team or primary health care provider immediately because this problem is an emergency. The other three actions may be applicable, but the priority is to notify the Rapid Response Team of primary health care provider.

22. Which neurological check finding does the nurse recognize as an early indicator of declining neurologic status? A. Change in level of consciousness B. Nonreactive and dilated pupils C. Loss of remote memory D. Decorticate posturing

22. A A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or primary health care provider immediately.

22. Which annual examinations to screen for kidney problems would the nurse recommend for an African-American client? A. Urinalysis, microalbuminuria, and serum creatinine B. Kidney ultrasound, blood urea nitrogen, and serum glucose C. Serum creatinine, blood urea nitrogen, and renal scan D. 24-hour urine collection, blood urea nitrogen, and urinalysis

22. A African-American clients are at greater risk for kidney failure than are white clients. The nurse recommends yearly health examinations including urinalysis, checking for the presence of microalbuminuria, and evaluating serum creatinine.

22. Which signs and symptoms will the nurse expect to see in a client who is diagnosed with advanced pancreatic cancer? Select all that apply. A. Light-colored urine and dark-colored stools B. Anorexia and weight loss C. Splenomegaly D. Ascites E. Leg or calf pain F. Weakness and fatigue

22. A, B, C, D, E, F All of the signs and symptoms listed are associated with pancreatic cancer.

22. Which priority teaching points will the nurse provide for a client with a spinal cord injury who is treated with a halo fixator with vest? Select all that apply. A. Be careful when leaning forward or backward because the weight of the halo device alters balance. B. Wear loose clothing, preferably with large openings for head and arms. C. Wash under the liner of the vest to prevent rashes or sores. D. Support your head with a small pillow when sleeping to prevent unnecessary pressure and discomfort. E. Do not drive because you can't turn your head from side to side so peripheral vision is impaired. F. Increase fluids and fiber in the diet to prevent constipation.

22. A, B, C, D, E, F All of these are important teaching points for a client with a spinal cord injury who is being treated with a halo fixator with vest. The client cannot turn his or her head to check for blind spots, so peripheral vision is limited and it is not safe to drive. See the box labeled Patient and Family Education: Preparing for Self- Management Use of a Halo Fixator with Vest in your text for additional suggested teaching points for this client.

22. Clients with which problems will the nurse assess most frequently for dehydration? Select all that apply. A. Fever of 103°F (39.4oC) B. Extensive burns C. Thyroid crisis D. Water intoxication E. Continuous fistula drainage F. Diabetes insipidus

22. A, B, C, E, F Common causes or risk factors for dehydration are those that increase fluid loss or interfere with fluid intake, including: hemorrhage, vomiting, diarrhea, profuse salivation, fistulas, ileostomy, profuse diaphoresis, burns, severe wounds, long- term NPO status, diuretic therapy, GI suction, hyperventilation, diabetes insipidus, difficulty swallowing, impaired thirst, unconsciousness, fever, and impaired motor function. Water intoxication is related to over hydration, not dehydration.

22. Which clients will the nurse suggest to be immunized against hepatitis B (HBV)? Select all that apply. A. People who have unprotected sex with more than one partner B. Men who have sex with men C. Any client scheduled for a surgical procedure D. Firefighters E. Health care providers F. Clients prescribed immunosuppressant drugs

22. A, B, D, E, F HBV can be spread by both the parenteral and sexual routes. Exposures are more likely to result in infection in clients who are immunosuppressed for any reason. Individuals who are exposed to blood and other bodily fluids in the workplace are at risk for exposure.

22. Which self-care management techniques will the nurse teach a client with polycystic kidney disease (PKD) to prevent constipation? Select all that apply. A. Consume adequate fluid intake of 2 to 3 liters daily. B. Use stool softeners daily. C. Take NSAIDs for discomfort. D. Avoid aspirin-containing drugs. E. Maintain your fiber intake and exercise regularly. F. Increase your dietary protein intake with meals.

22. A, B, E The nurse teaches the client who has adequate urine output to prevent constipation by maintaining adequate fluid intake (generally 2 to 3 liters daily in food and beverages), maintaining dietary fiber intake, and exercising regularly. The client is advised about the use of stool softeners and bulk agents, including careful use of laxatives, to prevent chronic constipation. Aspirin-containing drugs are avoided to decrease the risk of bleeding, not constipation. NSAIDs are used cautiously because they can reduce kidney blood flow, but do not cause constipation. Protein intake may be limited to slow the development of end-stage kidney disease (ESKD), but is not an action that will reduce constipation.

22. Which potential causes of organic erectile dysfunction does the nurse assess for in a client? Select all that apply. A. Kidney disease B. Diverticulitis C. Thyroid disorders D. Obesity E. Diabetes mellitus F. Penile trauma

22. A, C, E, F Potential causes of organic erectile dysfunction include: vascular endocrine, or neurologic diseases; chronic diseases (e.g., diabetes mellitus, renal failure); penile disease or trauma; and surgery or pharmaceutical therapies.

22. Which assessment findings for a community-dwelling client who reports "not feeling well" for about 2 months indicate to the nurse the possibility of active tuberculosis (TB)? Select all that apply. A. Fatigue B. Weight gain C. Night sweats D. Back soreness E. Persistent cough F. Low-grade fever G. Shortness of breath H. Blood-streaked sputum

22. A, C, E, F, G, H Indications of TB include persistent cough, unintended weight loss, anorexia, night sweats, hemoptysis, shortness of breath, low-grade fever, and chills. Back soreness is not a common symptom of TB.

22. For which client with gastric cancer does the nurse expect that minimal invasive surgery (MIS) plus radiation therapy or chemotherapy may be curative? A. 45-year-old with advanced disease B. 50-year-old with early disease C. 60-year-old with liver metastases D. 65-year-old with invasion of the stomach muscle

22. B In early stages of gastric cancer, laparoscopic surgery (minimally invasive surgery [MIS]) plus adjuvant chemotherapy or radiation may be curative.

22. What does the nurse suspect when assessing a client at risk for CVD who states, "my right foot turns very dark red when I sit too long and when I put my foot up, it turns pale?" A. Central cyanosis B. Arterial insufficiency C. Peripheral cyanosis D. Venous insufficiency

22. B Rubor (dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency. Central cyanosis involves decreased oxygenation of the arterial blood in the lungs and appears as a bluish tinge of the conjunctivae and the mucous membranes of the mouth and tongue. Peripheral cyanosis occurs when blood flow to the peripheral vessels is decreased by peripheral vasoconstriction. Venous insufficiency is a result of prolonged venous hypertension that stretches and damages the valves which can lead to backup of blood, edema, and decreased tissue perfusion.

22. What is the priority intervention when a client comes to the emergency department (ED) with extreme anxiety, tachycardia, struggling for air, and a moist cough productive of frothy and blood-tinged sputum? A. Prepare for endotracheal intubation and mechanical ventilation. B. Administer high-flow oxygen therapy by face mask. C. Prepare for continuous positive airway pressure ventilation. D. Apply a pulse oximeter and a cardiac monitor.

22. B The priority nursing action is to administer oxygen therapy at 5 to 12 L/min by simple facemask or at 6 to 10 L/min by nonrebreathing mask with reservoir (which may deliver up to 100% oxygen) to promote gas exchange and perfusion. In addition, if the client is not hypotensive, place him or her in a sitting (high-Fowler) position with the legs down to decrease venous return to the heart. Apply a pulse oximeter and titrate the oxygen flow to keep the client's oxygen saturation above 90%. If supplemental oxygen does not resolve the client's respiratory distress, collaborate with the respiratory therapist and cardiac health care provider for more aggressive therapy, such as continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) ventilation. Intubation and mechanical ventilation may be needed for some clients.

22. Which assessment findings will the nurse caring for a client who had an allograft for a large bone defect that resulted from tumor removal report immediately to the surgeon to prevent harm? Select all that apply. A. Pain at the surgical site B. Signs of infection C. Hemorrhage D. Fracture E. Difficulty ambulating F. Loss of muscle tone

22. B, C, D Hemorrhage, infection, and fracture represent serious complications of the allograft surgery and can result in graft loss, as well as an increased risk for sepsis. To prevent harm and possible limb loss, indications of these problems need to be reported to the surgeon or Rapid Response Team immediately.

22. Which gastrointestinal (GI) changes will the nurse expect in an older client with a GI problem? Select all that apply. A. Increased hydrochloric acid secretion B. Decreased absorption of iron and vitamin B12 C. Decreased peristalsis with constipation D. Increased cholesterol synthesis E. Decreased lipase with decreased fat digestion F. Decreased drug metabolism with risk of toxicities

22. B, C, E, F The nurse understands that as people age, and after 65 years of age, physiologic changes occur in the GI system. Options B, C, E, and F are expected changes that occur with aging. For additional changes, see the box titled Patient-Centered Care: Older Adult Considerations: Changes in the Gastrointestinal System Associated With Aging in your text.

22. Which are the nurse's priority actions when caring for a client who has labored, shallow respirations and a respiratory rate of 32 breaths/min with a pulse oximetry reading of 85%? Select all that apply. A. Notify the respiratory therapist to give the client a breathing treatment. B. Start oxygen using a nasal cannula at a rate of 2 L/min. C. Assess other indicators of adequate gas exchange. D. Obtain an order for a stat arterial blood gas (ABG). E. Assist with coughing and deep-breathing exercises. F. Place the client in an upright position.

22. B, C, F The client is demonstrating difficulty breathing and ineffective gas exchange with hypoxemia. Placing the client in an upright position may improve respiratory effectiveness. Oxygen therapy is an appropriate immediate action to prevent harm. Pulse oximetry is usually a good indicator of gas exchange; however, the equipment may be faulty or the probe incorrectly placed. Therefore, assessing other indicators of adequate gas exchange is an appropriate early action. None of the other actions will have an immediate effect on gas exchange,

22. Which laboratory result will the nurse expect when a client with chronic kidney disease reports fatigue, lethargy with weakness, and mild shortness of breath with dizziness when rising to a standing position? A. Low blood glucose B. Low white blood cell count C. Low blood urea nitrogen (BUN) D. Low hemoglobin/hematocrit

22. D The client's symptoms suggest anemia which is common in clients in the later stages of CKD and makes symptoms worse. The causes of anemia include a decreased production of erythropoietin by the kidneys which causes reduced red blood cell (RBC) production and low hemoglobin and hematocrit levels.

22. What priority teaching will the nurse provide for a client on migraine preventive therapy who is taking a beta blocker and a calcium channel blocker drug? A. Move slowly when getting out of bed. B. Use handrails whenever possible. C. Avoid calcium-based foods. D. Learn to check your pulse.

22. D The nurse will teach clients who take beta-adrenergic blockers or calcium channel blockers how to take their pulse because both drugs lower blood pressure and heart rate. Clients are taught to report bradycardia or adverse reactions such as fatigue and shortness of breath to their primary health care provider as soon as possible. Rising slowly from bed and using handrails are also useful but not the highest priority. The client would not be advised to avoid foods with calcium.

22. What is the nurse's first action on finding that the blood glucose level of a client with diabetes who is NPO for surgery in the next hour is 150 mg/dL (8.4 mmol/L)? A. Administer regular insulin IV. B. Administer a dose of glucagon. C. Notify the surgeon immediately. D. Document the finding as the only action.

22. D The recommended blood glucose level for a client who has diabetes during surgery is between 140 mg/dL (7.8 mmol/L) and 180 mg/mL (10 mmol/L). This client's blood glucose is within the recommended range and no action regarding the level at this time is needed.

"23. In which position will the nurse place a client after an open Whipple procedure for treatment of pancreatic cancer? A. Semi-Fowler position to reduce tension on the suture line B. Prone position to prevent acute respiratory distress syndrome C. Left lateral Sims' position with knees drawn up to the chest to reduce pain D. Right lateral Sims' position with knees drawn up to the chest to reduce pain"

23. A After a radical pancreatectomy, the client is kept in a semi-Fowler position to reduce tension on the suture line and anastamosis site.

23. What problem will the nurse suspect when a client reports urgency, frequency, and bladder pain but the urinalysis shows a few white blood cells and red blood cells, but no bacteria and the urine culture results are negative? A. Interstitial cystitis B. Urethritis C. Kidney stones D. Incompletely treated bacterial cystitis

23. A Cystoscopy is needed to accurately diagnose interstitial (noninfectious) cystitis. A urinalysis usually shows WBCs and RBCs but no bacteria.

23. Which priority teaching points will the nurse include when teaching a client how to prevent low back pain and injury? Select all that apply. A. Use good posture when sitting, standing, and walking. B. Participate in a regular exercise program that includes daily aerobic workouts C. Do not wear high-heeled shoes. D. Avoid prolonged sitting or standing. E. Ensure adequate calcium and vitamin D intake. F. Keep weight within 30% of ideal body weight.

23. A, C, D, E Important teaching points by the nurse for a client to prevent low back pain (LBP) and injury include: use safe manual handling practices, with specific attention to bending, lifting, and sitting; assess the need for assistance with household chores or other activities; participate in a regular exercise program that promotes back strengthening, such as swimming and walking; do not wear high-heeled shoes; use good posture when sitting, standing, and walking; avoid prolonged sitting or standing; use a footstool and ergonomic chairs and tables to lessen back strain; be sure that equipment in the workplace is ergonomically designed to prevent injury; keep weight within 10% of ideal body weight; ensure adequate calcium intake and consider vitamin D supplementation if serum levels are low; and stop smoking (if not able to stop, cut down on the number of cigarettes or decrease the use of other forms of tobacco). Aerobic exercise is not a recommendation for prevention of LBP.

23. Which drugs would the nurse prepare to administer to a client with HF who has developed pulmonary edema? Select all that apply. A. Nitroglycerin sublingual B. Lorazepam IV C. Oxygen at 1 L/min nasal canula D. Furosemide IV E. Metoprolol IV F. Nitroglycerin IV

23. A, D, F If the client's systolic blood pressure is above 100, administer sublingual nitroglycerin (NTG) as prescribed to decrease afterload and preload every 5 minutes for three doses while establishing IV access for additional drug therapy. IV nitroglycerin may also be administered. Give furosemide (a rapid-acting loop diuretic) IV push (IVP) over 1 to 2 minutes to avoid ototoxicity. IV morphine sulfate may be prescribed, 1 to 2 mg at a time, to reduce venous return (preload), decrease anxiety, and reduce the work of breathing; however there is discussion about the benefits of using this drug for HF. Oxygen should be given high-flow with a face mask, not at 1 L/minute. Oral beta blockers are often prescribed for clients with heart failure and continued after discharge. IV lorazepam is used for sedation.

23. How will the nurse interpret a client's laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present. B. Permanent immunity to HAV is present. C. This is the client's first infection to HAV. D. The risk for infection if exposed to HAV is high.

23. B Immunoglobulin G (IgG) directed against HAV are antibodies that indicate the client was previously exposed to HAV and developed immunity against it.

23. What is the nurse's best response to a 50-year-old male client scheduled for a bunionectomy with wire placement who states "Since this is ambulatory surgery and I won't have to spend the night, I can plan on participating in a 10 K race next month."? A. "You may have to change your plans and only run a 5 K next month." B. "This is ambulatory surgery but the healing time is usually at least 6 to 12 weeks." C. "After this surgery, it is unlikely you will ever be able to run more than a mile again." D. "If you wear the orthopedic boot, you can run again as soon as you can tolerate the pain."

23. B Recovery from any surgery on the foot is quite slow compared with that in any other body region because it is so far away from the heart. Complete healing may take longer than 6 to 12 weeks. Only partial weight-bearing is permitted. Walking is difficult with an orthopedic boot and running is very unlikely. This client needs to have an in-depth discussion with his surgeon for exactly what the surgery entails and what is expected after surgery. The length of time for the surgery and the fact that it usually does not require an overnight stay have no bearing on the length of healing time required.

23. What complication does the nurse suspect when a client who had a gastrectomy develops tachycardia, syncope, and a desire to lie down 30 minutes after eating? A. Fluid overload B. Early dumping syndrome C. Late dumping syndrome D. Vitamin B12 deficiency

23. B These are early manifestations of dumping syndrome, which typically occur within 30 minutes of eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse reports these manifestations to the surgeon and encourages the client to lie down.

23. The nurse collaborates with the registered dietician nutritionist (RDN) to teach a client about which recommendations for management of chronic kidney disease? Select all that apply. A. Reducing calories B. Controlling protein intake C. Limiting fluid intake D. Restricting potassium E. Increasing sodium F. Restricting phosphorus

23. B, C, D, F The nurse collaborates with the RDN to teach the client about diet changes that are needed as a result of CKD. Common changes include control of protein intake; fluid intake limitation; restriction of potassium, sodium, and phosphorus intake; taking vitamin and mineral supplements; and consuming enough calories to meet metabolic need.

23. What is the main reason a nurse caring for a postoperative surgical client in the recovery room carefully monitoring the client's urine output? A. Decreasing urine output indicates poor kidney function. B. Increasing urine output can indicate excessive IV fluid during surgery. C. Decreasing urine output may mean hemorrhage and risk for shock. D. Increasing urine output may mean that kidney function is returning to normal.

23. C Because urine output is related to blood pressure remaining high enough to perfuse the kidneys, urine output is a sensitive indicator of adequate fluid volume. When blood volume starts to decrease, the body attempts to conserve volume by decreasing urine output. Although decreasing output can be reflective of poor kidney function, that is not the reason it is measured so carefully after surgery when clients have an increased risk for hemorrhage.

23. For which client will the nurse question the diabetes health care provider's prescription for rosiglitazone? A. 22-year-old with new-onset asthma B. 40-year-old with hyperthyroidism C. 60-year-old with heart failure D. 65-year-old with kidney disease

23. C Rosiglitazone is a thiazolidinedione that has an increased risk for heart-related complications and deaths, bone fractures, and macular edema. Drugs from this class carry a black box warning to avoid their use in clients who have symptomatic heart failure.

23. Which instruction will the nurse provide to a client who is taking a phosphodiesterase-5 (PDE5) inhibitor drug for erectile dysfunction? A. If one pill does not work, wait an hour and take a second pill. B. Use relaxation techniques before and after taking this drug. C. Abstain from alcohol use before sexual intercourse. D. Do not perform heavy lifting while using this medication.

23. C The nurse teaches a client taking PDE5 inhibitors to abstain from alcohol before sexual intercourse because it may impair the ability to have an erection.

23. For which minimal risk diagnostic test will the nurse prepare the client with polycystic kidney disease to have as initial screening? A. Kidney-ureter-bladder (KUB) x-rays B. Computed tomography with angiography C. Renal ultrasonography D. Renal needle biopsy

23. C Ultrasound is the primary method for diagnosing PKD. The size of the kidney is measured by ultrasound as well as cysts within the kidney.

23. What is the minimum gauge of short peripheral catheter (SPC) through which a nurse can infuse a unit of packed RBCs for a client? A. 18 gauge B. 20 gauge C. 22 gauge D. 24 gauge

23. C Using a 22-gauge SPC is adequate for most therapies and blood can infuse without damage. Needles with a smaller gauge can damage blood cell membranes, making them useless in transfusion therapy.

23. Which health problem will the nurse assess for in an obese client who has a 40-inch waist circumference and a waist-to-hip ratio of 0.90? A. Rheumatoid arthritis B. Chronic kidney disease C. Cardiovascular disease D. Type 1 diabetes mellitus

23. C Waist circumference (WC) is a strong predictor of coronary artery disease (CAD), and WC greater than 35 inches (89 cm) in women and greater than 40 inches (102 cm) in men indicates central obesity. A waist-to-hip ratio (WHR) of 0.95 or greater in men (0.8 or greater in women) indicates android obesity with excess fat at the waist and abdomen, which is also a strong predictor of CAD. Rheumatoid arthritis symptoms are made worse by obesity but are not caused by it. Type 2 diabetes is associated with obesity but type 1 is not. Chronic kidney disease is not directly related to obesity.

23. Which assessment finding for a client who received the subcutaneous Mantoux skin test 72 hours ago will the nurse interpret as a positive test result for tuberculosis (TB)? A. Test area is red, warm, and blistered. B. A flat, erythematous skin rash is present at the test site. C. Induration/hardened area measures 5 mm or greater. D. Induration/hardened area measures 10 mm or greater.

23. D An area of induration (localized swelling with hardness of soft tissue), not just redness, measuring 10 mm or greater, indicates exposure to and possible active infection with TB.

23. What is the nurse's best action when a client is having a generalized tonic-clonic seizure and becomes cyanotic? A. Raise the head of the bed and apply oxygen by nasal cannula. B. Suction the client and alert the Rapid Response Team. C. Call the health care provider and obtain intubation equipment. D. Stay with the client because the cyanosis is usually self-limiting.

23. D It is not unusual for a client to become cyanotic during a generalized tonic-clonic seizure. The cyanosis is generally self- limiting, and no treatment is needed so the nurse would remain with the client. Some primary health care providers prefer to give a high-risk client (e.g., older adult, critically ill, or debilitated client) oxygen by nasal cannula or facemask during the postictal (after seizure) phase.

23. Which statement by a client indicates to the nurse lack of correct understanding about information provided regarding cerebral angiography? A. "I must not have anything to eat or drink for at least 4 to 6 hours before the procedure." B. "I will not be able to move my head during the procedure." C. "I will feel a warm sensation when the contrast dye is injected into my IV." D. "I will not be able to talk to anyone during the procedure."

23. D Prior to cerebral angiography, the nurse ensures that the client takes nothing by mouth (NPO) for 4 to 6 hours. Other important points to teach the client include: the head is immobilized during the procedure; the client may not move during the procedure; contrast dye is injected through a catheter placed in the femoral artery and the client will feel a warm or hot sensation when the dye is injected which is normal; and the client will be able to talk to health care professionals during the procedure and should let them know about pain or concerns.

23. Which client does the nurse expect is most likely to produce a urinalysis with a specific gravity (SG) of 1.004? A. Client with hypovolemia due to blood loss B. Client who has dehydration secondary to vomiting C. Client with syndrome of inappropriate antidiuretic hormone (SIADH) D. Client who is prescribed the diuretic medication furosemide every day

23. D The normal urine SG is 1.005 to 1.030; usually 1.010 to 1.025. A client may have decreased SG in chronic kidney disease, diabetes insipidus, malignant hypertension, diuretic administration (e.g. furosemide, hydrochlorothiazide), and lithium toxicity.

24. When the nurse is taking a history of an adult client who reports acute low back pain (LBP), which question is most likely to identify a causative factor? A. "Have you recently fallen or been lifting heavy objects?" B. "Are you having pain that radiates down your arm?" C. "Do you have a family history of neurologic disorders?" D. "Are you having trouble with walking or maintaining your balance?"

24. A LBP is most prevalent during the third to sixth decades of life but can occur at any time. Acute and subacute back pain usually result from injury or trauma such as during a fall, vehicular crash, or lifting a heavy object. Options B, C, and D are important questions but do not provide information that helps to identify the cause of the low back pain.

24. Which precaution to prevent harm is most important for the nurse to teach an overweight client who is prescribed to take orlistat? A. "Take a multivitamin daily because this drug prevents absorption of some vitamins." B. "Notify your primary health care provider if you have any thoughts about hurting yourself." C. "Be sure to use a reliable method of contraception because this drug can cause birth defects." D. "Watch for feelings of light-headedness and jitteriness because this drug can cause hypoglycemia."

24. A Orlistat inhibits lipase so that fats are only partially digested and absorbed. The nondigested fats and many fat-soluble nutrients are eliminated in the stool, potentially leading to vitamin deficiency.

24. Which issue does the nurse consider a priority when caring for a client diagnosed with atonic (akinetic) seizures? A. Possibility of injury related to falls B. Limited mobility related to lack of tonicity of muscles C. Confusion related to postictal period D. Organ ischemia related to decreased perfusion

24. A With an atonic (akinetic) seizure, the client has a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures cause the client to fall, which may result in injury.

24. Which actions will the nurse take to manage a client's dumping syndrome? Select all that apply. A. Providing smaller, more frequent meals B. Eliminating ingestion of fluids with meals C. Providing a high-carbohydrate diet D. Administering acarbose as prescribed E. Increasing fat and protein in the diet F. Administering subcutaneous octreotide three times a day before meals

24. A, B, D, E, F All of these actions will help with management of a client's dumping syndrome, except option C. The nurse teaches the client to eat a high-protein, high-fat, low- to moderate- carbohydrate diet.

24. Which substances does the nurse understand are not compatible with plastic containers when administering IV therapy to clients? Select all that apply. A. Insulin B. Nitroglycerin C. Propranolol D. Lorazepam E. Furosemide G. Fat emulsion

24. A, B, D, G A problem with using some plastic containers is that they are not compatible with substances such as insulin, nitroglycerin, lorazepam, fat emulsions, and lipid-based drugs. Nitroglycerin and insulin adhere to the walls of the polyvinyl chloride (PVC) container, making it impossible to know exactly how much medication the client is receiving.

24. Which actions will the nurse include as follow-up care for a client after cerebral angiography? Select all that apply. A. Check the dressing for bleeding and swelling around the site. B. Apply a heating pad to the site. C. Keep the extremity straight and immobilized. D. Maintain the pressure dressing for 2 hours. E. Check the extremity for adequate circulation. F. Monitor for contrast media reactions such as hives or flushing.

24. A, C, D, E, F All of these responses are appropriate to post-procedure care for a client with cerebral angiography except response B. Ice should be applied to the site, not heat.

24. For which symptoms or changes will the nurse instruct a client with polycystic kidney disease (PKD) to contact the health care provider immediately? Select all that apply. A. Presence of a foul urine odor B. Going more than 1 day between bowel movements C. Development of a headache that does not go away D. Getting up twice nightly to urinate E. Experiencing a sudden weight gain F. Consuming some small salty pretzels

24. A, C, E The nurse teaches a client and family to notify the primary health care provider for sudden weight gain, headache that does not go away, and for changes in urine such as a foul odor and new-onset blood in the urine. Missing a bowel movement for 1 day is not enough to establish constipation. Nocturia is characteristic of PKD. Consuming salty foods is a concern because of sodium restrictions, but eating a few small pretzels does not require notification of the primary health care provider.

24. Which key points would the nurse include when teaching a client about signs and symptoms of return or worsening of heart failure, that must be reported to the primary health care provider? Select all that apply. A. Cold symptoms (e.g., cough) lasting more than 3 to 5 days B. Rapid weight loss of 3 lb in a week C. Excessive awakening at night to urinate D. Increase in exercise tolerance lasting 2 to 3 days E. Development of dyspnea or angina at rest or worsening angina F. Increased swelling in feet, ankles, or hands

24. A, C, E, F Teach the client and caregiver to immediately report to the primary health care provider the occurrence of any of these symptoms, which could indicate worsening or recurrent heart failure: rapid weight gain (3 lb in a week or 1 to 2 lb overnight); decrease in exercise tolerance lasting 2 to 3 days; cold symptoms (cough) lasting more than 3 to 5 days; excessive awakening at night to urinate; development of dyspnea or angina at rest or worsening angina; and increased swelling in the feet, ankles, or hands.

24. Which situations or conditions will the nurse teach a client with diabetes are common causes of hypoglycemia? Select all that apply. A. Too much insulin taken compared with food intake B. Increased food intake especially after missed or delayed meals C. Insulin injected at the wrong time relative to food intake and physical activity D. Decreased insulin sensitivity as a result of regular exercise and weight loss E. Decreased insulin clearance from progressive kidney failure F. Decreased liver glucose production after alcohol ingestion

24. A, C, E, F The most common causes of hypoglycemia are: too much insulin compared with food intake and physical activity, insulin injected at the wrong time relative to food intake and physical activity, the wrong type of insulin injected at the wrong time, decreased food intake resulting from missed or delayed meals, delayed gastric emptying from gastroparesis, decreased liver glucose production after alcohol ingestion, and decreased insulin clearance due to progressive kidney failure.

24. What change in respiratory function does the nurse expect to find in a client who is dehydrated from severe diarrhea and vomiting? A. No changes, because the respiratory system is not involved B. Increased respiratory rate, because the body perceives dehydration as hypoxia C. Hypoventilation, because the respiratory system is trying to compensate for low pH D. Normal respiratory rate, but a decreased oxygen saturation

24. B Blood pressure decreases with dehydration because of a low blood volume. This condition is perceived by the body as hypoxia and impending shock. The respiratory rate increases to ensure adequate oxygenation even when blood pressure is low.

24. Which fluid and electrolyte balance assessment action will the nurse perform most often for a client with pancreatic cancer after surgery with a traditional Whipple procedure? A. Using a reflex hammer to check deep tendon reflexes B. Pinching up skin over the sternum and checking for tenting C. Applying a blood pressure cuff and assessing for a Trousseau sign D. Asking the client whether he or she has noticed tingling or numbness around the mouth

24. B Clients are at extreme risk for dehydration during and after a traditional Whipple surgical procedure for pancreatic cancer because of variety of factors. These factors include exposure of the bowel during surgery, extensive NPO status, the presence of drainage tubes, and protein malnutrition resulting in poor osmotic/oncotic pressure.

24. When the nurse assesses a client in the clinic for a physical examination and finds decreased skin temperature, what does this most likely indicate? A. Renal failure B. Arterial insufficiency C. Anemia D. Central cyanosis

24. B Decreased blood flow results in decreased skin temperature. It is lowered in several clinical conditions, including heart failure, peripheral vascular disease, and shock. It can be assessed for symmetry by touching different areas of the body with the dorsal (back) surface of the hand or fingers.

24. Which clients diagnosed with urinary tract infection (UTI) may need longer antibiotic treatment? Select all that apply. A. Postmenopausal woman B. Diabetic woman C. Immunosuppressed male D. Female client prescribed birth control E. Pregnant woman F. Older male with complicated UTI

24. B, C, E, F Longer antibiotic treatment (7 to 21 days) is required for hospitalized clients and those with complicated UTIs (e.g., men, pregnant women, and clients with anatomic, functional or metabolic derangements that affect the urinary tract). Men in general need longer antibiotic treatment. Postmenopausal women or women taking birth control pills do not require longer treatment.

24. What is the best explanation a nurse will provide to a client whose skin test result for tuberculosis (TB) is positive? A. "There is active disease, but you are not yet infectious to others." B. "There is active disease, and you need to start drug therapy immediately." C. "You have been infected, but this does not mean active disease is present." D. "A repeat skin test is necessary because the test could give a false-positive result."

24. C A positive reaction to a TB indicates exposure to TB or the presence of inactive (dormant) disease, not active disease. Additional testing is needed to rule out or confirm active TB.

24. Which instruction will the nurse give the assistive personnel (AP) about when it is best to collect a client's urinalysis sample? A. In the evening before bedtime B. An hour after any meal C. With the first morning void D. After drinking two full glasses of water

24. C Ideally, the urine specimen is collected at the morning's first voiding. Specimens obtained at other times may be too dilute.

24. Which instruction will the nurse give to the client with plantar fasciitis about self-management to reduce pain? A. Use rest, elevation, and warm packs. B. Perform gentle jogging exercises. C. Strap the foot to maintain the arch. D. Wear loose or open shoes, such as sandals.

24. C Plantar fasciitis is an inflammation of the fascia that holds foot bones in place to form the foot's arch. Supporting the arch by wearing shoes with a good arch support or an orthotic insert can help prevent the fascia from pulling and irritation. Strapping the center of the sole of the foot, which can be performed by the client, also helps maintain the arch and reduce the pain.

24. Which end-tidal carbon dioxide level in a client being monitored with capnography after anesthesia indicates to the nurse a possible early problem affecting gas exchange? A. 28 mm Hg B. 40 mm Hg C. 58 mm Hg D. 80 mm Hg

24. C The normal value of the partial pressure of end-tidal carbon dioxide ranges between 20 and 40 mm Hg. Thus options A and B are within the normal range. 58 mm Hg indicates a relatively early problem with effective gas exchange. Option D represents a severe or late problem with gas exchange.

24. To avoid harm and prevent osteodystrophy, which intracollaborative action does the nurse implement? A. Encouraging high-quality protein foods B. Administering iron supplements twice a day C. Encouraging extra milk with meals and snacks D. Administering phosphate binders with each meal

24. D Phosphorus restriction for control of phosphorus levels is started early in CKD to avoid renal osteodystrophy. The nurse administers phosphate binders at mealtime to increase their effectiveness in slowing or preventing the absorption of dietary phosphorus.

25. What would the nurse do when caring for an older adult client receiving IV fluids through a central line at 150 mL/hr, who becomes short of breath, develops puffiness around the eyes, and now has a cough? A. Place the client in an upright position, administer oxygen, slow the IV fluids, and notify the health care provider. B. Notify the health care provider, place the client in Trendelenburg position, and administer urokinase to unclot the catheter. C. Assess for patency of the central line catheter, change the tubing, and resume the IV fluids. D. Remove the central line, apply pressure, notify the health care provider, and place the client in a semi-Fowler's position.

25. A The client's symptoms point to circulatory overload, not a clot or other obstruction within the catheter. Key interventions at this time would include: slow the IV rate and notify the health care provider; raise client to an upright position; monitor vital signs and administer oxygen as prescribed; administer diuretics as prescribed. When breathing difficulties are present, lying flat or in Trendelenburg position makes breathing harder.

25. Which actions will the nurse take to ensure that a client's 24-hour urine collection is completed appropriately? Select all that apply. A. Teach the client that a 24-hour collection of urine is necessary to quantify or calculate the rate of clearance of a particular substance. B. Check with the laboratory or procedure manual for proper technique to maintain the 24-hour collection. C. Do not remove urine from the collection container for other specimens during the 24-hour period. D. On initiation of the collection, ask the client to void, discard the urine, and note the time, then begin the collection. E. Twenty-four hours after initiation, ask the client to empty the bladder 24 hours after initiation and add that urine to the container. F. Place signs appropriately, then inform all personnel or family caregivers that the test is in progress.

25. A, B, C, D, E, F All of these options are appropriate actions for the nurse to implement to ensure that a 24-hour urine collection is successfully completed. See Box 60.1 Collection of Urine Specimens in your text for additional information.

25. Which nutritional supplements does the nurse expect the health care provider will prescribe for a client with chronic kidney disease? Select all that apply. A. Water-soluble vitamins B. Calcium C. Iron D. Magnesium E. Vitamin D F. Phosphorus

25. A, B, C, E The nurse expects the health care provider to prescribe daily vitamin and mineral supplements for most clients with CKD. Low-protein diets are also low in vitamins, and water-soluble vitamins are removed from the blood during dialysis. Anemia also is a problem in clients with CKD because of the limited iron content of low-protein diets and decreased kidney production of erythropoietin. Thus, supplemental iron is needed. Calcium and vitamin D supplements may be needed, depending on the client's serum calcium levels and bone status.

25. Which techniques will the nurse teach a client with diabetes about how to prevent harm from loss of insulin potency? Select all that apply. A. "Avoid exposing insulin to temperatures below 36°F (2.2°C) or above 86°F (30°C)." B. "Freeze bottles of insulin for long-term storage." C. "Always shake NPH insulin to assure it is evenly cloudy." D. "Avoid exposing insulin to heat or light." E. "Store unopened insulin bottles in a refrigerator." F. "A slight loss in potency may occur for bottles in use for more than 30 days but can still be used."

25. A, D, E To prevent loss of drug potency, clients are taught to avoid exposing insulin to temperatures below 36°F (2.2°C) or above 86°F (30°C), to avoid shaking bottles/vials, and to protect insulin from direct heat and light. Insulin is not to be frozen. Insulin potency decreases rapidly when bottles/vials have been opened and used for longer than 28 days and clients are instructed to discard open bottles after 28 days of use.

25. Which assessment is the priority for the nurse to make in the immediate postoperative period for a client after bariatric surgery? A. Asking the client to rate his or her pain B. Checking oxygen saturation and respiratory effort C. Examining the wound for indications of infection or dehiscence D. Monitoring skinfold areas for cleanliness and indications of breakdown

25. B Although all the listed assessments are important, airway management is the priority in the immediate postoperative period after bariatric surgery. Obese clients often have short, thick necks and compromised airways. These clients are more likely to need mechanical ventilation or other types of respiratory support to ensure adequate gas exchange.

25. What is the correct technique for the nurse to use to check a client's lower extremities using the ankle-brachial index? A. Blood pressure in the legs is measured with the client supine; then the client stands for 5 minutes and blood pressure is measured in the arms. B. A blood pressure cuff is applied to the lower extremities and the systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. C. The dorsalis pedis and posterior tibial pulses are manually palpated and compared bilaterally for strength and equality and compared to a standard index. D. A blood pressure cuff is applied to the lower extremities to observe for an exaggerated decrease in systolic pressure of more than 10 mm Hg during inspiration.

25. B The ankle-brachial index (ABI) can be used to assess the vascular status of the lower extremities. A BP cuff is applied to the lower extremity just above the malleolus. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ABI. Normal values for the ABI are 1.00 or higher because BP in the legs is usually higher than BP in the arms.

25. Which statement by a client with heart failure indicates to the nurse the need for additional teaching? A. "If my heart feels like it's racing, I should call my health care provider." B. "I must weigh myself once a week and watch for signs of fluid retention." C. "I'll need periods of rest and activity and I should avoid activity after meals." D. "I'll need to consider and plan my activities for the day, and rest as needed."

25. B The client is taught to weigh himself or herself every day (not once a week). The other statements indicate that the client has an appropriate understanding of the treatment regimen for heart failure.

25. Which intracollaborative therapy does the nurse expect the health care provider to prescribe for a postmenopausal client diagnosed with noninfectious urethritis? A. Antibiotic therapy B. Frequent sitz baths C. Estrogen vaginal cream D. Culture of drainage

25. C Noninfectious urethritis symptoms usually resolve spontaneously over time, regardless of treatment. Postmenopausal women often have improvement in urethral symptoms with the use of estrogen vaginal cream. Estrogen cream applied in a thin layer locally to the vagina increases the amount of estrogen in the urethra as well, reducing irritating symptoms.

25. Which action will the nurse take to prevent infection when a 95- year-old nursing home resident has a productive cough, fever, chills, and a history of night sweats but the client's Mantoux test for tuberculosis (TB) is negative? A. Use Standard Precautions alone because the client does not have TB. B. Use Airborne Precautions because the client is at high risk for TB. C. Use Airborne Precautions until a chest x-ray shows the client not to have active TB. D. Use Standard Precautions alone because the client is taking penicillin therapy for another respiratory infection.

25. C When clients are very old or have severe immunodeficiency, their Mantoux skin tests may be negative even when active TB is present because their reduced immunity may result in too few immune system cells and cell products to mount an immune response to the test (anergy). Therefore, Airborne Precautions are used in addition to Standard Precautions with any older client who presents with clinical indications of TB until other tests also rule it out.

25. What is the priority action to prevent harm for a nurse to take before allowing a client who had a flexible bronchoscopy 2 hours ago to drink or eat? A. Assessing pulse oximetry to be sure oxygen saturation has returned to normal B. Measuring the client's end-tidal carbon dioxide level C. Asking whether the client has any nausea D. Checking for return of the gag reflex

25. D A flexible bronchoscopy is often performed using light sedation or local anesthesia, both of which can reduce the gag reflex. When the gag reflex is reduced or not intact, the risk for aspiration increases. Oxygen saturation and end-tidal carbon dioxide levels do not determine whether the client's gag reflex has returned. Although nausea should be ruled out, the priority action to prevent harm is ascertaining the presence of an intact gag reflex.

25. What does the nurse suspect when assessment of a client after gastric resection reveals a tongue that is smooth, shiny, and appears "beefy"? A. Inadequate nutrition B. Hypovolemia C. Anemia D. Atrophic glossitis

25. D After gastrectomy the nurse assesses for the development of atrophic glossitis secondary to vitamin B12 deficiency. In atrophic glossitis, the tongue takes on a shiny, smooth, and "beefy" appearance.

25. How will the nurse prepare a client for an electroencephalogram test? A. Encourage extra fluids during the evening before the test. B. Give the client a sedative before bedtime for sleep. C. Give nothing by mouth but ice chips after midnight. D. Instruct the assistive personnel to wash the client's hair.

25. D Fasting is avoided before EEG testing because hypoglycemia can alter the test results. Ensure that hair is clean and without conditioners, hair creams, lotions, sprays, or styling gels. Teach the client to avoid the use of sedatives or stimulants in the 12 to 24 hours preceding the EEG.

25. What is the nurse's priority concern when caring for clients with hydronephrosis or hydroureter? A. Dilute urine B. Dehydration C. Pain with urination D. Obstruction

25. D Hydronephrosis and hydroureter are problems of urinary elimination with outflow obstruction. Urethral strictures obstruct urine outflow and may contribute to bladder distention, hydroureter, and hydronephrosis. Prompt recognition and treatment are crucial to preventing permanent kidney damage.

25. Which is the best technique to use for assessing the skin turgor of an 80-year-old client? A. Observing the skin for a dry, scaly appearance and compare it to a previous assessment. B. Pinching the skin over the back of the hand and observe for tenting; count the number of seconds for the skin to recover position. C. Observing the mucous membranes and tongue for cracks, fissures, or a pasty coating. D. Pinching the skin over the sternum and observe for tenting and resumption of skin to its normal position after release.

25. D The skin of an older adult is usually dry and scaly. Thinning skin and loss of subcutaneous tissue on the back of the hand makes assessing skin turgor here unreliable because this skin may tent even when hydration is good. Observing mucous membranes is not assessing skin turgor. The skin on the forehead and sternum are recommended for assessing turgor on an older adult.

25. Which medication prescription will the nurse clarify before administering it to a client? A. Gabapentin for a client who has partial seizures B. Diazepam rectal gel for a client with status epilepticus C. Carbamazepine for a client with tonic-clonic seizures D. Warfarin for a client who takes phenytoin for seizures

25. D Using warfarin together with phenytoin may cause a client to bleed more easily. It may also increase phenytoin levels. Phenytoin levels and prothrombin time or international normalized ratio (INR) should be monitored whenever the dosage is changed or discontinued.

26. What is the best technique for assessing a client's right lower leg for arterial insufficiency? A. Palpate the peripheral arteries using a head-to-toe approach with side-to side comparison. B. Check all pulse points in the right leg in dependent and supine positions. C. Palpate the major arteries including the femoral, and observe for pallor. D. Use a Doppler to find the dorsalis pedis and posterior tibial pulses in the right leg.

26. A Assessment of arterial pulses provides information about vascular integrity and circulation. For clients with suspected or actual vascular disease, major peripheral pulses should be assessed for presence or absence, amplitude, contour, rhythm, rate, and equality. Palpate the peripheral arteries in a head-to-toe approach with a side-to-side comparison.

26. Which findings would the nurse expect in a client with mitral valve stenosis? Select all that apply. A. A client with mild mitral valve stenosis will likely be asymptomatic. B. Classic signs include dyspnea, angina, and syncope. C. Rumbling apical diastolic murmur D. Syncope on exertion E. Sinus tachycardia F. Right-sided heart failure with jugular (neck) vein distention

26. A, B, C, F Key features of mitral valve stenosis include fatigue; dyspnea of exertion; orthopnea; paroxysmal nocturnal dyspnea; hemoptysis; hepatomegaly; neck vein distention; pitting edema, atrial fibrillation; and rumbling apical diastolic murmur. Syncope on exertion occurs with aortic stenosis and sinus tachycardia with aortic regurgitation.

26. Which drugs and side effects will the nurse plan to teach a client with active non-drug-resistant tuberculosis (TB) who is being discharged on first-line therapy? Select all that apply. A. Rifampin; contact lenses can become stained orange B. Isoniazid; report yellowing of the skin or darkened urine C. Pyrazinamide; maintain a fluid restriction of 1200 mL/day D. Ethambutol; report any changes in vision E. Amoxicillin; take this drug with food or milk

26. A, B, D Amoxicillin is not prescribed for TB. Pyrazinamide, although prescribed for TB, calls for an increase in fluids, not fluid restriction. Rifampin, isoniazid, and ethambutol are first-line drugs for TB therapy and have side effects. The side effects listed with these drugs are appropriate to teach the client.

26. What equipment will the nurse ensure is in the room of a client being admitted on seizure precautions to prevent harm? Select all that apply. A. Oxygen equipment B. Padding for siderails C. Suctioning equipment D. Saline lock insertion equipment E. Padded tongue blade F. Neurological assessment flow sheet

26. A, C, D Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. If the client does not have an IV access, a saline lock should be inserted, especially if the client is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded siderails may be embarrassing to the client and family. Padded tongue blades do not belong at the bedside and should never be inserted into the client's mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk for aspirating tooth fragments than prevent the client from biting the tongue. Improper placement of a padded tongue blade can also obstruct the airway. The seizure must be documented but a neurological assessment flow sheet is not necessary.

26. Which assessment findings on a client who had a bronchoscopy using the local anesthetic benzocaine spray along with light sedation are most important to report to the health care provider who performed the procedure? Select all that apply. A. Oxygen saturation is 60% and does not increase with supplemental oxygen. B. Twenty minutes after the procedure, the client remains drowsy. C. Client coughed on first being awake but is no longer coughing. D. The client reports having a sore throat. E. Oral mucous membranes are cyanotic. F. Sputum is grossly bloody.

26. A, E, F The cyanosis and low oxygen saturation that does not improve with supplemental oxygen are very serious and could indicate methemoglobinemia associated with the use of benzocaine spray, which requires immediate intervention to prevent death. Grossly bloody sputum is not a normal expectation after the procedure and could herald hemorrhage. Most clients have a sore throat after bronchoscopy and remain somewhat drowsy for an hour or more after sedation. Neither of these responses are caused for alarm, nor is a reduction in coughing.

26. What problem does the nurse suspect when a client with well- controlled diabetes develops an unexpected increase in blood glucose level 2 days after surgery? A. Family bringing in food for client consumption B. Wound infection occurring before fever C. Response to interactions of newly prescribed drugs D. Progression of disease severity to type 1 diabetes

26. B The most common cause of an elevated blood glucose level in a client who has maintained long-term good control is infection. Often the blood glucose level will rise before other indications of infection are present, including fever.

26. What is the nurse's first action when a client with chronic kidney disease (CKD) develops restlessness, anxiousness, shortness of breath, a rapid heart rate, frothy sputum, and crackles in the bases of the lungs? A. Facilitating transfer to the intensive care unit for aggressive treatment B. Placing the client's head of bed in the high-Fowler position C. Monitoring vital signs and assessing the lungs every 15 minutes D. Administering an IV loop diuretic such as furosemide

26. B The nurse recognizes this client's symptoms as indicators of pulmonary edema. First, the client is placed in a high-Fowler position and given oxygen to improve gas exchange. Then health care provider or Rapid Response Team is notified for treatment and management of pulmonary edema.

26. Which action will the nurse include in postprocedural care for a client who has a renal scan? A. Administer captopril to increase renal blood flow. B. Encourage oral fluids to assist with excretion of the isotope. C. Insert a urinary catheter to measure urine output. D. Administer prescribed laxatives to cleanse the bowel.

26. B This imaging test is used to examine the perfusion, function, and structure of the kidneys by the IV administration of a radioisotope. The isotope is eliminated 6 to 24 hours after the procedure. The nurse encourages the client to drink fluids to aid in excretion of the isotope.

26. What is the nurse's interpretation of a client's urine specific gravity of 1.039? A. Overhydration B. Dehydration C. Normal value for an adult D. Renal disease

26. B With dehydration, the urine is usually concentrated, with a specific gravity greater than 1.030 and has a dark amber color and a strong odor. A urine specific gravity is reflective of dehydration. Overhydration (fluid overload) usually is associated with a very low specific gravity. Renal disease is based on parameters other than urine specific gravity.

26. Which technique will the nurse use to access a client's implanted port for chemotherapy? A. Palpate the port, scrub the skin, and access port with a butterfly needle. B. Scrub the port with alcohol and access the port with a needleless device. C. Palpate the port, scrub the skin, and access the port with a noncoring needle. D. Scrub the port with betadine and flush using saline in a 10-mL syringe.

26. C Port access should be done only by formally trained health care professionals using a mask and aseptic technique. Before puncture, palpate the port to locate the septum. Carefully palpate to feel the shape and depth of the port body to ensure puncture of the septum. Scrub the skin over the port with alcohol. Implanted ports are accessed by using a noncoring needle (a common brand name is Huber) that is specially designed with a deflected tip. This design slices through the dense septum without coring out a small piece of it, thus preserving the integrity of the septum.

26. Which laboratory result would the nurse notify the radiology department and health care provider about for a client who is scheduled to have a computed tomography (CT) scan with contrast media? A. Blood glucose higher than baseline B. Decreased white blood cell count C. Elevated creatinine level D. Abnormal urobilinogen level

26. C Prior to diagnostic test using contrast media, it is essential to evaluate current kidney function. Clients with a serum creatinine greater than or equal to 1.5 mg/dL or a calculated glomerular filtration rate (GFR) of less than 60 mL/min are at highest risk for kidney damage from contrast media.

26. Which circumstance does the nurse recognize as creating the greatest risk of recurrent urolithiasis when a client is admitted for an orthopedic procedure? A. Providing milk to the client with every meal tray or snack B. Insertion of an indwelling urinary catheter for the procedure C. Restricting foods and fluids for extended periods of time D. Administering an opioid narcotic drug for the severe pain

26. C The nurse urges clients to drink enough fluids to maintain dilute urine throughout the day and night unless fluid restriction is needed for another health problem. Some urologists recommend sufficient fluid intake to result in at least 1.5 L of urine output or 7 to 12 voidings daily. Food can provide 20% or more of fluid intake, particularly the intake of fruits and vegetables. Insufficient fluid intake can lead to recurrent urolithiasis (the presence of calculi [stones] in the urinary tract). A history of calculi in the urinary tract is also a risk factor for recurrence.

26. For which client will the nurse question the prescription of ziconotide for severe persistent back pain? A. Client with sciatic nerve pain B. Client using massage and heat for pain relief C. Client with severe mental health problems D. Client using NSAIDs and acupuncture for pain relief

26. C Ziconotide can be taken with opioid analgesics but should not be administered to clients with severe mental health or behavioral health problems because it can cause psychosis. If symptoms such as hallucinations and delusions occur, teach clients and families to stop the drug immediately and notify their primary health care provider.

26. What is the nurse's best first action when assessment findings on a client after gastric bypass surgery reveal increased back pain, restlessness, heart rate of 126 beats/min, and a urine output of only 15 mL for the past 2 hours? A. Increasing the IV infusion rate B. Inserting a fresh nasogastric tube C. Listening for bowel sounds in all abdominal quadrants D. Notifying the surgeon or Rapid Response Team immediately

26. D These assessment findings strongly suggest an anastamotic leak, which is an emergency and can lead to peritonitis, sepsis, and death.

27. What is the best place for the nurse to add a filter to a client's IV administration set? A. As close as possible to the catheter hub B. Immediately below the infusion pump C. As close to the solution container as possible D. At any convenient connection point unlikely to be disconnected

27. A The purpose of filters is to remove particulate matter, microorganisms, and air from the infusion system. Filters should be placed as close to the catheter hub as possible to prevent particulate matter (e.g., rubber pieces, glass particles, cotton fibers, drug particles, paper, and metal fibers) from becoming trapped in the small circulation of the lungs. A red blood cell is about 5 microns in diameter and is the largest size that can pass through the pulmonary capillary bed; IV fluids may contain particles larger than 5 microns. For patients receiving infusion therapy for long periods, a significant number of particles could block the blood flow through the pulmonary circulation. Microcirculation in the spleen, kidneys, and liver could also be affected

27. Which actions will the nurse take when caring for a client after bariatric surgery to prevent harm from complications? Select all that apply. A. Monitoring oxygen saturation B. Applying an abdominal binder C. Placing the client in semi-Fowler position D. Applying sequential compression stockings E. Assessing skinfolds for redness and excoriation F. Maintaining the client on bedrest for 24 to 48 hours

27. A, B, C, D, E With the exception of maintaining the client on bedrest for 24 to 48 hours, all of the above actions are recommended as best practices to prevent the many potential complications associated with bariatric surgeries.

27. Which clients will the nurse advise to receive the meningococcal vaccine? Select all that apply. A. Healthy 18-year-old who has enlisted in the military B. 25-year-old who had a splenectomy after an auto accident C. Healthy 24-year-old who is interning with a lawyer for the summer D. Healthy 20-year-old who plans to live in a university dormitory E. Healthy 22-year-old who is unsure about vaccination and plans to visit Asia F. 21-year-old who has a summer job with a moving company

27. A, B, D, E People aged 16 through 21 years have the highest rates of infection from life-threatening N. meningitidis meningococcal infection. The Centers for Disease Control and Prevention (CDC) recommends an initial meningococcal vaccine between ages 11 and 12 years with a booster at age 16 years. Adults are advised to get an initial or a booster vaccine if living in a shared residence (e.g., residence hall, military barracks, group home), or traveling or residing in countries in which the disease is common, or if they are immunocompromised as a result of a damaged or surgically removed spleen or a serum complement deficiency. If the client's baseline vaccination status is unclear and the immediate risk for exposure to N. meningitidis infection is high, the CDC recommends vaccination. It is safe to receive a booster as early as 8 weeks after the initial vaccine.

27. Which action to prevent harm is most important for a nurse to include when teaching a client with tuberculosis (TB) about the prescribed first-line drug therapy? A. "Wear a mask for the first 8 weeks on therapy at home and when away from home." B. "Do not drink alcohol in any quantity while taking these drugs." C. "Avoid grapefruit and grapefruit juice while taking these drugs." D. "Restrict fluid intake to 2 quarts of liquid a day."

27. B All the first-line drugs for TB are liver toxic and can cause liver damage. Drinking alcohol compounds this damage and should be ingested only in small quantities, if at all. Fluids are to be increased, not decreased. Clients do not need to wear masks in their own homes because family members and anyone else living in the home have already been heavily exposed to the bacillus. Grapefruit does not affect the absorption or metabolism of these drugs.

27. What is the nurse's best interpretation when a client is admitted with flank pain, and the urine report indicates turbidity, foul odor, rust color, presence of white and red blood cells as well as bacteria, and microscopic crystals? A. Staghorn calculus with infection B. Urolithiasis and infection C. Pyuria and cystitis D. Dysuria and urinary retention

27. B Hematuria during renal colic is common, and blood may make the urine appear smoky or rusty. RBCs are usually caused by stone- induced trauma to the lining of the ureter, bladder, or urethra. WBCs and bacteria may be present as a result of urinary stasis. Increased turbidity (cloudiness) and odor indicate that infection may also be present. Thus, the nurse's best interpretation of these results is urolithiasis with infection.

27. Which concept is most directly related to the nurse's teaching a client about smoking cessation to maintain or improve nervous system health? A. Comfort B. Perfusion C. Mobility D. Cognition

27. B Practicing a healthy lifestyle can help promote nervous system health. Smoking constricts blood vessels and can lead to decreased perfusion to the brain, resulting in a brain attack or stroke. The nurse teaches clients the importance of smoking cessation.

27. Which priority preoperative teaching about postoperative concerns does the nurse provide for a client scheduled for lumbar surgery? Select all that apply. A. Bedrest restriction for at least 48 hours B. Techniques for getting into and out of bed C. Limitations and restrictions for home activities D. Expectations for turning and moving in bed E. Immediate reporting of any numbness or tingling F. Dietary restrictions for sodium and fats

27. B, C, D, E The nurse teaches clients preoperatively about postoperative expectations because many clients are discharged to home within 23 to 48 hours after surgery. Priority teaching includes: techniques to get into and out of bed; expectations for turning and moving in bed; reporting immediately any new sensory perceptions, such as numbness and tingling, or new motor impairment that may occur in the affected leg or in both legs; and home care activities or restrictions. Because of the short hospital stay, the nurse teaches family members or other caregivers how to assist the client and what restrictions the client must follow at home before the surgery occurs

27. Which actions will the nurse teach to the spouse of a client with reduced cognition who has been treated twice in the emergency department for dehydration to prevent this condition? Select all that apply. A. Avoid offering fluids after 6.00 p.m. B. Weigh the client daily to check fluid status. C. Offer frequent snacks of gelatins and ice cream. D. Give the client salty crackers to increase his or her sensation of thirst. E. Offer four ounces of the client's favorite fluids every hour while awake. F. Watch the client while he or she drinks any liquids to ensure it is ingested. G. Estimate or measure the number of liquid ounces ingested daily to ensure an intake of at least 1500 mL.

27. B, C, E, F, G Options B, C, E, F, and G are recommended to help clients drink more fluids throughout the day and prevent dehydration. Avoiding fluids after early evening, a technique some families believe will reduce the risk for night time incontinence, does not reduce incontinence and may result in a lower daily intake of fluids. Salty food may not increase the sensation of thirst, especially in an older adult, and may induce an electrolyte imbalance.

27. For which finding in a client with mitral valve stenosis would the nurse immediately notify the primary health care provider because of the potential for decompensation? A. Slow, bounding peripheral pulses associated with bradycardia B. An increase and decrease in pulse rate that follows inspiration and expiration C. An irregular heart rhythm and ECG strip that indicate atrial fibrillation D. An increase in pulse rate and blood pressure after exertion

27. C Because the development of atrial fibrillation in a client with mitral valve stenosis indicates that the client may decompensate, the health care provider should be notified immediately of changes to the heart rhythm. Increase and decrease in pulse rate that varies with inspiration and expiration is characteristic of sinus arrythmia. An increase in heart rate and blood pressure is common for most clients. Bounding arterial pulses are associated with aortic regurgitation.

27. What common assessment finding would the nurse expect to find in an older adult with cardiovascular disease? A. Lower leg swelling B. Pericardial friction rub C. S4 heart sound D. Change in point of maximal impulse (PMI) location

27. C This question asks for a finding related to aging. An atrial gallop (S4) may be heard in clients with hypertension, anemia, ventricular hypertrophy, MI, aortic or pulmonic stenosis, and pulmonary emboli. It may also be heard with advancing age because of a stiffened ventricle. Edema, friction rubs, and PMI changes occur with CVD but are not just age related.

27. Which client will the nurse assess most often for the possibility of a postprocedure pneumothorax? A. Pulmonary function testing B. Flexible bronchoscopy C. Laryngoscopy D. Thoracentesis

27. D A pneumothorax (collapsed lung) is most common after invasive procedures that allow air into the intrapleural space, such as with a thoracentesis that involves having a needle penetrate through the chest wall into the pleural space. Pulmonary function testing is noninvasive; a flexible bronchoscopy does not penetrate the chest wall, and a laryngoscopy does not enter the lungs.

27. Which drug will the nurse avoid administering to a client with chronic kidney disease (CKD) to prevent harm? A. Opioids B. Antibiotics C. Oral antihyperglycemics D. Magnesium antacids

27. D The nurse questions a prescription for magnesium-containing antacids for clients with CKD because they cannot excrete magnesium and need to avoid any additional intake and build- up of magnesium. To avoid hypermagnesemia, the nurse teaches clients with kidney disease to avoid antacids containing magnesium.

27. What preprocedural instruction will the nurse provide for a client scheduled for an ultrasonography? A. "Empty your bladder just before the test begins." B. "Stop taking your routine medications 24 hours before the test." C. "You must have nothing to eat or drink after midnight before the test." D. "Drink 500 to 1000 mL of water 2 to 3 hours before the test."

27. D Ultrasonography usually requires a full bladder. The nurse asks the client to drink 500 to 1000 mL of water about 2 to 3 hours before the test to help fill the bladder. The nurse instructs the client not to void after drinking the water until the test is complete.

28. Which teaching would the nurse provide for the client and family on prevention of catheter-related bloodstream infection (CRBSI) before the IV catheter was inserted? Select all that apply. A. The type of catheter to be inserted B. Hand hygiene C. Aseptic technique for care of the catheter D. Activity limitations E. Signs and symptoms of complications F. Alternatives to catheter and therapy

28. A, B, C, D, E, F All options are correct responses to essential teaching that the nurse should provide for the client and family before an IV catheter is inserted for therapy.

28. Which findings indicate to the nurse that a client may have hypervolemia (fluid overload)? Select all that apply. A. Increased, bounding pulse B. Jugular venous distention C. Presence of crackles D. Excessive thirst E. Elevated blood pressure F. Orthostatic hypotension

28. A, B, C, E Common symptoms and problems associated with fluid overload first appear in the cardiopulmonary systems. These include: increased pulse rate, bounding pulse quality, elevated blood pressure, decreased pulse pressure, elevated central venous pressure, distended neck and hand veins, engorged varicose veins, weight gain, increased respiratory rate, shallow respirations, shortness of breath, and moist crackles on auscultation. Excessive thirst and hypotension are associated with dehydration.

28. Which client factors does the nurse consider a reason for implementation of a directly observed therapy (DOT) for antimicrobial therapy for tuberculosis (TB)? Select all that apply. A. Client is homeless. B. Client is often confused. C. TB is multidrug resistant. D. Client has gained 11 lb (5 kg) in 8 weeks. E. The main prescribed drug is bedaquiline. F. Symptoms have decreased after 4 weeks of therapy.

28. A, B, C, E Successful treatment of TB requires that prescribed antitubercular drugs be taken daily, exactly as prescribed, for as long as they are prescribed. Adherence is more difficult for anyone who is homeless or confused. When the disease is drug-resistant, adherence is even more important to prevent the client's death from disease progression. Bedaquiline is prescribed only for multidrug-resistant TB and has life-threatening serious side effects. For this reason, DOT therapy is recommended for bedaquiline. Weight gain and reduced symptoms are signs that therapy is effective, indicating that the client is adhering to the therapy regimen.

28. Which actions will the nurse include in postprocedural care for a client who had a cystoscopy with general anesthesia? Select all that apply. A. Monitor for airway patency and breathing. B. Provide frequent vital sign checks including temperature. C. Record and monitor for any changes in urine output. D. Report pink-tinged urine to the urology care provider immediately. E. Irrigate the urinary catheter with sterile saline if prescribed. F. Encourage the client to take oral fluids to increase urine output.

28. A, B, C, E, F All of these actions are appropriate to the postprocedural care of a client after a cystoscopy with general anesthesia except option D. Pink-tinged urine is expected after this procedure. However, gross bleeding is not and should be reported immediately. Also, notify the urologist for obvious blood clots and a decrease or absence of urine output. Irrigate the Foley catheter with sterile saline, if prescribed by the urologist.

28. Which client signs and symptoms cause the nurse to suspect the possibility of renovascular disease? Select all that apply. A. Sudden onset of hypertension B. Distended bladder on palpation C. Difficult to control hypertension D. Sustained hyperglycemia E. Elevated serum creatinine F. Decreased glomerular filtration rate

28. A, C, D, E, F All of these options suggest a diagnosis of renovascular disease except option B, distended bladder. Renovascular disease includes processes affecting the renal arteries that may severely narrow the lumens and greatly reduce blood flow to the kidney tissues.

28. Which are the characteristics that the nurse would expect when a client is diagnosed with mitral valve prolapse (MVP)? Select all that apply. A. Valve leaflets enlarge and bulge up into the left atrium during systole. B. Hepatomegaly is a late sign. C. Most clients are asymptomatic and this abnormality is benign. D. Many clients have normal heart rates and blood pressures. E. Older adults have increased risk for mitral valve prolapse. F. A midsystolic click and late systolic murmur is best heard at the apex of the heart.

28. A, C, D, F With MVP, the valvular leaflets enlarge and prolapse (bulge) upward into the left atrium during systole. This abnormality is usually benign. However, it may progress to pronounced mitral regurgitation in some clients. A normal heart rate and BP are usually found on physical examination. A midsystolic click and a late systolic murmur may be heard at the apex of the heart. MVP often begins in younger adults and has a familial tendency. Hepatomegaly occurs with mitral stenosis, not MVP.

28. Which signs and symptoms are commonly assessed by the nurse when a client is diagnosed with meningitis? Select all that apply. A. Disorientation to person, place, and time B. Nuchal rigidity (stiff neck) C. Severe, unrelenting headaches D. Positive Kernig's sign E. Decreased level of consciousness F. Generalized muscle aches and pain (myalgia)

28. A, C, E, F See the box labeled Key Features of Meningitis in your text for additional common signs and symptoms. The classic nuchal rigidity (stiff neck) and positive Kernig's and Brudzinski's signs have been traditionally used to diagnose meningitis, however, these findings occur in only a small percentage of clients with a definitive diagnosis.

28. Which postoperative assessment finding, for a client who underwent a laminectomy, does the nurse report immediately to the surgeon? A. Refusal of the client to cough and deep breathe B. Swelling or bulging at the operative site C. Pain along the operative incision site D. Serosanguineous drainage on the dressing

28. B The nurse will immediately report bulging at the incision site. This may be due to a cerebrospinal fluid (CSF) leak or a hematoma, both of which should be reported to the surgeon immediately. CSF may be visible as a "halo" around the outer edges of the dressing. The loss of a large amount of CSF may cause the client to report having a sudden headache.

28. Which problem does the nurse suspect in a client who is 4 weeks postoperative from gastric bypass surgery and reports that after a meal her heart races, she is nauseated, and has abdominal cramping with diarrhea? A. Hyperglycemia B. Intestinal obstruction C. Possible peritonitis D. Dumping syndrome

28. D Dumping syndrome occurs when food enters the small intestine rather than the stomach after gastric bypass surgery, which results in increased blood flow to that site with decreased blood flow elsewhere. This causes hypotension and tachycardia from reduced central circulation and increased intestinal peristalsis with abdominal cramping and diarrhea from the stimulation caused by the sudden expansion of the intestinal lumen.

28. Which is the best interpretation of client neurological assessment documentation that reads PERRLA? A. Peripheral nervous system is reactive and responsive when activated. B. Parasympathetic nervous system is responsible for reproductive actions. C. Pulses are equal in right arm and right leg and client is ambulatory. D. Pupils are equal in size, round, regular, and react to light and accommodation.

28. D Testing pupils is a common cranial nerve test performed by nurses. Pupil constriction is a function of cranial nerve III, the oculomotor nerve. Pupils should be equal in size, round, and regular in shape, and react to light and accommodation (PERRLA).

28. Which condition will the nurse monitor closely for in a client with type 1 diabetes who has blood glucose level of 438 mg/dL (24.4 mmol/L)? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

28. D The client is severely hyperglycemic and is using fat for fuel, which increases the amount of ketone bodies released into the blood from fatty acid breakdown. This situation leads to diabetic ketoacidosis (DKA), a type of metabolic acidosis, with a low pH as hydrogen ion concentration increases. Although the client's compensatory efforts with breathing more rapidly and deeply can cause some respiratory alkalosis with a lower-than-normal carbon dioxide level, the acidosis is more likely to have serious consequences.

28. What is the priority nursing concern when a client is admitted with a history of kidney stones and presents with severe flank pain, nausea and vomiting, pallor, and diaphoresis? A. Possible hemorrhage B. Urinary elimination blockage C. Impaired tissue perfusion D. Severe pain

28. D The major symptom of stones is severe pain, commonly called renal colic. Drug therapy is needed in the first 24 to 36 hours when pain is most severe. Opioid analgesics are used to control the severe pain caused by stones in the urinary tract and may be given IV for rapid pain relief.

29. Which essential nursing intervention will the nurse implement when a client returns from having shock wave lithotripsy? A. Strain the urine to monitor for the passage of stone fragments. B. Report bruising on the affected side immediately to the urologist. C. Apply a local anesthetic cream to the client's skin on the affected side. D. Continuously monitor the client's heart pattern for dysrhythmias.

29. A After lithotripsy, the nurse implements straining the urine to monitor the passage of stone fragments. Bruising on the affected side is expected after this procedure. Anesthetic cream is not needed after the procedure, nor is cardiac monitoring.

29. What is the priority nursing responsibility when a client is receiving IV therapy through an infusion pump? A. Monitor the client's infusion site and rate. B. Program the correct amount of fluid into the pump. C. Position the container for gravity flow. D. Check the equipment at the end of the infusion.

29. A The use of pumps does not decrease the nurse's responsibility to carefully monitor the client's infusion site and the infusion rate. Smart pumps (infusion pumps with dosage calculation software) have been promoted to reduce adverse drug events (ADEs). Incorrect programming of pumps without this feature is one of the most common types of drug errors, especially in hospitals.

29. Which are advantages of magnetic resonance imaging (MRI or MR) over computed tomography (CT) in the diagnostic imaging of a client's brain, spinal cord, and nerve roots? Select all that apply. A. MRI does not use ionizing radiation but instead relies on magnetic fields. B. Bony structures are viewed much clearer with MRI. C. Multiple sets of images are taken that are used to determine normal and abnormal anatomy. D. MRI testing is best for clients who are confused or claustrophobic. E. Images may be enhanced with the use of gadolinium, a non- iodine-based contrast medium. F. Some facilities have a functional MRI (fMRI) machine that can assess blood flow to the brain.

29. A, C, E, F Magnetic resonance imaging (MRI or MR) has advantages over CT in the diagnostic imaging of the brain, spinal cord, and nerve roots. It does not use ionizing radiation but instead relies on magnetic fields. Multiple sets of images are taken that are used to determine normal and abnormal anatomy. Images may be enhanced with the use of gadolinium, a non-iodine-based contrast medium. MRIs of the spine have largely replaced CT scans and myelography for evaluation. Bony structures cannot be viewed with MRI; CT scans are the best way to see bones. Some facilities have a functional MRI (fMRI) machine that can assess blood flow to the brain rather than merely show its anatomic structure. MRI may be contraindicated for clients who are confused, claustrophobic, or unstable.

29. Which signs and symptoms would the nurse expect to assess when a client is diagnosed with aortic stenosis? Select all that apply. A. Dyspnea on exertion B. Atypical chest pain C. Angina D. Hemoptysis E. Harsh, systolic crescendo-decrescendo murmur F. Orthopnea

29. A, C, E, F Signs and symptoms of aortic stenosis include dyspnea on exertion; angina; syncope on exertion; fatigue, orthopnea, paroxysmal nocturnal dyspnea; and harsh, systolic crescendo- decrescendo murmur. Atypical chest pain is characteristic of mitral valve prolapse and hemoptysis occurs with mitral stenosis.

29. For which situations will the nurse teach a client to perform urine ketone testing? A. Anytime he or she is acutely ill or severely stressed B. When blood glucose levels are above 200 mg/dL (11.1 mmol/L) C. When symptoms of diabetic ketoacidosis (DKA) are present D. While participating in a weight-loss program E. Before engaging in strenuous exercise F. After eating citrus fruit or drinking alcohol

29. A, D, E An acute illness or severe stress increases release of corticosteroids and results in high blood glucose levels that could increase the use of fatty acids for fuel and cause ketosis. Participation in a weight-loss program can result in insufficient intake of carbohydrates and result in increased breakdown of fatty acids, which causes formation of ketone bodies. Before heavy exercise, clients need to ensure a blood glucose level high enough to support the increased metabolism generated. When ketone bodies are present in the urine before exercise, they indicate that a client does not have a sufficient glucose level to support exercise at this time. The client is taught to not exercise when ketone bodies are present and to test blood glucose levels. Ketones are rarely present when blood glucose levels are no higher than 200 mg/dL (11.1 mmol/L). The client who suspects DKA is present needs to go to the nearest emergency department and not waste time testing for ketone bodies. Citrus fruit does not increase acid production directly and alcohol causes hypoglycemia.

29. What is the nurse's best response when a client with renovascular disease asks why the endovascular procedure, stent placement, is preferable to surgery to correct his or her condition? A. "The procedure will make a bypass route for blood to enter your kidney and does not leave a scar." B. "Stent placement is less risky and requires less time for recovery than does renal artery bypass surgery." C. "A synthetic blood vessel graft is inserted to redirect blood flow from the abdominal aorta into the renal artery." D. "An endovascular procedure is more cost-effective and does not need to be repeated."

29. B Endovascular techniques are nonsurgical approaches to repair renal artery stenosis. Stent placement with or without balloon angioplasty is an example of an endovascular intervention. These techniques are less risky and require less time for recovery than does renal artery bypass surgery. The procedure does not create a bypass route. Depending on other client factors, the procedure may need to be repeated.

29. What does the nurse suggest when the client prescribed first-line therapy for tuberculosis develops nausea from the drugs? A. "Stop taking the drugs." B. "Try taking the drugs at bedtime." C. "Take the drugs on an empty stomach." D. "Take the drugs individually throughout the day."

29. B It is critically important to continue taking these drugs. Often, taking the drugs at bedtime prevents the client from being aware of nausea. Taking the drugs on an empty stomach would enhance their absorption and generally increase the likelihood of nausea. Taking the drugs throughout the day could prolong the sensation of nausea.

29. How does the nurse interpret a serum sodium finding of 126 mEq/L (126 mmol/L) for a client with bacterial meningitis? A. An early warning sign that the electrolyte imbalance will potentiate an acute myocardial infarction B. Evidence of syndrome of inappropriate antidiuretic hormone which is a complication of bacterial meningitis C. Within normal limits considering the diagnosis of bacterial meningitis but test should be repeated looking for downward trend D. A protective measure that causes increased urination and therefore reduces the risk of increased intracranial pressure

29. B Seizure activity may occur when meningeal inflammation and infection spreads to the cerebral cortex. Inflammation can also result in abnormal stimulation of the hypothalamic area where excessive amounts of antidiuretic hormone (ADH) (vasopressin) are produced. Excess vasopressin results in water retention and dilution of serum sodium caused by increased sodium loss by the kidneys. This syndrome of inappropriate antidiuretic hormone (SIADH) may lead to further increases in ICP.

29. What is the priority nursing assessment for a client who has undergone a kidney biopsy? A. Monitor for urinary retention. B. Assess for onset of hypertension. C. Perform frequent checks for hemorrhage. D. Observe for signs of nephrotoxicity.

29. C After a percutaneous kidney biopsy, the major risk is bleeding into the kidney or into the tissues external from the kidney at the biopsy site. For 24 hours after the biopsy, the nurse monitors the dressing site, vital signs (especially fluctuations in blood pressure), urine output, hemoglobin level, and hematocrit.

29. For which client problem will the nurse question a prescription for a diuretic? A. Pulmonary edema B. Heart failure C. End-stage renal disease D. Ascites

29. C Diuretics are a common and effective drug for the fluid overload associated with pulmonary edema, heart failure, and ascites. They are only used when kidney function is normal or at least adequate. In end-stage kidney disease kidney function is greatly and perhaps totally impaired.

3. Which symptom does the nurse expect to see first in a client whose plasma volume has an increased hydrostatic pressure? A. Dependent edema B. Decreased urine output C. Poor skin turgor with "tenting" D. Greatly increased sensation of thirst

3. A Hydrostatic pressure is a "water pushing" pressure and will move water from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure. When the plasma volume hydrostatic pressure increases, the water will first move into the interstitial space and cause edema formation.

3. Which bone problem will the nurse expect in a client who has a tumor that secretes excessive amounts of parathyroid hormone (PTH)? A. Increased osteoclastic activity with osteoporosis B. Increased osteoblastic activity and foot enlargement C. Decreased growth hormone levels and thinning of facial bones D. Decreased bone phosphorus levels resulting in bone spur formation

3. A PTH is a hormone normally secreted by the parathyroid glands to prevent serum calcium levels from becoming too low. One of its action is moving calcium out of the bones (calcium resorption) and into the blood by increasing osteoclastic activity. When osteoclastic activity is prolonged and not balanced by osteoblastic activity, bone density is lost and osteoporosis occurs.

3. What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins causing replacement with scar tissue formation

3. A Portal hypertension caused by stiffened liver tissue results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. This increased portal vein pressure causes backflow of blood into the spleen, resulting in splenomegaly.

3. What does the nurse suspect when assessment of a client with HF reveals pulses that alternate in strength? A. Pulsus alternans B. Pulsus paradoxus C. Orthostatic hypotension D. Angina

3. A Pulsus alternans is a type of pulse in which a weak pulse alternates with a strong pulse despite a regular heart rhythm; seen in clients with severely depressed cardiac function such as heart failure. Pulsus paradoxus is an exaggerated decrease in systolic blood pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle (normal is 3 to 10 mm Hg); indicative of cardiac tamponade, constrictive pericarditis, and pulmonary hypertension. Angina is chest pain. Orthostatic hypotension occurs when there is a systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of a client moving from a lying to a sitting or standing position.

3. Which client will the nurse determine has the highest risk for osteoporosis? A. 30-year-old female who drinks 48 oz (∼1250 mL) of diet cola daily and uses high-protection sunscreen B. 40-year-old male who is 72 inches (1.8 m) tall, eats a vegan diet, and participates in competitive martial arts C. 50-year-old male with type 1 diabetes mellitus who lifts weights for exercise D. 60-year-old female who is 15 lb (6.8 kg) overweight and walks 2 miles daily

3. A Risk factors for osteoporosis include being female, consuming excessive amounts of phosphorus (which is a major component of carbonated soft drinks), and being deficient in vitamin D. Not only does the amount of soft drinks consumed daily increase the blood levels of phosphorus, it may well be consumed in place of calcium and vitamin D containing dairy products. The use of high-protection sunscreen limits the amount of vitamin D activated in the skin by exposure to sunlight.

3. What will be the nurse's first intervention when a client states, "I've been dealing with the symptoms of MS for so long. Why won't anyone help me?" A. Encourage the client to verbalize his or her feelings and frustrations. B. Help the client locate and make an appointment with a specialist. C. Ask the client to describe in detail the symptoms and past treatments. D. Give the client a brochure about the diagnosis and treatment of MS.

3. A The client and family may be relieved to have a definite diagnosis but may also express anger and frustration that it took a long time to start appropriate treatment. The priority at this time is to establish open and honest communication with the client and allow him or her to share frustrations, anger, and anxiety.

3. Which laboratory tests would the nurse expect the health care provider to order when a client has acute pyelonephritis? Select all that apply. A. Urine culture for specific infective organism to be treated B. Complete blood count with differential to monitor for increased WBCs C. Urinalysis for bacteria, leucocyte esterase, nitrate, and RBCs D. C-reactive protein and erythrocyte sedimentation rate (ESR) to determine immune response and inflammation E. Blood urea nitrogen (BUN) and serum creatinine levels to monitor for elevation F. Test to determine whether a woman is pregnant

3. A, B, C, D, E, F The nurse expects that all of these laboratory tests will be ordered to determine the presence of acute pyelonephritis.

3. For which deficits in cognition does the nurse assess in a client with Alzheimer disease? Select all that apply. A. Attention and concentration B. Judgment and perception C. Learning and memory D. Aggressiveness and rapid mood swings E. Communication and language F. Speed of information processing

3. A, B, C, E, F Deficits in all of these areas of cognition should be assessed. Option D does not assess changes in cognition, but assesses changes in behavior and personality.

3. When the nurse takes a history from an older adult, which drugs will he or she recognize as possible contributing factors to urinary incontinence? Select all that apply. A. Diuretics B. Opioid analgesics C. Beta3 blockers D. Anticholinergic drugs E. Topical estrogen F. Tricyclic antidepressants

3. A, B, D Diuretics cause frequent urination, often in large amounts. Opioid analgesics decrease a client's level of consciousness and awareness of the need to void. Anticholinergic drugs affect the ability to urinate as well as cognition. Beta3 blockers, estrogen cream, and tricyclic antidepressants are used to treat incontinence.

3. Which functions will the nurse assess as cerebellar when checking a client's neurologic status? Select all that apply. A. Keeping an extremity from overshooting an intended target B. Moving from one skilled movement to another in an orderly sequence C. Controlling involuntary movement D. Maintaining equilibrium E. Predicting distance or gauging the speed with which one is approaching an object F. Controlling awakeness and awareness

3. A, B, D, E Cerebellar function enables a person to: keep an extremity from overshooting an intended target; move from one skilled movement to another in an orderly sequence; predict distance or gauge the speed with which one is approaching an object; control voluntary (not involuntary) movement; and maintain equilibrium. The brainstem (not the cerebellum) contains special cells that constitute the reticular activating system (RAS), which controls awareness and alertness.

3. Which questions will the nurse ask a client to determine the presence of signs and symptoms of benign prostatic hyperplasia (BPH)? Select all that apply. A. "Have you noticed a sensation of incomplete bladder emptying?" B. "Have you recently experienced a testicular or bladder infection?" C. "Have you noticed dribbling or leaking after you finish urination?" D. "How many times do you have to get up during the night to urinate?" E. "Have you noticed blood at the start or at the end of urination?" F. "Have you noticed increased force or size of your urine stream?"

3. A, C, D, E The nurse asks the client about the number of times he awakens during the night to void (nocturia). Other important topics to question a client about include: difficulty in starting (hesitancy) and continuing urination; reduced force and size of the urinary stream ("weak" stream); sensation of incomplete bladder emptying; straining to begin urination; postvoid (after voiding) dribbling or leaking; and hematuria (blood in the urine) when starting the urine stream or at the end of urination.

3. When the nurse collects a client's gastrointestinal (GI) history, which substances are most likely to be risk factors for peptic ulcer disease or GI bleeding? Select all that apply. A. Caffeine B. Furosemide C. Aspirin D. Desmopressin E. Alcohol F. Ibuprofen

3. A, C, E, F Large amounts of aspirin or NSAIDs (e.g., ibuprofen) can predispose a client to peptic ulcer disease (PUD) and GI bleeding. Alcohol and caffeine consumption are of concern because both substances are associated with many GI disorders, such as gastritis and peptic ulcer disease.

3. When prerenal and postrenal causes of acute kidney injury occur, how does the nurse expect a client's kidneys to compensate? Select all that apply. A. Constricting of blood vessels in the kidneys B. Restricting of secretion of glucocorticoids C. Releasing antidiuretic hormone (ADH) D. Crushing then passing fragments of kidney stones E. Dilating of peripheral arteries throughout the body F. Activating the renin-angiotensin-aldosterone pathway

3. A, C, F When prerenal or postrenal causes of AKI occur, the kidneys compensate by three responses: constricting kidney blood vessels, activating the renin-angiotensin-aldosterone pathway, and releasing antidiuretic hormone (ADH).

3. Which client conditions does the nurse recognize as most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? Select all that apply. A. Alkalosis B. Increased body temperature C. Reduced blood and tissue pH D. Increased metabolic demands E. Reduced blood and tissue levels of oxygen F. Reduced blood and tissue levels of diphosphoglycerate (DPG)

3. A, F The oxyhemoglobin dissociation curve is shifted to the left when conditions are present that reduce overall oxygen needs. This left shift makes it harder for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with slower or lower metabolism and oxygen need. These include less DPG, and alkalosis (fewer hydrogen ions). Reduced pH, increased metabolic demand, increased body temperature, and hypoxia are all associated with increased oxygen need and a right shift in the oxyhemoglobin dissociation curve.

3. What is the RN generalist's role for a client in need of infusion therapy? A. Placement of a peripherally inserted central catheters (PICC) B. Changing dressing on all intravenous sites every 48 hours C. Insertion of short peripheral catheters (SPC) D. Providing services such as hypodermoclysis and intraosseous infusions

3. C The registered nurse (RN) generalist is taught to insert peripheral IV lines; most institutions have a process for demonstrating competency for this skill (e.g., demonstrate successful placement a specified number of times on clients with a preceptor watching). Options A and D are specialty actions not usually performed by a generalist nurse. Option B is wrong because of the time frame which varies depending on the type of IV line and dressing.

30. Which urgent intervention is required when the nurse reviews the results of diagnostic testing for a client with aortic stenosis and discovers that the surface area of the valve is less than 1 cm? A. Surgical aortic heart valve replacement B. Aortic valvuloplasty in the cardiac catheterization laboratory C. Physical therapy to create an individualized exercise program D. Therapy with drugs that will increase myocardial contractility

30. A As stenosis worsens, cardiac output becomes fixed and cannot increase to meet the demands of the body during exertion and symptoms develop. Eventually the left ventricle fails, blood backs up in the left atrium, and the pulmonary system becomes congested. Right-sided HF can occur late in the disease. When a client has aortic stenosis and the surface area of the valve becomes 1 cm or less, surgery is indicated on an urgent basis!

30. Which instruction will the nurse be sure to give the assistive personnel (AP) when checking the blood pressure of a client receiving IV therapy? A. "Avoid taking blood pressure in an extremity with any type of IV catheter in place." B. "Put the pump on hold while you take the client's blood pressure, then restart it." C. "Remind the phlebotomist to draw blood from the extremity without an IV catheter." D. "You can check blood pressure with a short peripheral catheter, but not with a midline catheter."

30. A Remind assistive personnel (AP) to avoid taking blood pressures in an extremity with any type of catheter in place. If a short peripheral catheter is being used for continuous infusion, the compression while taking the blood pressure can increase venous pressure, causing fluid to overflow from the puncture site and infiltration. When a midline catheter or PICC is being used, compression from the blood pressure cuff could increase vein irritation and lead to phlebitis.

30. Which postoperative action will the nurse take for a client who had a nephrostomy and a nephrostomy tube is now in place? A. Monitor the amount of drainage in the collection bag. B. Keep the client NPO for at least 6 to 8 hours. C. Irrigate the tube until the return drainage is clear. D. Instruct the client to sleep with the operative side down.

30. A The nurse monitors the nephrostomy site for leaking urine or blood as well as amount of drainage. Urine drainage may be bloody for the first 12 to 24 hours after the procedure but should gradually clear. If prescribed, the nephrostomy tube can be irrigated with 5 mL sterile saline to check patency and dislodge clots. However, the volume used for this purpose is not intended to irrigate the nephrostomy until urine drainage is clear. Diuresis can occur once the tube is in place.

30. Which important points does the nurse teach a client after an anterior cervical discectomy with fusion (ACDF) and prior to discharge? Select all that apply. A. Information about all prescribed medications B. How to care for the surgical incision C. A care provider must be with the client for a few days after surgery D. Home restriction for lifting and activity E. Wear brace or collar as prescribed F. Driving is permitted after 3 days

30. A, B, C, D, E Important points the nurse will include with discharge teaching include: be sure that someone stays with the client for the first few days after surgery; review drug therapy; teach care of the incision; review activity restrictions including no heavy lifting; no driving until surgeon gives permission and no strenuous activities; walk every day; call the primary health care provider if symptoms of pain, numbness, and tingling worsen or if swallowing becomes difficult; and wear a brace or collar per the primary health care provider's prescription.

30. For which reasons does the nurse expect the health care provider to perform a lumbar puncture on a client? Select all that apply. A. To obtain cerebrospinal fluid (CSF) pressure readings with a manometer B. To obtain CSF for analysis C. To check for spinal blockage caused by a spinal cord lesion D. To inject contrast medium or air for diagnostic study E. To inject spinal anesthetics F. To inject selected drugs

30. A, B, C, D, E, F Lumbar puncture (spinal tap) is the insertion of a spinal needle into the subarachnoid space between the third and fourth (sometimes the fourth and fifth) lumbar vertebrae. A lumbar puncture (LP) is used to: obtain cerebrospinal fluid (CSF) pressure readings with a manometer; obtain CSF for analysis; check for spinal blockage caused by a spinal cord lesion; inject contrast medium or air for diagnostic study; inject spinal anesthetics; and inject selected drugs.

30. Which techniques would the medical/surgical nurse use when inspecting a client's precordium? Select all that apply. A. Look at the chest from the side, at a right angle, and downward over areas of the precordium where vibrations are visible. B. Note any movement over the aortic, pulmonic, and tricuspid areas. C. Use percussion over the heart area to determine its size. D. Observe for the location of the point of maximal impulse (PMI) and note any shift. E. Palpate the areas over the aortic, pulmonic, and tricuspid valves. F. Listen to the heart sounds in a systematic order.

30. A, B, D Inspect the chest from the side, at a right angle, and downward over areas of the precordium where vibrations are visible. Cardiac motion is of low amplitude, and sometimes the inward movements are more easily detected by the naked eye. Note any prominent pulses. Movement over the aortic, pulmonic, and tricuspid areas is abnormal. Pulses in the mitral area (the apex of the heart) are considered normal and are referred to as the apical impulse, or the point of maximal impulse (PMI). The PMI should be located at the left fifth intercostal space (ICS) in the midclavicular line. If it appears in more than one ICS and has shifted lateral to the midclavicular line, the client may have left ventricular hypertrophy. Palpation and percussion are usually not performed by medical/surgical nurses. Listening to the heart sounds would be part of auscultation assessment.

30. Which information will the nurse include when teaching a client self-care measures after shock wave lithotripsy for kidney stones? Select all that apply. A. Finish the entire prescription of antibiotics to prevent infection. B. Pain in the region of the kidneys or bladder is to be expected. C. Balance regular exercise with adequate sleep and rest. D. Drink at the very least 3 liters of fluids every day. E. Your urine may appear bloody for a few days after the procedure. F. Watch for and immediately report any bruising to the urologist.

30. A, C, D, E Options A, C, D, and E include important content for the nurse to teach a client for self-management after lithotripsy. See Patient and Family Education: Preparing for Self-Management Urinary Calculi in your text for additional content to teach a client after lithotripsy.

30. What are the criteria used for selection of clients for hemodialysis (HD)? Select all that apply. A. Client values and preferences B. Client's family member or partner who is willing to learn about HD C. Irreversible kidney failure when other therapies are unacceptable or ineffective D. No disorders that would seriously complicate HD E. Expected ability to continue or resume roles at home, work, or school F. Insurance plan will cover costs of procedures

30. A, C, D, E Selection criteria for HD include: irreversible kidney failure when other therapies are unacceptable or ineffective; no disorders that would seriously complicate HD; client values and preferences; and expected ability to continue or resume roles at home, work, or school.

30. For which circumstance will the nurse select the male icon for a female client when performing a bladder scan? A. Female who self identifies as a male B. Woman with a history of hysterectomy C. Female who is 5 years postmenopausal D. Woman with a history of bladder cancer

30. B Before bladder scanning, the nurse selects the male or female icon on the bladder scanner. Using the female icon allows the scanner software to subtract the volume of the uterus from any measurement. Use the male icon on all men and on women who have undergone a hysterectomy.

30. What is the nurse's best response when the family of a client who has been receiving first-line therapy for tuberculosis (TB) for 8 weeks and has shown clinical improvement asks if the client is still infectious? A. "He or she will remain infectious until the entire treatment period is completed." B. "The ability to spread the infection remains as long as his or her skin test remains positive." C. "Although he or she is no longer infectious, treatment may need to continue for at least 18 more weeks." D. His or her sputum will likely always remain infectious although treatment is not needed after the cough has resolved."

30. C Generally, clients who have shown clinical improvement after 8 weeks of therapy are no longer infectious but must continue the prescribed therapy for at least 18 more weeks. Once the infection has been eradicated, the sputum is no longer infectious. The skin test remains positive after successful treatment of TB and is not an indication of infectious status.

30. In collaboration with the registered dietitian nutritionists, what principle is most important for the nurse to reinforce to the client about changes in meal planning needed for management of type 1 diabetes? A. Eating at least five smaller meals per day plus a bedtime snack B. Taking extra insulin when planning to eat sweet foods C. Ensuring the inclusion of high-protein, low-carbohydrate, and low-fiber foods D. Considering the effects and peak action times of the prescribed insulin

30. D The guiding principle for meal planning for a client on insulin therapy (regardless of the specific insulin regimen) must take into consideration the effects and peak action times of all prescribed insulin. Meal times, composition, and sizes are based on these actions to promote euglycemia.

30. Which diagnostic test does the emergency department nurse anticipate for a client admitted with headache, fever, nausea, and light sensitivity, and who has been living with two people recently diagnosed with meningitis? A. Skull x-rays B. Myelography C. Cerebral angiogram D. Lumbar puncture

30. D The nurse would anticipate assisting the health care provider with a lumbar puncture. The most significant laboratory test used in the diagnosis of meningitis is the analysis of the cerebrospinal fluid (CSF). Clients older than 60 years, those who are immunocompromised, or those who have signs of increased ICP usually have a CT scan before the lumbar puncture. If there will be a delay in obtaining the CSF, blood is drawn for culture and sensitivity. A broad-spectrum antibiotic should be given before the lumbar puncture. The CSF is analyzed for cell count, differential count, and protein. Glucose concentrations are determined, and culture, sensitivity, and Gram stain studies are performed.

31. Which priority teaching will the nurse provide to prevent harm for a client after a renal biopsy? A. Avoid lifting heavy objects for 1 to 2 weeks after the procedure. B. Do not go up or down stairs for at least 10 days. C. Avoid light house work including cooking and washing dishes. D. Stay out of the sun until after your follow-up appointment.

31. A If no bleeding occurs, the nurse teaches the client that he or she can resume general activities after 24 hours (e.g., light housework, such as cooking or washing dishes). The client is instructed to avoid lifting heavy objects, exercising, or performing other strenuous activities for 1 to 2 weeks after the biopsy procedure. Driving may also be restricted.

31. What recommendations does the nurse make to the client who has rhinosinusitis? Select all that apply. A. Get plenty of rest, at least 8-10 hours per day. B. Keep fluid intake between 1000 and 1200 mL/day. C. Use a humidifier to help relieve congestion. D. Use nasal saline irrigation to safely relieve symptoms. E. Try sleeping with the head of your bed flat for better drainage. F. Limit exposure to any allergic causes.

31. A, C, D, F Rhinosinusitis is often managed at home. In addition to decongestants and any needed antimicrobials, recommendations include supportive therapy such as humidification, nasal irrigation, getting plenty of rest, increasing fluid intake, and sleeping with the head of the bed elevated. Regardless of the cause of rhinosinusitis, discomfort increases when exposures to allergens occur.

31. For which client would the health care provider avoid harm by not performing a lumbar puncture? A. Client who is unable to ambulate B. Client with severe increase in intracranial pressure C. Client with hyperactive deep tendon reflexes D. Client with muscle weakness in all four extremities

31. B Because of the danger of sudden release of CSF pressure, a lumbar puncture is not done for clients with symptoms indicating severely increased intracranial pressure (ICP).

31. Which intervention would the nurse use to reduce the risk of infection when a client is receiving IV drugs by way of a needleless system? A. Always use a hand scrub when entering a client's room. B. Clean all needleless system connections with an antimicrobial agent for 10-15 seconds before connecting infusion sets. C. Use tape to assure that secondary IV sets remain attached to primary IV sets. D. Disconnect secondary IV sets after each dose of IV drug is completed.

31. B Clean all needleless system connections vigorously with an antimicrobial agent (usually 70% alcohol or alcohol and 2% chlorhexidine swabs) for 10-15 seconds before connecting infusion sets or syringes, paying special attention to the small ridges in the Luer-Lok device. The "scrub the hub" technique suggests generating friction by scrubbing the connection hubs in a twisting motion.

31. Which class of antidiabetic drug will the nurse hold for a client after an imaging test using contrast medium until adequate kidney function is established? A. Alpha-glucosidase inhibitors B. Biguanides C. Meglitinides D. Second-generation sulfonylureas

31. B Metformin, the only drug in the biguanide class, can cause lactic acidosis in patients with kidney impairment and is not to be used by anyone with kidney disease. To prevent lactic acidosis and acute kidney injury, the drug is withheld before and after using contrast medium or any surgical procedure requiring anesthesia until adequate kidney function is established.

31. Which type of heart valvular disease does the nurse suspect when a client's assessment reveals pitting edema? A. Aortic valve stenosis and regurgitation B. Mitral valve stenosis and regurgitation C. Mitral valve prolapse D. Tricuspid valve prolapse

31. B Pitting edema is characteristic of mitral valve stenosis and regurgitation. Left heart failure eventually leads to signs of right heart failure with signs of peripheral volume overload such as hepatomegaly and pitting edema.

31. Which gastrointestinal changes does the nurse expect to find when assessing a client with uremia? A. Increased salivation B. Halitosis C. Stomatitis D. Anorexia E. Nausea and vomiting F. Hiccups

31. B, C, D, E, F Uremia affects the entire GI system. The flora of the mouth change with uremia. The mouth contains the enzyme urease, which breaks down urea into ammonia. The ammonia generated remains and then causes halitosis (uremic fetor) and stomatitis (mouth inflammation). Anorexia, nausea, vomiting, and hiccups are common in clients with uremia. For more information about uremic changes in the body, see chart 63.2 Key Features of Uremia.

31. What is the nurse's best response when a client with kidney cancer, who had a nephrectomy, asks if the remaining kidney can take over kidney function immediately? A. "Your remaining kidney isn't able to provide adequate function, so other therapies will be necessary." B. "That's a good question. We'll ask your health care provider about it during next rounds." C. "The kidney you have left will provide adequate function, but it may take a few days or weeks." D. "It varies from person to person, but you can expect normal kidney function to return the same day."

31. C Although overall kidney function decreases after a nephrectomy, the remaining kidney tissue usually works well enough for a healthy life. It may take a few days or weeks for the remaining kidney to assume all kidney functions.

31. What is the nurse's best action when auscultating S1 for a client is difficult? A. Ask the assistive personnel (AP) to do a 12-lead electrocardiogram (ECG). B. Auscultate with the bell of the stethoscope instead of the diaphragm. C. Have the client lean forward or roll to his or her left side. D. Instruct the client to take deep breaths and hold them for 5 seconds.

31. C When there is difficulty hearing heart sounds, have the client lean forward or roll to his or her left side. These actions move the heart closer to the chest wall and can facilitate hearing the heart sounds more clearly.

31. Which report or manifestation indicates to the nurse that a client's treatment for renal colic has been successful? A. Urine is pink tinged. B. Urine output is 50 mL per hour. C. Bladder scan shows no residual urine. D. Client reports that pain is relieved.

31. D Renal colic is the severe pain that occurs with the presence of kidney stones. When the treatment is successful, the client's pain is relieved.

32. Which specific discharge instruction will the nurse provide to prevent harm in a client with advanced heart failure who is at continued risk for fluid volume overload? A. Greater than 3 lb gained in a week or greater than 1 to 2 lb gained in a 24-hour period B. Greater than 5 lb gained in a week or greater than 1 to 2 lb gained in a 24-hour period C. Greater than 15 lb gained in a month or greater than 5 lb gained in a week D. Greater than 20 lb gained in a month or greater than 5 lb gained in a week

32. A Rapid weight gain is a good and reliable indicator of fluid retention, which would indicate worsening of heart failure that requires intervention. Usually only 0.5 lb of weight gain in a day represents true weight gain. Any amount above that is fluid retention.

32. What type of exercise will the nurse recommend for the client with diabetic retinopathy? A. Non-weight-bearing activities such as swimming B. Weight-bearing activities such as jogging C. Gradually increasing aerobic and resistance exercises D. Weight training and heavy lifting

32. A The client with retinopathy is at high risk for blindness as a result of increased bleeding inside the eye. These clients are taught to avoid any type of exercise that may increase damage to these blood vessels and cause vascular damage to many organs. Swimming is the only listed exercise that does not increase this risk.

32. Which specific actions will the nurse take when assessing a client's IV site? Select all that apply. A. Look for redness, swelling, hardness, or drainage. B. Check integrity of the dressing to make sure it is clean, dry, and adherent to the skin on all sides. C. Ensure that all connections are taped to prevent disconnection and leaking of fluids. D. Check the rate and amount of fluid that has infused. E. Be sure that the correct type of fluid is being infused. F. Check the skin around the dressing for medical adhesive- related skin injury (MARSI).

32. A, B, D, E Options A, B, D, and E are appropriate to assessing a client's IV site. Connections should not be taped. The skin under the dressing (not around) should be checked for medical adhesive- related skin injury (MARSI).

32. Which may be causes of a client's pericardial friction rub? Select all that apply. A. Myocardial infarction B. Pulmonary edema C. Cardiac tamponade D. Infection E. Inflammation F. Thoracotomy

32. A, C, D, E, F A pericardial friction rub originates from the pericardial sac and occurs with the movements of the heart during the cardiac cycle. They are usually transient and are a sign of inflammation, infection, or infiltration. They may be heard in clients with pericarditis resulting from MI, cardiac tamponade, or post- thoracotomy. Pulmonary edema is not a cause of a pericardial friction rub.

32. Which therapy does the nurse expect after a client's nephrectomy to prevent an adrenal complication? A. Administration of a potassium supplement B. Prescription for steroid supplement C. Addition of extra calcium to diet D. Estrogen supplements for postmenopausal women

32. B Adrenal insufficiency is possible as a complication when a kidney and adrenal gland are removed. Although only one adrenal gland may be affected, the remaining gland may not be able to secrete sufficient glucocorticoids immediately after surgery and steroid replacements may be needed.

32. What is the nurse's best response when a client asks how often and for how long he or she will have to go for hemodialysis (HD)? A. "It varies and you will need to discuss this with your nephrology health care provider for specific instructions." B. "Most clients require about 12 hours per week, which is usually divided into three 4-hour treatments." C. "If you follow the diet and fluid therapies you will spend less time in dialysis, about 8 hours each week." D. "Many clients prefer to have home treatment dialysis that occurs every night while sleeping."

32. B The best answer the nurse can provide this client is the most common treatment. Most clients receive three 4-hour treatments over the course of a week. The nurse provides additional information for some clients with ongoing urine production, who may need only two 5- to 6-hour treatments a week. If a client gains large amounts of fluid, a longer HD treatment time may be needed to remove the fluid without hypotension or other severe side effects.

32. Which client with valvular heart disease would benefit from the nonsurgical invasive procedure balloon valvuloplasty? A. Older adult who needs a valve replacement B. Middle-aged adult whose open-heart surgery failed C. Young adult with a genetic valve defect D. Older adult who is not a surgical candidate

32. D Balloon valvuloplasty, an invasive nonsurgical procedure, is possible for stenotic mitral and aortic valves; however, careful selection of clients is needed. It may be the initial treatment of choice for people with noncalcified, mobile mitral valves. Clients selected for aortic valvuloplasty are usually older and are at high risk for surgical complications. The benefits of this procedure for aortic stenosis tend to be short lived, rarely lasting longer than 6 months. Aortic valvuloplasty may be beneficial as a bridge to either surgical or percutaneous aortic valve replacement.

32. Which client would the nurse expect is at highest risk for development of bladder cancer? A. 25-year-old woman who has experienced three episodes of bacterial cystitis over the past year B. 27-year-old man with type 1 diabetes who is nonadherent with his therapeutic regimen C. 60-year-old woman with malnutrition secondary to chronic alcoholism and self-neglect D. 64-year-old man who smokes two packs of cigarettes a day and works in a chemical factory

32. D Exposure to toxins such as gasoline and diesel fuel, as well as to chemicals used in hair dyes and in the rubber, paint, electric cable, and textile industries, increases the risk for bladder cancer. The greatest risk factor for bladder cancer is tobacco use.

33. Which is the most common and normal response by a client to a cardiovascular illness? A. Denial B. Fear C. Loss of control D. Depression

33. A A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care.

33. How does the nurse best interpret a condition when a client is undergoing hemodialysis (HD) and develops symptoms including headache, nausea, vomiting, and fatigue? A. Mild dialysis disequilibrium syndrome B. Adverse reaction to the dialysate solution C. Transient symptoms in a client new to hemodialysis D. Expected manifestations of end-stage kidney disease

33. A Dialysis disequilibrium syndrome may develop during HD or after HD has been completed. It is characterized by mental status changes and can include seizures or coma, although this severity of disequilibrium syndrome is rare with today's HD practice. A mild form of disequilibrium syndrome includes symptoms of nausea, vomiting, headaches, fatigue, and restlessness. It is thought to be the result of a rapid reduction in electrolytes and other particles.

33. Which urinary characteristic most concerns the nurse when assessing a client whose lifestyle choices and occupational exposure indicate a high risk for bladder cancer? A. Painless hematuria B. Occasional incontinence C. Increased nocturia D. Frequent voidings

33. A The nurse's highest concern is blood in the urine because it is often the first indication of bladder cancer. It may be gross or microscopic and is usually painless and intermittent.

33. The nurse will monitor which clients for development of hyponatremia? Select all that apply. A. Postoperative client who has been NPO (nothing by mouth) for 24 hours with no IV fluid infusing B. Client with decreased fluid intake for 3 days C. Client receiving excessive intravenous fluids with 5% dextrose in water D. Client with diabetes who has a blood glucose of 250 mg/dL E. Client with overactive adrenal glands F. Tennis player in 100°F (37.7oC) weather who has been drinking water

33. A, C, D, F Without sodium intake, hyponatremia can develop. Although dextrose 5% in water is technically isotonic, as soon as it is infused the dextrose is metabolized and the fluid is very hypotonic, capable of diluting blood and causing it to be hyponatremic. The high blood glucose level makes the blood hyperosmotic, which then pulls fluid from the interstitial and intracellular spaces into the plasma volume, diluting both the glucose and the sodium levels. Heavy sweating results in both water and sodium losses. Replacing the loss with only water can cause hyponatremia.

33. Which assessment findings will the nurse expect to see documented when a client is first admitted with renal cell carcinoma? A. Gross hematuria, hypertension, diabetes, and oliguria B. Flank pain, blood in the urine, palpable renal mass, and renal bruit C. Nocturia and urinary retention with difficulty initiating the urine stream D. Dysuria, polyuria, dehydration, and palpable kidney mass

33. B Clients with renal cell carcinoma (RCC) have flank pain, obvious blood in the urine, and a kidney mass that can be palpated. The abdominal mass may be felt with gentle palpation and a renal bruit may be heard on auscultation.

33. Which action will the nurse teach a client with diabetes performing self-monitoring of blood glucose (SMBG) levels to prevent harm from bloodborne infections? A. Washing hands before beginning the test B. Not sharing the monitoring equipment with others C. Blotting away any excess blood from the strip D. Using gloves during monitoring

33. B Small particles of blood can adhere to the monitoring device and infection can be transported from one user to another. Therefore, the client is taught to not share his or her monitoring equipment with others. Washing hands helps prevent general infection but not blood-borne infections.

33. Which essential medications would the nurse provide teaching about postoperatively for a client who received a prosthetic valve replacement? A. Immunosuppressants B. Antibiotics C. Anticoagulants D. Diuretics

33. C When a client has a mechanical valve, lifelong anticoagulant therapy with warfarin is required. Teach the client that the international normalized ratio (INR) will need to be monitored frequently. The therapeutic goal for clients with mechanical heart valves is 3.0 to 4.0

33. How often would the nurse routinely change the transparent dressing on a client's central venous IV site? A. Every 24 hours B. Every 48 hours C. Every 3 days D. Every 5 to 7 days

33. D For central IV lines, when a transparent dressing (e.g., Tegaderm) is used, the dressing is routinely changed every 5 to 7 days. If the dressing does not adhere to the skin or is loose, it may need to be changed sooner.

33. For which symptom does the nurse teach the client who is going home with a peritonsillar abscess to go to the emergency department immediately? A. Persistent cough B. Sore throat C. Nausea and vomiting D. Stridor or excessive drooling

33. D Stridor and/or drooling indicate at least a partial airway obstruction. The client needs immediate care to prevent the partial obstruction from becoming a complete obstruction, leading to death. Persistent cough, sore throat, and nausea and vomiting are not life-threatening.

34. Which additional assessment finding in a client who has a severe sore throat with pain that radiates behind the ear and difficulty swallowing supports the nurse's suspicion that the client may have a peritonsillar abscess? A. Deviated uvula B. Bad breath C. Coated tongue D. Beefy red mucous membranes

34. A A major indication of a peritonsillar abscess is a collection of pus behind the tonsil causing swelling on one side of the throat that pushes the uvula toward the unaffected side. Bad breath and a coated tongue can occur with any sore throat. Beefy red mucous membranes occur with any oral infection.

34. Which serum value indicates to the nurse that the client has hyponatremia? A. Sodium 129 mEq/L (mmol/L) B. Chloride 98 mEq/L (mmol/L) C. Sodium 144 mEq/L (mmol/L) D. Chloride 103 mEq/L (mmol/L)

34. A Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hyponatremia is a serum sodium value lower than 136 mEq/L (mmol/L). The other values are within their normal ranges.

34. What will the nurse teach a client and family about prevention of kidney and genitourinary trauma? Select all that apply. A. Wear a seat belt. B. Practice safe walking habits. C. Use caution when riding bicycles and motorcycles. D. Wear appropriate protective clothing when participating in contact sports. E. Avoid all contact sports and high-risk activities if you have only one kidney. F. Penetrating trauma is responsible for most kidney injuries.

34. A, B, C, D, E All of these options are appropriate for the nurse to teach a client and family for prevention of traumatic kidney or genitourinary injuries except option F. The main cause of kidney trauma is blunt injuries.

34. Which points will the nurse, in collaboration with a registered dietitian nutritionist, use to individualize a meal plan for a client with diabetes? Select all that apply. A. Maintaining blood glucose levels at or near the client's target range B. Allowing client food preferences whenever possible C. Permitting clients to eat as much as they desire D. Honoring the client's cultural preferences E. Limiting food choices to proteins and vegetables F. Suggesting the client avoid all forms of dietary fats

34. A, B, D The client is most likely to follow a diabetes diet plan when he or she is an active participant in plan development. Dietary habits of a lifetime are difficult to change. While maintaining blood glucose levels within the client's established target range is the desired outcome, this is more likely to be achieved when the plan includes some level of the client's specific food preferences and those that he or she considers part of their ethnic and cultural heritage. All food substances, including carbohydrates and fats, are included in a balanced diet, not just protein and vegetables, although the amount of the substances is more limited, as is the total caloric amount permitted daily.

34. Which assessment data would the nurse expect for a client diagnosed with angina? Select all that apply. A. Pain relieved at rest B. Sudden onset of pain C. Intermittent pain relieved by sitting upright D. Substernal pain that may spread across chest, back, and arms E. Sharp, stabbing pain that is moderate to severe F. Pain that usually lasts less than 15 minutes

34. A, B, D, F Angina pain is usually sudden in onset, in response to exertion, emotion, or extremes in temperature. It is usually located on the left side of chest without radiation but can be substernal and may spread across the chest and the back and/or down the arms. It usually lasts less than 15 minutes and is relieved with rest, nitrate administration, or oxygen therapy. See Table 30.1 in the text.

34. Which techniques will the nurse use to prevent air emboli when changing the IV administration set or connectors for a client with a central venous catheter? Select all that apply. A. Placing the client flat or in Trendelenburg so that the catheter site is below the heart B. Using sterile technique when handling the IV set and connectors C. Asking the client to perform the Valsalva maneuver by holding his or her breath and bearing down D. Timing the IV set change to the expiratory cycle if the client is spontaneously breathing E. Having an assistive personnel (AP) apply pressure at the insertion site F. Timing the IV set change to the inspiratory cycle when the client is receiving positive-pressure mechanical ventilation

34. A, C, D, F Techniques used to increase the intrathoracic pressure and prevent air embolism during IV set change include: placing the client in a flat or Trendelenburg position to ensure that the catheter exit site is at or below the level of the heart; asking the client to perform a Valsalva maneuver by holding his or her breath and bearing down; timing the IV set change to the expiratory cycle when the client is spontaneously breathing; and timing the IV set change to the inspiratory cycle when the client is receiving positive- pressure mechanical ventilation. Intravenous sets and connectors are not sterile except for where they connect together. The AP would not be asked to apply pressure at the insertion site during an IV set change.

34. Which priority information would the nurse be sure to provide for a client who is scheduled for mitral valve replacement with a xenograft valve? A. "You will need an individualized exercise program to develop collateral circulation." B. "Your xenograft valve will need to be replaced in about 7 to 10 years." C. "You must take and record your temperature daily and watch for signs of rejection." D. "You will require frequent laboratory tests to monitor your coagulation status."

34. B Biologic valve replacements may be xenograft (from other species), such as a porcine valve (from a pig) or a bovine valve (from a cow). Because tissue valves are associated with little risk for clot formation, long-term anticoagulation is not indicated. Xenografts are not as durable as prosthetic valves and usually must be replaced every 7 to 10 years.

34. Which home care instructions will the nurse provide the client who receives intravesical instillation of bacille Calmette-Guerin. At the outpatient clinic to prevent recurrence of superficial bladder cancer? A. "Your urine will be radioactive for 24 hours so avoid contact with children and pregnant women." B. "Drink a lot of extra fluid to flush your bladder but otherwise there are no special instructions." C. "For 24 hours others should not share your toilet and then you should clean it with 10% bleach before anyone else uses it." D. "Flush the toilet twice after every voiding and remind all family members to practice safe hand hygiene."

34. C Prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guérin (BCG), a live virus compound, is used to prevent tumor recurrence of superficial cancers. Usually the agent is instilled in an outpatient cancer clinic and allowed to dwell in the bladder for a specified length of time. When the client urinates, live virus is excreted with the urine. The nurse teaches clients receiving this treatment to prevent contact of the live virus with other members of the household by not sharing a toilet with others for at least 24 hours after instillation. Instruct men to urinate while sitting down to avoid splashing the urine. After 24 hours, the toilet should be completely cleaned using a solution of 10% liquid bleach.

34. What instructions will the nurse give to the assistive personnel (AP) regarding care of a client with an arteriovenous fistula? A. Assess for bleeding at the needle insertion sites every 2 hours. B. Monitor the client's distal pulses and capillary refill for circulation. C. Palpate the dialysis site for thrills and auscultate for a bruit every 4 hours. D. Avoid taking blood pressure readings on the client's arm with the arteriovenous fistula.

34. D The AP's scope of practice includes taking and recording vital signs. For a hemodialysis client, checking blood pressure includes not taking blood pressure readings using the extremity in which the vascular access is placed. Assessment, monitoring, palpation, and auscultation are more advanced skills performed by the professional registered nurse. For more information on care of a client's arteriovenous fistula, see Best Practice for Patient Safety & Quality Care Caring for the Patient With an Arteriovenous Fistula or Arteriovenous Graft in your text.

35. Which points are essential for the nurse to include in the teaching plan when instructing a client with diabetes how to select and wear appropriate shoes? A. "Have your shoes fitted by an experienced shoe fitter such as a podiatrist." B. "Make sure the shoes are 1 to 1.5 inches longer than your longest toe." C. "The heels of the shoes should be less than 2 inches high." D. "Avoid tight-fitting shoes that can damage your feet." E. "Rotate your shoes so you don't wear the same shoes 2 days in a row." F. "Get measured for shoes later in the day, when feet are normally larger."

35. A, C, D, E, F All of the points are important for the client with diabetes to use when buying and wearing new shoes to prevent harm, with the exception of option B. Although the shoes should not be too tight, shoes that are too large can also injure the foot and cause the client to have a poor walking gait.

35. Which question is most important to ask a client who may have an endemic respiratory infection with fever, cough, headache, muscle aches, chest pain, and night sweats, and tests negative to the common forms of influenza? Select all that apply. A. Do you have any known allergies? B. What medications do you take daily? C. Do you have a chronic illness of any kind? D. Where have you traveled in the past 2 to 4 weeks? E. Have you ever been ill with these symptoms before? F. What type of heating system do you have in your home?

35. B, C, D An endemic respiratory infection is one in which the causative organism is much more common within a geographic location. Adults living in these areas have often developed some immunity to the organism over time and usually only develop the infection if they come into contact with large numbers of the organism or have a severely reduced immune response. Those who do not live in the region may have no immunity to it and become ill after traveling in the area and becoming exposed. Important questions related to a potential endemic respiratory infection include history of recent travel (and the exact location visited), whether the client is taking a drug that reduces immunity, and whether he or she has a chronic illness that would either reduce immunity or increase susceptibility. Questions pertaining to allergies, the type of heating system used, and whether or not the client has ever had these symptoms before are less important

35. Which questions would the nurse ask a client when a client is admitted reporting chest pain? Select all that apply. A. "How do you feel about the chest pain?" B. "How long does the pain last and how often does it occur?" C. "Where does the pain occur and what does it feel like?" D. "Have you had other symptoms that occur with the chest pain and what are they?" E. "What activities were you doing when the pain occurred?" F. "Is this episode of chest pain different from other episodes you have had?"

35. B, C, D, E, F If pain is present, ask whether it is different from any other episodes of pain. Ask the client to describe which activities he or she was doing when it first occurred, such as sleeping, arguing, or running (precipitating factors). If possible, the client should point to the area where the chest pain occurred (location) and describe if and how the pain radiated (spread). In addition, ask how the pain feels and whether it is sharp, dull, or crushing (quality of pain). To understand the severity of the pain, ask the client to grade it from 0 to 10, with 10 indicating severe pain (intensity). He or she may also report other signs and symptoms that occur at the same time (associated symptoms), such as dyspnea, diaphoresis (excessive sweating), nausea, and vomiting. Other factors that need to be addressed are those that may have made the chest pain worse (aggravating factors) or less intense (relieving factors). Asking how the client feels about the pain should be part of the psychosocial assessment.

35. Which topics would the nurse be sure to cover when providing discharge instructions for a client with prosthetic valve surgery? Select all that apply. A. Avoid heavy lifting for 3 to 6 weeks. B. Report dyspnea, syncope, dizziness, edema, and palpitations to your health care provider. C. Use an electric razor to avoid skin cuts. D. Increase your consumption of foods that are high in vitamin K. E. Notify your health provider for any bleeding or excessive bruising. F. Watch for and report any fever or drainage and redness at the surgical site.

35. B, C, E, F A client receiving a prosthetic valve will be taking anticoagulants for the rest of his or her life. Teach nutritional considerations (if taking warfarin) and the prevention of bleeding. For example, the client is taught to avoid foods high in vitamin K, especially dark green leafy vegetables, and to use an electric razor to avoid skin cuts. Also teach him or her to report any bleeding or excessive bruising to the primary health care provider. Reinforce how to care for the sternal incision and instruct him or her to watch for and report any fever, drainage, or redness at the site. Most clients return to normal activity after 6 weeks, but should avoid heavy physical activity involving their upper extremities for 3 to 6 months to allow the incision to heal. Teach the client to report any changes in cardiovascular status, such as dyspnea, syncope, dizziness, edema, and palpitations.

35. What solution and volume does the nurse typically use to flush a client's short peripheral catheter IV saline lock? A. 3 mL heparinized saline B. 5 mL bacteriostatic saline C. 3 mL normal saline D. 5 mL heparin solution

35. C For short peripheral catheters, usually 3 mL normal saline is adequate to flush the catheter. For all other catheters, 5 to 10 mL of preservative-free normal saline is needed. Flush catheters immediately after each use. A saline lock should be flushed at least once each shift. Research has shown that for SPCs, 3 mL of saline is just as effective at maintaining patency of the catheter without the risks associated with the use of heparin flushes.

35. What does the nurse expect when comparing a client's posthemodialysis weight and blood pressure with predialysis data? A. Blood pressure is increased and weight is decreased B. Blood pressure and weight are slightly increased C. Blood pressure and weight are the same D. Blood pressure and weight are decreased

35. D Posthemodialysis, the nurse obtains vital signs and weight for comparison with predialysis measurements. After dialysis, the nurse expects blood pressure and weight to be reduced as a result of fluid removal.

36. Which complication is a client at most risk for when the nurse notes that excessive fluid was seen in the pericardial cavity on echocardiogram? A. Cardiac tamponade B. Pericardial friction rub C. Systemic emboli D. Splinter hemorrhages

36. A Cardiac tamponade is compression of the myocardium by fluid that has accumulated around the heart. This compresses the atria and the ventricles, prevents them from filling adequately, and reduces cardiac output.

36. Which drug therapy does the nurse expect the health care provider to prescribe for a client with low serum sodium and signs of hypervolemia? A. Conivaptan B. Furosemide C. Hydrochlorothiazide D. Bumetanide

36. A The drug therapy should increase water loss without causing sodium loss. Furosemide, hydrochlorothiazide, and bumetanide all promote sodium loss as well as water loss.

36. Which actions must the nurse follow to remove a short peripheral catheter (SPC) when a client is ready for discharge to home? Select all that apply. A. Flush the SPC before removal. B. Remove the SPC dressing. C. Explain the procedure to the client. D. Rapidly withdraw the catheter from the skin. E. Immediately cover the puncture site with dry gauze. F. Hold pressure until hemostasis is achieved. G. Assess the catheter tip to ensure it is intact and completely removed. H. Document catheter removal and appearance of site.

36. B, C, E, F, G, H All options are appropriate actions for removal of an SPC, except A and D. It is not necessary to flush the catheter before removing it. The catheter should be slowly (not rapidly) withdrawn from the skin.

36. Which priority teaching will the nurse provide to the client receiving peritoneal dialysis (PD) when the effluent becomes cloudy? A. The change means that more waste products are being removed from the blood. B. The presence of cloudiness is an early sign of an infection called peritonitis and is very serious. C. Effluent cloudiness is the result of eating foods that contain too much protein and electrolytes. D. The effluent is expected to be cloudy because it has spent time (dwelled) in the abdomen, in close contact with the intestines.

36. B. The nurse teaches the client to recognize indications of peritonitis (e.g., cloudy dialysate outflow [effluent], fever, abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting). Cloudy or opaque effluent is the earliest indication of peritonitis. The client is taught to examine all effluent for color and clarity to detect peritonitis early and to report indications of peritonitis immediately to the nephrology health care provider.

36. What does the nurse suspect when a client states "I get short of breath whenever I lie down for several hours?" A. Dyspnea on exertion B. Orthopnea C. Paroxysmal nocturnal dyspnea D. Fatigue

36. C. Paroxysmal nocturnal dyspnea (PND) develops after the client has been lying down for several hours. In this position, blood from the lower extremities is redistributed to the venous system, which increases venous return to the heart. A diseased heart cannot compensate for the increased volume and is ineffective in pumping the additional fluid into the circulatory system. Pulmonary congestion results, and the client awakens abruptly, often with a feeling of suffocation and panic. He or she sits upright and dangles the legs over the side of the bed to relieve the dyspnea. This sensation may last for 20 minutes. Dyspnea associated with activity is dyspnea on exertion. Orthopnea is dyspnea whenever a client lies flat and may require three to four pillows for sleep. Fatigue is a feeling of tiredness as a result of activity.

37. Which nursing action is essential when a client is receiving infusion therapy through an intra-arterial catheter placed in the carotid artery? A. Monitor respirations for rate and regularity. B. Perform frequent neurologic and cognitive status assessments. C. Assess the extremities for sensation and peripheral pulses. D. Place antiembolic stockings on client's lower extremities.

37. B When the carotid artery is used for intra-arterial infusion, perform neurologic and cognitive assessments to determine adequate blood flow to the brain. When a femoral catheter is used, the client will have very limited movement so apply antiembolic stockings or other measures to prevent deep vein thrombosis.

37. Which actions will the nurse take to check the peritoneal dialysis system of a client when the dialysate outflow is slow? Select all that apply. A. Ensuring that the drainage bag is elevated above the client's abdomen B. Inspecting the tubing to ensure there is no kinking or twisting C. Making sure that clamps are open and unclamped D. Repositioning the client to the other side and ensuring good body alignment E. Instructing the client to stand up at the bedside and cough F. Placing the client in a supine low-Fowler position

37. B, C, D, F When PD outflow drainage is slow, actions that can help improve flow include: ensuring that the drainage bag is lower than the client's abdomen to enhance gravity drainage; inspecting the connection tubing and PD system for kinking or twisting; and ensuring that clamps are open. If outflow drainage is still inadequate, reposition the client to stimulate outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Having the client in a supine low- Fowler position reduces abdominal pressure. Increased abdominal pressure from sitting or standing or from coughing contributes to leakage at the PD catheter site.

37. Which actions by an older adult are likely to cause the experience of syncope? Select all that apply. A. Walking briskly for 20 minutes B. Turning the head C. Laughing D. Performing a Valsalva maneuver E. Rapidly swallowing fluids F. Shrugging the shoulders

37. B, D, F Syncope in an older adult may result from hypersensitivity of the carotid sinus bodies in the carotid arteries. Pressure applied to these arteries while turning the head, shrugging the shoulders, or performing a Valsalva maneuver (bearing down during defecation) may stimulate a vagal response and syncope. Walking, laughing, or swallowing fluids does not usually cause syncope in older adults.

37. Which symptom in a client with psychiatric issues who is continuously drinking water will the nurse monitor as an indicator of potential hyponatremia? A. Insomnia B. Pitting edema C. Tremors D. Decreased cognition

37. D Hyponatremia increases intracranial pressure and decreases central nervous system excitability. Behavioral and cognitive changes are often the first changes apparent in a person who develops hyponatremia because of excessive water consumption in a short period of time.

37. What is the most appropriate action for the nurse to take when a client who has used insulin for diabetes control for 20 years now has a spongy swelling at the site used most frequently for insulin injection? A. Applying ice to this area B. Documenting the finding as the only action C. Assessing the client for other indications of cellulitis D. Instructing the client to use a different site for insulin injection

37. D The client has hypertrophic lipodystrophy as a result of repeated injections at the same site. Avoiding this site for an extended period of time allows the dystrophic changes to regress or at least not become worse.

38. Which factor increases the likelihood that a client who comes into the emergency department (ED) after a serious motor crash is a candidate for intraosseous (IO) therapy? A. Endotracheal intubation is difficult to accomplish. B. IV access cannot be established within a few minutes. C. Client is an older adult and very thin. D. Client has a history of chronic renal failure.

38. B Adult victims of trauma benefit from IO therapy because health care providers often cannot access these clients' vascular systems for traditional IV therapy.

38. Which clients are at greatest risk for development of infective endocarditis? Select all that apply. A. Clients after myocardial infarction B. Clients who are IV drug users C. Clients with poor dental health D. Clients with opioid addictions E. Clients with systemic alterations in immunity F. Clients postoperative after valve replacement

38. B, C, D, E, F Infective endocarditis occurs primarily in clients with injection drug use (IDU), and who have had valve replacements, have experienced systemic alterations in immunity, or have structural cardiac defects. It is not associated with myocardial infarction or cardiac dysrhythmias. Possible ports of entry for infecting organisms include: the oral cavity (especially if dental procedures have been performed); skin rashes, lesions, or abscesses; infections (cutaneous, genitourinary, GI, systemic); and surgery or invasive procedures, including IV line placement. These clients are also at risk for infective endocarditis.

38. What is the best method for the nurse to monitor the weight of a client who is receiving peritoneal dialysis (PD)? A. Calculating the client's dry weight by comparing daily weights to baseline weights B. Determining dry weight by comparing the client's weight to a standard weight chart C. Checking the weight after a drain and before the next fill to monitor the dry weight D. Weighing the client daily and subtracting dialysate volume to determine dry weight

38. C The client's actual weight is his or her "dry weight". For a client receiving PD, dry weight is checked after a drain and before the next fill. The client is always weighed on the same scale, with the same amount of clothes.

38. What is the priority problem when a nurse assesses a client with CVD and notes skin that is pale, cool, and moist? A. Skin integrity B. Abnormal body temperature C. Peripheral neurovascular dysfunction D. Decreased perfusion

38. D Decreased perfusion is manifested as cool, pale, and moist skin. If there is normal blood flow or adequate perfusion to a given area in light-colored skin, it appears pink, perhaps rosy, and is warm.

39. Which key points would the nurse teach a client about intraosseous (IO) therapy? Select all that apply. A. The only absolute contraindication is fracture in the bone to be used as a site. B. The IO route is for short term use and should not be used for more than 24 hours. C. The most common site accessed for IO therapy is the distal femur. D. The same fluids and drugs given IV can be given IO. E. During the IO procedure, most clients rate the pain as a 2 or 3 on a scale of 0 to 10. F. For access, 12- or 14-gauge needles specifically designed for IO therapy are preferred.

39. A, B, D, E Options A, B, D, and E are appropriate for the nurse to teach a client about IO therapy. The most commonly used site is the proximal tibia (not the distal femur). The preferred access needles are 15- or 16-gauge needles specifically designed for IO therapy.

39. What is the best advice the nurse would give to a client with moderate-to-severe cramping sensation in their legs or buttocks associated with an activity such as walking? A. "Elevating the affected extremity may help relieve the pain." B. "Resting or lowering the affected extremity can relieve the pain." C. "Placing a nitroglycerine tablet under your tongue may relieve the pain." D. "Losing some weight can take pressure off the extremity and relieve the pain."

39. B Clients who report a moderate-to-severe cramping sensation in their legs or buttocks associated with an activity such as walking have intermittent claudication related to decreased arterial tissue perfusion. Resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow usually relieves claudication pain. Leg pain that results from prolonged standing or sitting is related to venous insufficiency from either incompetent valves or venous obstruction. Elevating the extremity may relieve this pain. Nitroglycerine is given to relieve angina. Weight loss will not relieve the pain of intermittent claudication.

39. Which findings does the nurse expect when assessing a client with infective endocarditis? Select all that apply. A. Grating pain that is aggravated by breathing B. Osler nodes on palms of hands and soles of feet C. Splinter hemorrhages D. Janeway lesions on the hands and feet E. Anorexia and weight loss F. Pericardial friction rub

39. B, C, D, E Manifestation of infective endocarditis include: fever associated with chills, night sweats, malaise, and fatigue; anorexia and weight loss; cardiac murmur (newly developed or change in existing); development of heart failure; evidence of systemic embolization; petechiae; splinter hemorrhages; Osler nodes (on palms of hands and soles of feet); Janeway lesions (flat, reddened maculae on hands and feet); Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina); and positive blood cultures.

39. A client is talking to the nurse about sodium intake. Which statement by a client indicates to the nurse a correct understanding of high-sodium food sources? A. "I have bacon and eggs every morning for breakfast." B. "We never eat seafood because of the salt water." C. "I love Chinese food, but I gave it up because of the soy sauce." D. "Pickled herring is a fish, and my doctor told me to eat a lot of fish."

39. C Soy sauce is a source of sodium because 1 tablespoon (15 mL) has nearly 900 mg of sodium. Clients who are to restrict sodium intake should be taught to avoid foods that contain significant amounts of soy sauce. Seafood itself does not contain high concentrations of sodium. Bacon and pickled herring do contain higher concentrations of sodium.

39. What is the nurse's best action when a client receiving PD has slightly less outflow than inflow? A. Placing the client on an oral fluid intake restriction B. Notifying the nephrology health care provider C. Recording the difference as intake on the flow sheet D. Instructing the client to stand and walk then measuring the next outflow

39. C When outflow is less than inflow, the difference is retained by the client during dialysis and it is counted as fluid intake.

4. What would the nurse calculate the cardiac output to be when the client's heart rate is 68 beats/min and the stroke volume is 50 mL? A. 3400 L/min B. 4000 L/min C. 4400 L/min D. 4800 L/min

4. A Cardiac output (CO), is the amount of blood pumped from the left ventricle each minute. CO depends on the relationship between heart rate (HR) and stroke volume (SV); it is the product of these two variables: CO = SV × HR i.e., 50 × 68 = 3400 mL/min.

4. What priority teaching points will the nurse include when instructing a client and family about how to prevent gastritis? Select all that apply. A. Eat a well-balanced diet and exercise regularly. B. Do not take large doses of aspirin, other NSAIDs (e.g., ibuprofen), and corticosteroids. C. Decrease the amount of smoking and/or use of other forms of tobacco. D. Manage stress levels using complementary and integrative therapies such as relaxation and meditation techniques. E. Use over-the-counter (OTC) proton pump inhibitors if you experience symptoms of esophageal reflux. F. Protect yourself against exposure to toxic substances in the workplace such as lead and nickel.

4. A, B, D, F See the box entitled Patient and Family Education: Preparing for Self-Management Gastritis Prevention in your text for additional points for preventing gastritis. Option C is not correct because the client should stop smoking and using tobacco products. Option E is not correct because the client should seek medical care for symptoms of reflux and not use OTC drugs.

4. Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? Select all that apply. A. Onset of or when the client first noticed dyspnea B. Results of most recent pulmonary function test C. Conditions that relieve the dyspnea sensation D. Whether or not dyspnea interferes with ADLs E. Inspection of the external nose and its symmetry F. Whether stridor is present with dyspnea

4. A, C, D, F Dyspnea, especially if it is new onset, is a sensitive indicator of the possible presence of life-threatening respiratory problems. Dyspnea is subjective and determining onset, relieving factors, interference with ADLs, and presence of stridor should be elicited from the client to help assess severity and determine the level of intervention needed. Pulmonary functioning and inspection of the external nose are objective data.

4. Which intravenous (IV) fluid would the nurse infuse for a client when the health care provider prescribes a hypotonic solution? A. 0.9% NaCl B. 0.45% NaCl C. Lactated Ringer's solution D. 5% dextrose with 0.9% saline

4. B A hypotonic solution has a lower than normal blood plasma osmolarity (fluids less than 270 mOsm/L). An example of a hypotonic solution is half-strength saline (0.45% NaCl).

4. Which assessment action is a priority for the nurse to perform first to prevent harm for a client with diabetes whose blood osmolarity is 345 mOsm/L? A. Checking skin turgor B. Measuring blood pressure C. Testing for ketones in the urine D. Checking the most recent serum electrolyte values

4. B All the assessment actions are important for this client who is likely to be severely dehydrated. The priority assessment action is to measure blood pressure because the severe dehydration can cause profound hypotension with orthostatic hypotension leading to dangerously reduced organ perfusion and increasing the risk for falls.

4. Based on the nurse's knowledge of gastrointestinal (GI) changes that occur with age, for which disorder in an older client will the nurse vigilantly monitor related to decreased peristalsis? A. Loss of appetite for favorite foods B. Constipation with possible impaction C. Vomiting that occurs after eating D. Indigestion related to consuming spicy foods

4. B As clients age, peristalsis decreases and GI nerve impulses are dulled. This leads to decreased sensation for defecation and can result in postponement of bowel movements, which can lead to constipation and impaction.

4. Which priority teaching point will the nurse be sure to include when instructing a client with MS about the prescribed drug fingolimod? A. "You must be carefully monitored for allergic reactions because the level of fingolimod tends to build up in the body." B. "We will need to teach you how to check your pulse because fingolimod can cause slowing of your heart rate." C. "Fingolimod will improve your ability to walk, but will also increase the risk for seizure activity." D. "Fingolimod will decrease the frequency of clinical relapses, but there is an increased risk for stroke."

4. B Fingolimod was the first oral immunomodulator approved for the management of MS. The capsules may be taken with or without food. Teach clients to monitor their pulse every day because the drug can cause bradycardia, especially within the first 6 hours after taking it.

4. What does the Mini-Mental State Examination (MMSE) measure when the nurse assesses an older adult client with Alzheimer disease? A. Level of intelligence B. Severity of cognitive impairment C. Alterations in communication D. Functional ability

4. B The Mini-Mental State Examination (MMSE) is an example of a tool used to determine the onset and severity of cognitive impairment. The MMSE, also known as the "mini-mental exam", assesses five major areas—orientation, registration, attention and calculation, recall, and speech-language (including reading).

4. Which client will the nurse monitor carefully for highest risk of developing acute pyelonephritis? A. 32-year-old man with diabetes insipidus B. 34-year-old woman with diabetes mellitus in the second trimester of pregnancy C. 75-year-old man who drinks four beers each day D. 78-year-old woman prescribed diuretics for mild heart failure

4. B The woman in option B has two risk factors for pyelonephritis: diabetes and pregnancy. Pyelonephritis from an ascending infection may follow manipulation of the urinary tract (e.g., placement of a urinary catheter), particularly in clients who have reduced immunity or diabetes. Hormonal changes as well as obstruction caused by the fetus during pregnancy make acute pyelonephritis more common during the second trimester and beginning of the third trimester.

4. Which activities are most important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? Select all that apply. A. Avoid alcoholic beverages. B. Eat soft foods and cool liquids. C. Do not engage in strenuous exercise or heavy lifting. D. Try to eat six smaller meals daily instead of three larger ones. E. Be sure to keep your mouth open when sneezing or coughing. F. Cross your legs only at the ankles when sitting, rather than the knees.

4. B, C Esophageal varices are thin-walled blood vessels that bleed easily with mechanical irritation or any increase in pressure within the portal system. Clients must avoid any activity that increases intra-abdominal pressure such as strenuous exercise and heavy lifting. Hard or rough foods can mechanically open the varices and cause bleeding. Avoiding alcohol may prevent worsening of the liver problems but does not directly prevent bleeding or hemorrhage. None of the other activities alter intra-abdominal pressure or prevent direct injury to the varices.

4. Which client risk factors or health problems will the nurse associate with osteoporosis? Select all that apply. A. Muscle cramps B. Sedentary lifestyle C. Back pain relieved by rest D. Fracture E. Urinary or renal stones F. High-cholesterol diet

4. B, C, D A sedentary lifestyle with little weight-bearing activity contributes to the development of osteoporosis. Health problems that can result from osteoporosis include back pain relieved by rest and fragile fractures. Muscle cramps and urinary stones do not result in or from osteoporosis. Although poor nutrition is associated with osteoporosis, no evidence suggests that a high-cholesterol diet increases the risk for osteoporosis.

4. Which symptom reported by a client after eating eggs indicates to the nurse a possible allergy to eggs rather than an egg intolerance? A. Diarrhea B. Excessive flatulence C. Throat itching and swelling D. Nausea when smelling eggs

4. C A true food allergy is an immune and inflammatory response that can occur as a systemic response, as well as in tissues that came into direct contact with the allergen in the food. A food intolerance is seen as a physiologic change in gastrointestinal responses that indicate a problem with digesting the food item. The nausea after smelling the odor of eggs is a learned behavior that is neither a food allergy nor a physiologic food intolerance.

40. Which statements does the nurse recognize as true when providing care for a client receiving intraperitoneal (IP) infusions? Select all that apply. A. IP infusion therapy involves the administration of chemotherapy agents into the peritoneal cavity. B. An IP catheter has large internal lumens with multiple side- holes along the catheter length to allow for delivery of large quantities of fluid. C. Clean techniques are used when handling IP access and supplies. D. IP therapy is used for clients who are receiving medications for diagnostic tests. E. IP therapy includes three phases. the instillation phase; the dwell phase, usually 1 to 4 hours; and the drain phase. F. Strict aseptic techniques are used when handling the IP access and supplies.

40. A, B, E, F Options A, B, E, and F are correct statements about IP therapy. Microbial peritonitis and inflammation of the peritoneal membranes from the invasion of microorganisms is a complication of IP therapy, so it is essential to use aseptic technique (not clean) to decrease the risk of this occurrence. IP therapy is used for administration of chemotherapy agents into the peritoneal cavity and to treat intra-abdominal malignancies such as ovarian and GI tumors, not for diagnostic purposes.

40. Which client conditions will the nurse recognize as absolute contraindications to receiving a kidney transplant? Select all that apply. A. Breast cancer and metastasis to the lungs B. Type 2 diabetes controlled with diet and exercise C. Urinary tract infection D. Active treatment for peptic ulcer disease E. Chemical dependency F. Living related donor

40. A, C, E Absolute contraindications to kidney transplant include active cancer, current infection, active psychiatric illness, active substance abuse, and nonadherence with dialysis or medical regimen.

40. Which treatment best applies to the care of a client newly diagnosed with infective endocarditis? A. Long-term anticoagulant therapy with IV heparin followed by oral warfarin B. Hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home C. Complete bedrest for the duration of the treatment with subcutaneous enoxaparin D. Administration of IV penicillin, followed by oral penicillin for 6 to 10 weeks

40. B Antimicrobials are the main treatment for infective endocarditis, with the choice of drug depending on the specific organism involved. Because vegetations surround and protect the offending microorganism, an appropriate drug must be given in a sufficiently high dose to ensure its destruction. Antimicrobials are usually given IV, with the course of treatment lasting 4 to 6 weeks. For most bacterial cases, the ideal antibiotic is one of the penicillins or cephalosporins. Clients may be hospitalized for several days to institute IV therapy and then are discharged for continued IV therapy at home.

40. The nurse observes clients with which of the following conditions for potential hypernatremia? Select all that apply. A. Chronic constipation B. Heart failure C. Severe diarrhea D. Decreased kidney function E. Profound diaphoresis F. Cushing's syndrome

40. C, D, E, F Severe diarrhea and profound diaphoresis cause both water loss and some sodium loss. However, water loss is greater than sodium loss and can result in a relative hypernatremia. Cushing syndrome with increased levels of cortisol causes an increased reabsorption of sodium from the kidneys leading to hypernatremia. Decreased kidney function reduces the normal amount of sodium that is excreted in the urine leading to hypernatremia. Constipation has no effect on loss or reabsorption of sodium. Heart failure is affected by excess sodium but does not lead to excess sodium.

41. Which sign or symptom does the nurse expect to see in a client who has mild hypernatremia? A. Muscle twitching and irregular muscle contractions B. Inability of muscles and nerves to respond to a stimulus C. Muscle weakness occurring bilaterally with no specific pattern D. Reduced or absent bilateral deep tendon reflexes

41. A Movement of sodium into the intracellular fluid from the extracellular fluid is a trigger for depolarization of excitable membranes. Higher than normal sodium levels increase muscle twitching and contractions with a lower stimulus and sometimes even without a stimulus.

41. What is the nurse's best action when a client receiving IP therapy reports nausea and vomiting? A. Reduce the IP flow rate and administer antiemetics. B. Help the client move from side to side to distribute the fluid evenly. C. Flush the catheter with normal saline after the fluid has drained. D. Notify the health care provider and obtain a prescription for abdominal x-ray.

41. A Reducing the flow rate and treatment with antiemetic drugs can reduce symptoms of nausea and vomiting. Option B will evenly distribute the IP fluid but will not relieve nausea and vomiting. Option C ensures patency of the catheter but does not relieve nausea and vomiting. With option D, the nurse would notify the health care provider for something to relieve nausea and vomiting, but the abdominal x-ray would not do this.

41. Which client serum lipid tests suggest an increased risk for cardiovascular disease (CVD)? Select all that apply. A. HDL 65 mg/dL B. LDL 170 mg/dL C. Triglycerides 185 mg/dL D. Total cholesterol 175 mg/dL E. VLDL 39 mg/dL F. Total cholesterol 250 mg/dL

41. B, C, E, F See Laboratory Profile Cardiovascular Assessment Box in text. This box lists the normal results and states which lipid results increase the risk for CVD. The desired ranges for lipids are: Total cholesterol less than 200 mg/dL; Triglycerides between 40 and 160 mg/dL for men and between 35 and 135 mg/dL for women; HDL more than 45 mg/dL for men; more than 55 mg/dL for women ("good" cholesterol); and LDL less than 130 mg/dL; VLDL is 7-32 mg/dL or 0.18-0.83 mmol/L (SI units). A fasting blood sample for the measurement of serum cholesterol levels is preferable to a nonfasting sample.

41. For how many hours will the nurse instruct the assistive personnel (AP) to check the hourly urine output of a postoperative client who had a kidney transplant? A. 8 hours B. 12 hours C. 24 hours D. 48 hours

41. D A postoperative client who had a kidney transplant has a urinary catheter in place for accurate measurements of urine output and decompression of the bladder. Decompression prevents stretch on sutures and ureter attachment sites on the bladder. The nurse and AP check urine output at least hourly during the first 48 hours. This includes examining the urine for color.

42. Which laboratory value test elevation does the nurse consider most significant in the diagnosis of a client's myocardial infarction (MI)? A. Troponin T and I B. Myoglobin C. Highly sensitive C-reactive protein D. Creatinine kinase MB

42. A Troponin is a myocardial muscle protein released into the bloodstream with injury to myocardial muscle. Troponins T and I are not found in healthy clients, so any rise in values indicates cardiac necrosis or acute MI. Before the development of highly sensitive troponin levels, providers relied on creatinine kinase (CK), its isoenzyme (CK-MB), and myoglobin to assist with diagnosis of acute myocardial infarction. Highly sensitive C- reactive protein (hsCRP) has been the most studied marker of inflammation.

42. Why will the nurse immediately notify the nephrology health care provider if a client develops hypotension and diuresis postoperatively after a kidney transplant? A. These problems place the client at risk for hypervolemia and dehydration. B. Dehydration with hypotension reduces perfusion and oxygen to the new kidney. C. These assessment findings are indicators of a possible serious acute infection. D. Increased work by the kidney for diuresis results in excessive buildup of cellular toxins that damage the new kidney's tubules.

42. B If hypotension or excessive diuresis (e.g., unanticipated urine output 500 to 1000 mL greater than intake over 12 to 24 hours or other goal for intake and output) is present, respond by notifying the nephrology health care provider because hypotension reduces perfusion and oxygen to the new kidney, threatening the kidney's survival.

42. Which site will the nurse choose for a client who is to receive hypodermoclysis treatment for palliative care? A. Anterior forearm B. Lateral aspect of the upper arm C. Area under the clavicle D. Posterior tibial area

42. C When choosing the infusion site, consider the client's level of activity. The area under the clavicle or the abdomen prevents difficulty with ambulation. In general, extremities are avoided for hypodermoclysis because other sites provide larger surface areas for absorption and the client's use of upper extremities is not restricted.

42. What does the nurse suspect when a client describes substernal pain that radiates to the left shoulder, is grating, and worsens with inspiration and coughing? A. Chronic constrictive pericarditis B. Cardiac tamponade C. Hypertrophic cardiomyopathy D. Acute pericarditis

42. D A client with acute pericarditis would experience substernal precordial pain that radiates to the left side of the neck, the shoulder, or the back. The pain is classically grating and oppressive and is aggravated by breathing (mainly on inspiration), coughing, and swallowing. The pain is worse when the client is in the supine position and may be relieved by sitting up and leaning forward.

42. Which intervention does the nurse anticipate for a client who has hypernatremia caused by reduced kidney sodium excretion? A. IV administration of 0.9% sodium chloride solution B. IV administration of Ringer's lactate solution C. Administration of convaptan D. Administration of furosemide

42. D Both IV solutions contain isotonic levels of sodium chloride and would not significantly reduce the hypernatremia. The fluid may be problematic if the client's kidney function is low. Convaptan would increase water excretion and not induce sodium excretion, which would make the sodium level even higher. Furosemide increases both water and sodium excretion, along with other electrolytes.

43. For which conditions does the nurse consider intrathecal infusion appropriate for a client? Select all that apply. A. Traumatic brain injury B. Leukemia C. Multiple sclerosis D. Cancer of the central nervous system E. Cerebral palsy F. Chronic pain

43. A, C, D, E, F Intrathecal infusion of chemotherapy is used for treating central nervous system (CNS) cancers and postoperative pain. It can also be used to manage chronic pain and treat spasticity of neurologic diseases such as cerebral palsy, multiple sclerosis, reflex sympathetic dystrophy, and traumatic brain injuries. It is not an appropriate therapy for the treatment of leukemia in adults.

43. What does the nurse expect the nephrology health care provider to prescribe when a post kidney transplant client develops oliguria, elevated temperature of 100° F (37.8° C), increased blood pressure, and signs of fluid retention 9 days after the surgery? A. Immediate removal of the transplanted kidney B. Increased doses of immunosuppressive drugs C. Immediate return to either hemodialysis or peritoneal dialysis D. Antibiotic therapy until infection symptoms are resolved

43. B These symptoms within the time frame of a week or more indicate that the client may be having an acute rejection. The treatment for acute rejection is increased dosages of immunosuppressive drugs. Immunosuppressive drugs protect the transplanted organ. These drugs include corticosteroids, inhibitors of T-cell proliferation and activity (azathioprine, mycophenolic acid, cyclosporine, and tacrolimus), mTOR inhibitors (to disrupt stimulatory T-cell signals), and monoclonal antibodies.

43. Which common signs and symptoms will the nurse be sure to assess for in the older client whose serum sodium level is 152 mEq/L? Select all that apply. A. Intact recall of recent events B. Increased pulse rate C. Weight loss D. Hypertension E. Muscle weakness F. Difficulty palpating peripheral pulses

43. B, D, E, F Elevated sodium levels increase vascular volume "where sodium goes, water follows," increasing heart rate and blood pressure. With increased edema associated with hypernatremia, pulses may be difficult to palpate. Although mild hypernatremia increases the irritability of excitable membranes causing muscle twitching and irregular contraction, higher levels of sodium dehydrate excitable tissues, including muscle cells, to the extent that they may not be able to contract. Confusion and weight gain are associated with hypernatremia, especially when it is accompanied by hypervolemia.

43. What is the best method for the nurse to use when auscultating a client's pericardial friction rub with a stethoscope? A. Place the bell just below the left clavicle. B. Place the diaphragm at the apex of the heart. C. Place the diaphragm at the left lower sternal border. D. Place the bell at several points while the client holds his or her breath.

43. C A pericardial friction rub may be heard with the diaphragm of the stethoscope positioned at the left lower sternal border. This scratchy, high-pitched sound is produced when the inflamed, roughened pericardial layers create friction as their surfaces rub together.

43. What action does the nurse plan to take prior to a cardiac catheterization when a client states he or she has an allergy to seafood and iodine-containing dyes? A. Inform the cardiologist because the test must be delayed for a week. B. Prepare to administer anticoagulation therapy before the test. C. Administer an antihistamine and / or a steroid before the test. D. Instruct the client that the test will be conducted using noncontrast dye.

43. C Before the procedure, question the client about any history of allergy to iodine-based contrast agents. An antihistamine or steroid may be given to a client with a positive history or to prevent a reaction. The test does not need to be delayed and contrast dye is necessary to see any coronary artery blockages. Anticoagulants would not be given because that would cause bleeding.

44. Which statements about intravascular ultrasonography (IVUS) are accurate? Select all that apply. A. A flexible catheter with a miniature transducer is introduced at the distal tip to view the coronary arteries. B. Injection of a contrast dye through a catheter permits viewing the coronary arteries. C. The catheter has a transducer which emits sound waves that reflect off the plaque and the arterial wall to create an image of the blood vessel. D. The catheter is advanced through either the inferior or the superior vena cava and is guided by fluoroscopy. E. IVUS can be used in vessels as small as 2 mm to assess the nature of plaques or vessel condition following an intervention. F. The cardiologist advances the catheter against the blood flow from the femoral, brachial, or radial artery up the aorta, across the aortic valve, and into the left ventricle.

44. A, C, E Options A, C, and E are accurate about the intravascular ultrasonography (IVUS) procedure. Options B, D, and F are descriptions related to the usual cardiac catheterization procedure.

44. Which precaution is most important for the nurse to teach a client at continued risk for hypernatremia? A. Avoid salt substitutes. B. Avoid aspirin and aspirin-containing products. C. Read labels on canned or packaged foods to determine sodium content. D. Increase daily intake of caffeine-containing foods and beverages.

44. C Most canned and prepared packaged foods contain high levels of sodium and their intake should be limited. Saltvsubstitutes have a much lower sodium content than standard table salt and is recommended for clients who need to limit sodium intake. Aspirin has no influence on serum sodium levels. Caffeinated food and beverages can increase water excretion without increasing sodium excretion and lead to higher serum sodium levels.

44. For which potential problem does the nurse assess the client after receiving epidural therapy when symptoms of headache, stiff neck, or temperature higher than 101°F (38.3°C) develop? A. Allergic reaction B. Leakage of cerebrospinal fluid C. Meningitis D. Catheter migration

44. C The client may also exhibit neurologic and systemic signs of infection (e.g., meningitis) such as headache, stiff neck, or temperature higher than 101°F (38.3°C). Report any neurologic change to the primary health care provider immediately!

45. At what rate would the nurse set the infusion when a client is to receive 0.45% normal saline, 1000 mL over 15 hours? A. 50 mL/hr B. 67 mL/hr C. 75 mL/hr D. 83 mL/hr

45. B 1000mL / 15 hr = 66.6 rounded up to 67 mL/hr

45. Which action does the nurse perform to prevent kidney toxicity when caring for a client after cardiac catheterization? A. Assess pedal pulses every 15 minutes. B. Provide intravenous and oral fluids for 12 to 24 hours. C. Check the catheterization site every hour for 8 hours. D. Keep the catheterized extremity straight for 6 hours.

45. B Contrast-induced renal dysfunction can result from vasoconstriction and the direct toxic effect of the contrast agent on the renal tubules. Hydration pre- and post-study helps eliminate or minimize contrast-induced renal toxicity.

45. Which serum laboratory value does the nurse expect to see in the client with hypokalemia? A. Sodium less than 8.0 mEq/L (mmol/dL) B. Potassium less than 3.5 mEq/L (mmol/dL) C. Chloride less than 100.0 mEq/L (mmol/dL) D. Calcium less than 9.0 mg/dL (2.25 mmol/dL)

45. B Hypokalemia refers to a lower than normal serum potassium level, not sodium, chloride, or calcium. The normal serum potassium level is 3.5 to 5.0 mEq/L or mmol/L.

45. What does the nurse instruct a client with pericarditis to do to make him or her will feel more comfortable? A. Lie down and bend the legs at the knees. B. Sit in a semi-Fowler position with pillows under each arm. C. Sit up and lean forward. D. Lie on the side in a fetal position.

45. C The pain is worse when a client with acute pericarditis is in the supine position and may be relieved by sitting up and leaning forward.

46. Which effect on respiratory effort does the nurse expect to find in a client with severe hypokalemia? A. Shallow respirations and low oxygen saturation B. Deep, rapid respirations with high oxygen saturation C. Deep, slow respirations with high oxygen saturation D. No specific change in respiratory rate or effectiveness

46. A Severe hypokalemia causes profound skeletal muscle weakness. Because skeletal muscle contraction is absolutely required for the ventilation of respiration, muscle weakness reduces respiratory depth and effectiveness, leading to low oxygen saturation. The most common cause of death with severe hypokalemia is respiratory failure.

46. Which priority concept concerns the nurse when performing infusion therapy for any client? A. Fluid and electrolyte balance B. Tissue integrity C. Acid-base imbalance D. Perfusion

46. A The priority concept for when a nurse is providing infusion therapy for any client is fluid and electrolyte balance. The interrelated concept for infusion therapy is tissue integrity.

46. Which instructions would the nurse give the LVN/LPN monitoring a client after cardiac catheterization by radial artery approach? Select all that apply. A. Monitor the client's vital signs every 15 minutes for 1 hour. B. Assess the insertion site for bloody drainage or hematoma. C. Keep the client in bed for at least 6 hours. D. Assess peripheral pulses and skin temperature and color with every vital sign check. E. Monitor intake and output. F. Provide oral fluids for adequate contrast excretion.

46. A, B, D, E, F All options except C are correct for safe recovery of the client after a cardiac catheterization. Keeping the client in bed for more than 2 hours is not necessary when the radial approach is used for the test.

46. Which are proposed criteria for diagnosis of a client with acute pericarditis? Select all that apply. A. Chest pain that lasts longer than 3 months B. Pericardial chest pain C. Presence of a pericardial friction rub D. New ST elevation in all ECG leads or PR-segment depression E. New or worsening pericardial effusion F. Hepatic engorgement

46. B, C, D, E The proposed diagnostic criteria for acute pericarditis are presence of two of the following: pericardial chest pain; presence of pericardial rub; new ST elevation in all ECG leads or PR-segment depression; and new or worsening pericardial effusion.

47. Which GI complication will the nurse monitor for in a client who has a serum potassium level of 2.4 mEq/L (mmol/L)? A. Hyperactive bowel sounds B. Paralytic ileus C. Esophageal reflux D. Excessive flatus

47. B Hypokalemia reduces GI motility and greatly increases the risk for a paralytic ileus.

47. What is the definitive treatment for chronic constrictive pericarditis? A. Pericardiocentesis B. Surgical removal of the pericardium C. Placement of a pericardial drain D. Creation of a pericardial window

47. B The definitive treatment for chronic constrictive pericarditis is surgical excision of the pericardium (pericardiectomy). Pericardiocentesis, placement of a drain, or creation of a pericardial window are all interventions for clients with acute pericarditis.

47. Which tests will the nurse teach a client are routinely done for follow-up monitoring when the client is discharged with a prescription for warfarin? A. Complete blood count and platelet count B. Partial thromboplastin time (PTT) and serum potassium C. Prothrombin time (PT) and international normalized ratio (INR) D. Serum and urine electrolyte studies

47. C Prothrombin time (PT) and international normalized ratio (INR) are used when initiating and maintaining therapy with oral anticoagulants, such as sodium warfarin. They measure the activity of prothrombin, fibrinogen, and factors V, VII, and X. INR is the most reliable way to monitor anticoagulant status in warfarin therapy. The therapeutic ranges vary significantly based on the reason for the anticoagulation and the client's history. The normal INR is 0.8-1.1. An INR range of 2.0-3.0 is generally an effective therapeutic range for people taking warfarin.

48. Which are potential causes of dilated cardiomyopathy? Select all that apply. A. Alcohol abuse B. Sedentary lifestyle C. Cigarette smoking D. Infection E. Chemotherapy F. Poor nutrition

48. A, D, E, F Causes of dilated cardiomyopathy may include alcohol abuse, chemotherapy, infection, inflammation, and poor nutrition.

48. Which instruction would the nurse give a client who is to have an exercise electrocardiography test? A. "Someone must drive you home because of sedative effects of the medications." B. "Wear comfortable loose-fitting clothes and supportive, rubber- soled shoes." C. "Avoid smoking or drinking alcohol for at least a week before the test." D. "Do not eat or drink anything after midnight."

48. B Clients are advised to wear comfortable, loose clothing and rubber-soled, supportive shoes. Instruct the client to get plenty of rest the night before the procedure. He or she may have a light meal 2 hours before the test but should avoid smoking or drinking alcohol or caffeine-containing beverages on the day of the test. Usually cardiovascular drugs such as beta blockers or calcium channel blockers are withheld on the day of the test to allow the heart rate to increase during the stress portion of the test. Sedation drugs are not given with this test.

48. Which conditions or health problems increase a client's risk for hypokalemia? Select all that apply. A. Liver failure B. Metabolic alkalosis C. Cushing syndrome D. Hypothyroidism E. Paralytic ileus F. Kidney failure

48. B, C Metabolic alkalosis causes a relative hypokalemia by increasing movement of potassium ions from the extracellular fluid into the intracellular fluid in exchange for hydrogen ions. Cushing syndrome involves higher than normal levels of cortisol, which increases potassium loss resulting in an actual hypokalemia. Paralytic ileus is caused by hypokalemia and does not cause it. Kidney failure causes hyperkalemia. Potassium levels are not affected directly by hypothyroidism or liver failure.

49. For which serious complication will the nurse administering an IV potassium solution to a client carefully monitor to prevent harm? A. Pulmonary edema B. Cardiac dysrhythmia C. Postural hypotension D. Kidney failure

49. B If the potassium solution raises the serum potassium level too rapidly, hyperkalemia can result. Higher-than-normal serum potassium levels delay electrical conduction through the heart and can cause a variety of dysrhythmias, including asystole.

49. Which parameter indicates to the nurse that a client's exercise electrocardiogram (ECG) should be stopped? A. Increase in heart rate B. Increase in blood pressure C. ECG shows P waves before every QRS complex D. ECG shows ST-segment depression

49. D Increases in heart rate and blood pressure are expected. P waves before each QRS complex is a normal finding. The client exercises until one of these findings occurs: a predetermined HR is reached and maintained; signs and symptoms such as chest pain, fatigue, extreme dyspnea, vertigo, hypotension, and ventricular dysrhythmias appear; or significant ST-segment depression or T-wave inversion occurs.

49. Which type of cardiomyopathy may present with sudden death as the first symptom? A. Dilated B. Arrhythmogenic right ventricular C. Restrictive D. Hypertrophic

49. D Sudden death may be the first symptom of hypertrophic cardiomyopathy (HCM), although the primary symptoms of HCM are exertional dyspnea, angina, and syncope. The chest pain is atypical in that it usually occurs at rest, is prolonged, has no relation to exertion, and is not relieved by the administration of nitrates. A high incidence of ventricular dysrhythmias is also associated with HCM.

5. For which finding does the nurse alert the health care provider immediately after assessing a client's abdomen? A. Bulging, pulsating mass B. Borborygmus C. Unintentional weight loss D. Reflux with dyspepsia

5. A If a bulging, pulsating mass is present during assessment of the abdomen, the nurse does not touch the area because the client may have an abdominal aortic aneurysm which is a life-threatening problem. The nurse notifies the health care provider of this finding immediately!

5. What is the nurse's priority action when caring for a client with acute cholecystitis who now has severe abdominal pain, diaphoresis, heart rate of 118 beats/min, BP 95/70, respirations 32 breaths/min, and temperature 101°F (38.3°C)? A. Initiating the Rapid Response Team B. Assisting the client to a semi-Fowler position C. Administering the prescribed opioid analgesic D. Auscultating the client's abdomen in all four quadrants

5. A The client is exhibiting the symptoms associated with biliary colic and possible shock. This is an emergency and, if the client's primary health care provider is not immediately available, initiating the Rapid Response Team is a priority.

5. Which type of intravenous (IV) access would the nurse use to administer a client's chemotherapy treatment? Select all that apply. A. Intra-arterial catheter B. Peripherally inserted central catheter (PICC) C. Implanted port D. Short peripheral catheter E. Dialysis catheter F. Midline catheter

5. A, B, C Use of an intra-arterial catheter for infusion therapy is not common and is generally used for direct treatment of tumor sites. Chemotherapy agents administered arterially allow infusion of a high concentration of drug directly to the tumor site. With a PICC line, there are no limitations on the pH or osmolality of fluids that can be infused. Clients requiring lengthy courses (more than 14 days) of antibiotics, chemotherapy agents, parenteral nutrition formulas, and vasopressor agents can benefit from a PICC. Implanted ports are used most often for clients receiving chemotherapy.

5. Which recommendations will nurses follow to create a safe, welcoming environment for LGBTQ client care? Select all that apply. A. Designating unisex or single-stall restrooms B. Making waiting rooms inclusive of LGBTQ clients and families C. Not limiting gender options on medical forms to "male" and "female" D. Ensuring that visitation policies are equitable for families of LGBTQ clients E. Reflecting the client's choice of terminology in communication and documentation F. Including gender-neutral language on all medical forms and documents

5. A, B, C, D, E, F All of these options will help make waiting rooms safer and more welcoming for LBGTQ clients. See the box titled Best Practice for Patient Safety & Quality Care The Joint Commission Recommendations for Creating a Safe, Welcoming Environment for LGBTQ Patients in your text for additional suggestions.

5. Which nonsurgical actions would the nurse include in the care of a middle-age female client with stress incontinence? Select all that apply. A. Suggest keeping a diary of urine leakage, activities, and foods eaten. B. Teach performance of pelvic floor (Kegel) exercise therapy. C. Encourage the client to take in adequate fluids, especially water. D. Instruct the client to consume a glass of cranberry juice every day. E. Refer to a registered dietitian nutritionist for diet or weight loss therapy. F. Prepare the client for a surgical sling or bladder suspension procedure.

5. A, B, C, E Options A, B, C, and E are appropriate nonsurgical stress incontinence management strategies. Option D, the use of cranberry juice may be recommended to prevent urinary tract infections, but does not affect incontinence. Surgical sling or bladder suspension procedures are both surgical management options for treatment of stress incontinence.

5. The nurse assessing a client's respiratory status finds fremitus has increased from the assessment performed yesterday. For which possible respiratory problem will the nurse assess further? A. Pneumothorax B. Pneumonia C. Pleural effusion D. Emphysema

5. B Fremitus is a vibration that can be felt on the chest wall when the client speaks. It is decreased if the transmission of sound waves from the larynx to the chest wall is slowed, such as when the pleural space is filled with air (pneumothorax) or fluid (such as with a pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses because the increased density of the chest enhances transmission of the vibrations.

5. Which behavioral modification instructions will the nurse teach a client with benign prostatic hyperplasia (BPH)? Select all that apply. A. Take diuretics to increase urine output. B. Limit alcohol intake. C. Avoid caffeine containing beverages. D. Do not consume large amounts of fluid in a short time. E. Avoid sexual intercourse. F. Avoid taking antihistamine drugs.

5. B, C, D, F Behavioral modifications that the nurse teaches a client with BPH include avoidance of drinking large amounts of fluid in a short period of time, especially before going out or at bedtime; limiting caffeine and alcohol consumption, as these have a diuretic effect; and avoiding drugs that can cause urinary retention, especially anticholinergics, antihistamines, antipsychotics, and muscle relaxants.

5. Which condition will the nurse recognize increases the risk for a client with benign prostatic hyperplasia (BPH) to develop? A. Perfusion reduction (prerenal failure) B. Intrinsic or intrarenal failure C. Urine flow obstruction (postrenal failure) D. End-stage kidney disease

5. C BPH (enlarged prostate gland) increases the client's risk for urine flow obstruction leading to postrenal failure because the prostate gland surrounds and puts pressure on the urethra.

5. What is the nurse's priority concern when a client has an ischemic brainstem stroke with damage to the medulla area of the brain? A. Increased intracranial pressure B. Seizure activity C. Respiratory arrest D. Brainstem herniation

5. C Brainstem functions of the medulla include: respiratory center; cardiac slowing center; and functions of these cranial nerves: cranial nerve nuclei IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) and parts of cranial nerves VII (facial) and VIII (vestibulocochlear). The priority concern for this client is the risk for respiratory arrest which is life threatening.

5. Which diagnostic test does the nurse expect will be ordered for a client with suspected gastritis? A. Computed tomography (CT) scan B. Upper gastrointestinal (GI) series C. Esophagogastroduodenoscopy (EGD) D. Barium swallow

5. C Esophagogastroduodenoscopy (EGD) via an endoscope with biopsy is the gold standard for diagnosing gastritis. The primary health care provider performs a biopsy to establish a definitive diagnosis of the type of gastritis

5. Which action is best for the nurse to take while caring for a client with late-stage advanced Alzheimer disease in a long-term care setting? A. Repeating the date, time, and place frequently B. Using memory aids such as pill reminders C. Reflecting a client's feelings and concerns D. Providing puzzles, games, and hands-on activities

5. C For the client in the later stages of AD or another form of dementia, reality orientation does not work and often increases agitation. The interprofessional health care team uses validation therapy for the client with moderate or severe AD. In validation therapy, the staff member recognizes and acknowledges the client's feelings and concerns.

5. What immediate response does the nurse expect as a result of infusing 1 liter of an isotonic intravenous solution into a client over a 3-hour time period if urine output remains at 100 mL per hour? A. Extracellular fluid (ECF) osmolarity increases; body weight increases B. Extracellular fluid (ECF) osmolarity decreases; body weight decreases C. Extracellular fluid (ECF) osmolarity is unchanged; body weight increases D. Extracellular fluid (ECF) osmolarity is unchanged; body weight decreases

5. C Isotonic solutions have the same tonicity as plasma and other extracellular fluids. Therefore, the intravenous fluid would not change the ECF osmolarity. When 1000 mL is infused within 3 hours and the client only urinates 300 mL, the extra fluid would increase the client's weight. Remember that 1 liter of fluid is equal to 2.2 lb.

5. What is the client's pulse pressure when the nurse finds that his or her blood pressure is 148/86 mm Hg? A. 48 mm Hg B. 56 mm Hg C. 62 mm Hg D. 86 mm Hg

5. C The difference between the systolic and diastolic values is referred to as pulse pressure. 148 - 86 = 62 mm Hg.

5. When a client's kidney hormonal function is not working properly, which condition does the nurse expect to occur? A. Leukemia B. Thrombocytopenia C. Anemia D. Neutropenia

5. C The kidneys produce the hormone erythropoietin for red blood cell (RBC) synthesis. When kidney function is poor, erythropoietin production decreases and anemia results.

5. Which assessment findings in an older client indicate to the nurse that this client is at increased risk for developing undernutrition? Select all that apply. A. Male B. Is of Jewish ethnicity C. Reports chronic diarrhea D. Receiving oxygen after surgery E. Does not consume pork products F. Has chronic obstructive pulmonary disease G. Presence of chronic draining pressure injury H. Presence of swollen gums and many missing teeth

5. C, F, G, H The risk for malnutrition is not particularly associated with ethnicity or gender. Conditions that increase nutrient loss, such as chronic wounds and chronic diarrhea contribute to undernutrition risk. Poor dentition interferes with a client's ability to consume adequate nutrients. Health problems that increase energy expenditure, such as COPD, greatly increase caloric need and promote undernutrition. Although pork is an animal protein source, its elimination from the diet does not alone contribute to undernutrition. Receiving oxygen after surgery is common and not an indicator of undernutrition risk.

5. Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

5. D Clients with advanced liver disease, such as cirrhosis with ascites, are unable to metabolize fats and absorb fat-soluble vitamins from the GI tract. As a result, vitamin K is deficient. (Vitamin C is water-soluble.)

5. For which serious complications of the infection will the nurse caring for a client who has seasonal influenza continuously monitor? Select all that apply. A. Chronic obstructive pulmonary disease (COPD) B. Fever C. Hypertension D. Pneumonia E. Renal failure F. Sepsis

5. D, F The two most common complications of seasonal influenza are pneumonia and sepsis. Influenza is not a risk factor for development of chronic obstructive pulmonary disease. Fever is a symptom of influenza, not a complication. Hypertension is not associated with influenza. Renal failure can accompany sepsis but is not associated with seasonal influenza although it is associated with MERS.

50. Which criteria are appropriate for a client with dilated cardiomyopathy to become a candidate for heart transplant surgery? Select all that apply. A. Life expectancy greater than 2 years B. Age generally less than 65 years C. New York Heart Association Class III or IV D. Normal or only slightly increased pulmonary vascular resistance E. Consumes less than five to six beers per day F. Absence of active infection

50. B, C, D, F Candidate selection criteria for heart transplantation include: life expectancy less than 1 year; age generally less than 65 years; New York Heart Association (NYHA) Class III or IV; normal or only slightly increased pulmonary vascular resistance; absence of active infection; stable psychosocial status; and no evidence of current drug or alcohol misuse.

51. Which statement best describes the functional capability of a client who is categorized as New York Heart Association Class II? A. Ordinary physical activity results in fatigue, palpitations, dyspnea, and anginal pain. B. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. C. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. D. If any physical activity is undertaken, discomfort is increased.

51. A With regard to physical activity, the New York Heart Association Functional Classification of Cardiovascular Disability describes the four classes as follows: Class I, ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain; Class II, ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain; Class III, less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain; and Class IV, if any physical activity is undertaken, discomfort is increased.

51. Which assessment findings would suggest to the nurse that a client who received a heart transplant was experiencing organ rejection? Select all that apply. A. Shortness of breath B. Hypotension C. Abdominal pain D. Decreased activity tolerance E. Fluid gain (edema, increased weight) F. Atrial fibrillation or flutter

51. A, B, D, E, F Signs and symptoms of heart transplant rejection include: shortness of breath; fatigue; fluid gain (edema, increased weight); abdominal bloating; new bradycardia; hypotension; atrial fibrillation or flutter; decreased activity tolerance; and decreased ejection fraction (late sign).

51. Which action is most important for the nurse to perform to prevent harm before starting an IV infusion of potassium to a client who has a low serum potassium level? A. Determine IV line patency and blood return. B. Assess oxygen saturation level with pulse oximetry. C. Evaluate baseline mental status. D. Check the apical pulse for a full minute. E. Check deep tendon reflexes. F. Measure intake and output.

51. A, D Potassium is a severe tissue irritant and can cause damage (as well as pain) if the IV line extravasates or infiltrates. The nurse must ensure the line is patent and has a good blood return before administering IV fluids containing potassium. Elevated serum potassium levels can cause bradycardia and dysrhythmias. Therefore, it is best to establish the client's baseline heart rate and rhythm before administering any IV potassium solution.

52. Which client statement indicates to the nurse a correct understanding of the management of hyperkalemia? A. "My wife does all the cooking. She shops for food high in calcium." B. "When I take the liquid potassium in the evening, I'll eat a snack beforehand." C. "I will avoid bananas, orange juice, organ meats, and salt substitutes." D. "If I switch to a vegetarian diet, I can stop taking the liquid potassium."

52. C In option A, the client is confusing calcium with potassium. Foods with more potassium include bananas, orange juice, and organ meats. Salt substitutes are about 50% potassium.

53. The pharmacy sends a 250-mL IV bag of dextrose in water with 40 mEq of potassium, marked "to infuse over 1 hour" for a client with hypokalemia. What is the nurse's best action? A. Obtain a pump and administer the solution. B. Double-check the prescription and call the pharmacy. C. Recheck the client's potassium level to ensure the IV is safe to administer. D. Recalculate the rate so that it is safe for the client.

53. B Intravenous potassium is a high-alert dangerous drug that can lead to death if administered too rapidly or at too a high concentration. The maximum allowable infusion rate is 5 to 10 mEq (mmol) per hour. The rate of 40 mEq (mmol) in 1 hour is completely unsafe even if it is administered with a pump or controller. Whether or not the label matches the health care provider's prescription, the rate of infusion is wrong and both the prescription and label must be clarified. The nurse is not the prescriber and cannot change the prescribed infusion rate.

54. Which foods does the nurse teach a client to include in his or her diet to help prevent future episodes of hypokalemia? Select all that apply. A. Soybeans B. Bananas C. Cantaloupe D. Potatoes E. Peaches F. Lettuce

54. A, B, C, D Soybeans, bananas, cantaloupe, and potatoes are good sources of potassium. Peaches and lettuce contain little, if any potassium.

55. Which serum potassium value indicates to the nurse that a client has hyperkalemia? A. 2.9 mEq/L (mmol/L) B. 3.9 mEq/L (mmol/L) C. 4.9 mEq/L (mmol/L) D. 5.9 mEq/L (mmol/L)

55. D The normal range for serum potassium level is 3.5 to 5.0 mEq/L (mmol/L). Hyperkalemia is a serum potassium level higher than 5.0 mEq/L (mmol/L).

56. In reviewing a client's electrocardiogram (ECG), which finding does the nurse associate with hyperkalemia? A. Tall peaked T waves B. Narrow QRS complex C. Tall P waves D. Elevated ST segment

56. A Hyperkalemia has deleterious effects on electrical conduction through the heart and can cause death. Some earlier changes in the ECG reflecting a rising potassium level include tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes.

57. Which medication or class of drugs taken regularly at home does the nurse associate with a newly admitted client's laboratory finding of hyperkalemia? A. Insulin B. Beta blocker C. Cephalosporin antibiotic D. Spironolactone

57. D Spironolactone is a potassium-sparing diuretic that increases its reabsorption in the kidney. Taking it daily can lead to hyperkalemia. Insulin is associated with hypokalemia. The beta blocker and antibiotic are not associated with disturbances of potassium.

58. Which assessment findings does the nurse expect to see in a client who has mild hyperkalemia? Select all that apply. A. Wheezing on exhalation B. Numbness in hands, feet, and around the mouth C. Hyperactive bowel sounds D. Irregular heart rate E. Skeletal muscle twitching F. Excessive skin dryness

58. B, C, D, E Hyperkalemia increases GI motility and changes electrical conduction through the heart, which induces an irregular heart rate. In the early stages of hyperkalemia (mild potassium elevations), paresthesias are present as is skeletal muscle twitching. The respiratory muscles are not affected until potassium levels are very high. Potassium excesses do not result in skin manifestations.

59. Which additional laboratory changes does the nurse anticipate in a client who has hyperkalemia resulting from dehydration? A. Increased hematocrit and hemoglobin levels B. Decreased serum electrolyte levels C. Increased urine potassium levels D. Decreased serum creatinine levels

59. A In dehydration-associated hyperkalemia, the amount of total potassium is not increased but water loss from the plasma fluid increases the concentration of all electrolytes and blood cells.

6. Ankle and foot edema in a nurse who has been standing for 12 hours is a result of which type of pressure, force, or influence? A. Filtration from the plasma volume to the interstitial space as a result of increased capillary hydrostatic pressure B. Filtration from the plasma volume to the interstitial space as a result of decreased capillary hydrostatic pressure C. Osmosis from the interstitial space to the plasma volume as a result of increased osmotic pressure because the nurse also was dehydrated as well as overworked D. Osmosis from the plasma volume to the interstitial space as a result of decreased cellular osmotic pressure because tissues damaged from standing released intracellular fluid

6. A Gravity affects hydrostatic pressure in capillaries. When in the standing position, hydrostatic pressure increases in the dependent areas of the ankles and feet. This increased capillary hydrostatic pressure forces fluid to leave the ankle and feet capillaries into the interstitial spaces resulting in the formation of visible edema in these dependent areas.

6. Which client will the nurse assess for the possibility of regional osteoporosis? A. 40-year-old who has been in a long leg cast for 10 weeks B. 45-year-old on long-term corticosteroid therapy for a chronic inflammation C. 55-year-old who is being managed for hyperparathyroidism D. 60-year-old who is postmenopausal with a history of falls

6. A Regional osteoporosis results from conditions that affect only one body region or area. Having a leg in a long leg cast for 10 weeks can result in bone density loss from reduced mobility and disuse. The other conditions can cause generalized osteoporosis rather than regional problems.

6. Which outcome statement indicates to the nurse that the client's goal for pelvic floor (Kegel) exercises has been met? A. Client has no urinary leakage between voidings. B. Incontinence is still present, but frequency is decreased. C. Client is using fewer absorbent undergarments for protection. D. Reports of dysuria are no longer heard from the client.

6. A With appropriate therapy, the client with altered urinary elimination due to incontinence is expected to develop continence of urine elimination. For stress urinary incontinence, the best indicator is no urine leakage between voidings and no urine leakage with increased abdominal pressure (e.g., sneezing, laughing, lifting).

6. Which assessment findings in a 33-year-old female client indicate to the nurse that she has an increased risk for type 2 diabetes? Select all that apply. A. A1C is 5.8% B. Weight is 25 lb (11.3 kg) above ideal C. Had a 10 lb (4.5 kg) baby 2 years ago D. Has irritable bowel syndrome with constipation E. Fasting blood glucose (FBG) level is 119 mg/dL (6.5 mmol/L) F. Mother, sister, and maternal grandmother all have type 2 diabetes

6. A, B, C, E, F Risk factors for type 2 diabetes include obesity, indications of gestational diabetes (first baby larger than 9 lb [4.1 kg]), and a family history of a parent or other first-degree relative with type 2 diabetes. In addition, although this client's A1C and FBG levels are not high enough for a diabetes diagnosis, they are consistent with prediabetes, a strong risk factor for development of type 2 diabetes. Irritable bowel syndrome is not a diabetes risk factor.

6. Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum bilirubin level? Select all that apply. A. Pruritus B. Icterus C. Hypertension D. Jaundice E. Pale, clay-colored stools F. Dark, coffee-colored urine

6. A, B, D, E, F Bilirubin is a bile pigment. Elevated serum bilirubin levels stain the skin yellow (jaundice) and the eyes yellow (icterus). Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee-colored. With liver disease and reduced function, the bilirubin does not reach the intestinal system where it is normally broken down to give stool its dark brown color. Because the bilirubin does not reach the GI tract, stools are light with a gray or clay color.

6. Which are purposes of the interprofessional team with regard to management of clients with multiple sclerosis (MS)? Select all that apply. A. To modify the disease's effects on the immune system B. To cure the client's illness C. To prevent exacerbations D. To manage symptoms E. To improve function F. To maintain quality of life

6. A, C, D, E, F The purposes of interprofessional management for MS are to modify the disease's effects on the immune system, prevent exacerbations, manage symptoms, improve function, and maintain quality of life. There is no cure for MS.

6. Which findings will the nurse be sure to document after inspecting a client's abdomen during assessment? Select all that apply. A. Overall asymmetry of the abdomen B. Size of percussed abdominal organs C. Discoloration or scarring D. Abdominal distention and skin folds E. High-pitched musical sounds F. Location and size of pressure injuries

6. A, C, D, F After inspecting a client's abdomen, the nurse documents these findings: overall asymmetry of the abdomen; discoloration or scarring; abdominal distention; bulging flanks; taut, glistening skin; skin folds; subcutaneous fat; and location, size, and description of any pressure injuries. Percussion and auscultation are not parts of abdominal inspection.

6. Which assessment questions are most appropriate for the nurse to ask a client at risk for acute kidney injury (AKI)? Select all that apply. A. "Have you noticed any changes in your urine's appearance, frequency, or volume?" B. "Have you experienced any leakage of urine when coughing or laughing?" C. "Do you weigh yourself and have you noticed any unexpected weight loss?" D. "Do you have a history of diabetes, hypertension, or peripheral vascular disease?" E. "Do you use any nonsteroidal anti-inflammatory drugs regularly?" F. "Have you had and recent surgeries, traumas, or transfusions?"

6. A, D, E, F The nurse asks about any noted changes in urine, as well as any exposure to nephrotoxic substances or drugs. Other important information from the client's medical history includes surgeries, trauma, transfusions, and chronic conditions such as diabetes, hypertension, and peripheral vascular disease. For additional essential topic, see the History section on AKI in your text.

6. Which assessment findings will the nurse expect in an older female client who has osteoporosis? Select all that apply. A. Gait changes B. Inability to bear weight C. Muscle atrophy D. History of fractures E. Swelling in the finger joints F. Spinal curvature with postural changes

6. A, D, F Osteoporosis occurs with severe osteopenia in which there is great loss of bone density. Less dense bones, especially in the spine, result in kyphosis with postural changes, and gait changes. The loss of bone density increases the risk for fragile factures even with minimal trauma. Clients usually can still weight bear. Osteoporosis is not directly responsible for muscle atrophy and does not cause joint swelling.

6. With which client will the nurse avoid relying on body mass index (BMI) as an indicator of nutrition status? A. 25-year-old female with anorexia B. 35-year-old male weight-lifter who works out daily C. 55-year-old female runner who is post-menopausal D. 65-year-old male who plays golf twice a week and walks 5 miles daily

6. B BMI is an unreliable indicator of overnutrition or undernutrition in adults who are very athletic and muscular. When muscle mass is significantly greater than average, the client will weigh more even though the percentage of body fat is low.

6. Which client does the nurse expect is most likely to exceed the renal threshold when he or she is noncompliant with the prescribed therapeutic regimen? A. 45-year-old with biliary obstruction B. 55-year-old with type 2 diabetes mellitus C. 65-year-old with recurrent kidney stones D. 75-year-old with functional incontinence

6. B The point where the kidney is overwhelmed with glucose (e.g., diabetes mellitus) and can no longer reabsorb is called the renal threshold or transport maximum (tm) for glucose reabsorption. The renal threshold for glucose is greater than 180 mg/dL (10 mmol/L). When blood glucose levels are greater than 180 mg/dL (10 mmol/L), some glucose stays in the filtrate and is present in the urine.

6. What assessment findings would the nurse expect to find in a client with right heart failure? Select all that apply. A. Weight loss B. Dependent edema C. Neck vein distention D. Angina E. Hepatomegaly F. Weak peripheral pulses

6. B, C, E Assessment findings of right ventricular failure are related to systemic congestion. They include: jugular (neck vein) distention; enlarged liver and spleen; anorexia and nausea; dependent edema (legs and sacrum); distended abdomen; swollen hands and fingers; polyuria at night; weight gain; and increased blood pressure (from excess volume) or decreased blood pressure (from failure).

6. Which statements about blood pressure are accurate? Select all that apply. A. The right ventricle of the heart generates the greatest amount of blood pressure. B. Diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction. C. Systolic blood pressure is the amount of pressure or force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart. D. Diastolic pressure is the highest pressure generated during contraction of the ventricles. E. To maintain adequate blood flow through the coronary arteries, mean arterial pressure (MAP) must be at least 90 mm Hg. F. Paradoxical blood pressure is an exaggerated decrease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle.

6. B, C, F The left ventricle generates the greatest amount of blood pressure. To maintain adequate blood flow through the coronary arteries, MAP must be at least 60 mm Hg. Systolic pressure is the highest pressure during contraction of the ventricles. Options B, C, and F are accurate.

6. Which drugs will the nurse expect to give a client with acute gastritis that are antisecretory agents? Select all that apply. A. Famotidine B. Omeprazole C. Sucralfate D. Pantoprazole E. Nizatidine F. Calcium carbonate

6. B, D H2-receptor antagonists, such as famotidine and nizatidine, are typically used to block gastric secretions. Sucralfate, a mucosal barrier fortifier, may also be prescribed. Antisecretory agents (proton pump inhibitors [PPIs]), such as omeprazole or pantoprazole, are prescribed to suppress gastric acid. Calcium carbonate (chewable or liquid) is also a potent antacid.

6. Which condition best indicates to the nurse that a client's fluid intake is sufficient to manage acute pyelonephritis? A. Client estimates an intake of 1.5 liters of water per day. B. Client reports no burning or pain with urination. C. Urine output is clear yellow and dilute. D. Antibiotic treatment was completed exactly as prescribed.

6. C Fluid intake is recommended at 2 L/day, sufficient to result in dilute (pale yellow) urine, unless another health problem requires fluid restriction.

6. In the event of a new pandemic influenza outbreak, such as COVID-19, what is the nurse's primary role? A. Immediately report new cases to the Centers for Disease Control and Prevention (CDC). B. Administer oxygen, standard antibiotics, and supportive therapies to clients. C. Prevent the spread of infection to other employees and clients D. Ensure all unit staff have annual influenza vaccination.

6. C The primary nursing role is helping to contain the outbreak by preventing spread of the infection to employees, other clients, and visitors. The facility's administrators have the responsibility to report the infection. Antibiotics do not combat influenza. Annual influenza vaccinations are not effective against new pandemic influenzas and the nurse can only recommend annual vaccination to co-workers not ensure compliance.

6. Which factor does the nurse teach clients as the most common cause of chronic respiratory problems and physical limitations? A. Annual chest x-ray exposure to ionizing radiation B. Age-related decreased strength of respiratory muscles C. Failure to receive influenza and pneumonia vaccinations D. Smoking cigarettes or chronic exposure to cigarette smoke

6. D Although age-related decreased muscle strength can increase the work of breathing and not having up-to-date immunizations increases the risk for respiratory infection, exposure to cigarette smoke (directly or indirectly as secondhand smoke) is the single most common factor causing chronic respiratory problems and physical limitations. Ionizing radiation exposure is an uncommon source of respiratory injury and chronic respiratory problems.

6. What instruction will the nurse provide to a client to prepare him or her to undergo ultrasonography of the right upper abdominal quadrant to diagnose gallstones? A. Do not eat or drink for at least 6 hours before the test. B. Shower with an antibacterial soap the morning before the test. C. Be sure to have someone come with you who can drive you home. D. A small instrument will be rolled over your upper abdomen and there will be no pain.

6. D An ultrasound is performed with an electronic probe lubricated and rolled on the skin over the area to be examined. It causes no pain, does not require the client to be NPO or to be sedated, and special cleansing of the area is not needed.

6. What is the priority for interprofessional care of clients with Alzheimer disease (AD)? A. Preserving memory B. Promoting functional abilities C. Teaching clients and families D. Keeping clients safe

6. D For clients with AD, the priority for interprofessional care is safety. Chronic confusion and physical deficits place the client with AD at a high risk for injury, accidents, and elder abuse.

6. Which client does the nurse find at the greatest disadvantage with regard to the blood-brain barrier (BBB)? A. Client with pneumonia who needs supplemental oxygen B. Client who is dehydrated and needs IV fluids to correct fluid status C. Client in need of major surgery and requires general anesthesia D. Client with bacterial meningitis in need of antibiotics

6. D The blood-brain barrier keeps some substances in the bloodstream out of the cerebrospinal circulation and out of brain tissue. Substances that can pass through the BBB include oxygen, glucose, carbon dioxide, alcohol, anesthetics, and water. Large molecules such as albumin, any substance bound to albumin, and many antibiotics are prevented from crossing the barrier.

6. In which circumstance will the nurse make a clinical judgment to forgo extensive questioning about a client's gender identity? A. The client is dressed like a man and wants information about hormones that feminize the body. B. The client has recurrent urinary tract infections despite compliance with the medication treatment regime. C. The client appears to be male but requests a pelvic examination by a female health care provider. D. The client requires treatment for a severely sprained ankle sustained during a soccer game.

6. D The treatment of the injury for the client in option D does not require sexual assessment, so there is no need to ask extensive questions about sexual identity. The clients in options A, B, and C have problems that will likely require questioning about sexual identity.

60. Which foods does the nurse recommend to a client who remains at continued risk for hyperkalemia? Select all that apply. A. Avocados B. Butter C. Cranberries D. Lettuce E. Eggs F. Dried beans G. Grapefruit H. Strawberries

60. B, C, D, E, G, H Avocados and dried beans are a rich source of potassium and should be avoided by clients requiring potassium restriction. Many clients believe that all fruit contains high levels of potassium. This is not true. The fruits listed are all low in potassium as are butter and eggs.

61. Which serum calcium level in a client laboratory findings does the nurse interpret as normal? A. 3.7 mEq/L (1.05 mmol/L) B. 1.05 mEq/L (3.75 mmol/L) C. 9.5 mEq/L (2.38 mmol/L) D. 2.38 mEq/L (9.5 mmol/L)

61. C The normal range for serum calcium levels is 9.0 to 10.5 mEq/L (or 2.25 to 2.75 mmol/L).

63. Which measure put into place by the nurse while caring for a client with severe hypocalcemia is most likely to prevent harm? A. Urge the client to eat foods high in calcium content. B. Instruct the client to increase his or her intake of water. C. Instruct assistive personnel (AP) to avoid taking blood pressures. D. Use a lift sheet to move or reposition the client.

63. D With hypocalcemia, calcium leaves bone storage sites, causing a loss of bone density. Bones are less dense, more brittle and fragile, and may break easily with slight trauma. Using a lift sheet rather than pulling the client helps prevent harm. Eating a high-calcium diet can help the hypocalcemia but does not directly prevent harm. Hypocalcemia is not caused by water loss, and increasing fluid intake may dilute the already low serum calcium level. Clients with hypocalcemia are at risk for hypotension and orthostatic hypotension. Blood pressure still needs to be measured and does not pose a risk to safety.

64. Which is the correct technique for the nurse to use when assessing the client for a positive Chvostek sign? A. Client flexes arms against the chest and the nurse attempts to pull the arms away from the chest. B. The nurse inflates a blood pressure cuff around the upper arm to higher than the client's systolic pressure. C. The nurse taps the client's face just below and in front of the ear. D. The nurse lightly taps the client's patellar tendon with a reflex hammer and measures the movement.

64. C To test for Chvostek sign, the nurse taps the face just below and in front of the ear to trigger facial twitching of one side of the mouth, nose, and cheek (a positive response). Option A is a test of muscle strength. Option B describes correct technique for measuring Trousseau sign. Option D describes correct technique for assessing a deep tendon reflex.

65. With which client conditions does the nurse remain alert for potential hypocalcemia? Select all that apply. A. Crohn disease B. Acute pancreatitis C. Removal or destruction of parathyroid glands D. Immobility E. Use of beta-adrenergic inhalers F. GI wound drainage

65. A, B, C, D, F Many conditions lead to an actual or relative hypocalcemia, especially GI conditions that interfere with calcium absorption or increase calcium loss, and anything that impairs parathyroid activity. Immobility causes bone resorption of calcium causing a whole body reduction of calcium. Beta-adrenergic drugs do not affect calcium metabolism.

66. Which client assessment findings are related to hypercalcemia? Select all that apply. A. Increased heart rate B. Paresthesia C. Decreased deep tendon reflexes D. Hypoactive bowel sounds E. Shortened QT interval F. Profound muscle weakness

66. A, C, D, E, F Hypercalcemia at first causes increased heart rate and blood pressure and later causes depressed electrical conduction, slowing heart rate and shortening the QT interval. Deep tendon reflexes and GI motility are decreased. Paresthesias are associated with hypocalcemia. The excess calcium stabilizes skeletal muscle membranes slowing or preventing depolarization, which leads to severe muscle weakness.

67. Which action does the nurse anticipate in the management of a client who has mild hypercalcemia? A. Administering IV normal saline (0.9% sodium chloride) B. Massaging calves to encourage blood return to the heart C. Providing vitamin D supplementation D Monitoring for tetany

67. A Often the cause of hypercalcemia is dehydration. Increasing fluids, especially IV normal saline, can bring the serum calcium level back to normal. Hypercalcemia promotes excessive clot formation. Calves are not massaged to prevent movement of any existing clot. Vitamin D supplementation would increase calcium absorption and potentially worsen hypercalcemia. Tetany is associated with hypocalcemia.

1. Which system is most important for the nurse to monitor closely for a client who has severe hypomagnesemia? A. Autonomic nervous system B. Gastrointestinal C. Cardiovascular D. Renal/urinary

68. C Cardiovascular changes associated with hypomagnesemia are serious. Low magnesium levels increase the risk for hypertension, atherosclerosis, hypertrophic left ventricle, and a variety of dysrhythmias. The dysrhythmias include premature contractions, atrial fibrillation, ventricular fibrillation, and long QT intervals.

69. How does the nurse prepare to administer the prescribed magnesium sulfate (MgSO4) for a client with severe hypomagnesemia? A. Orally B. Subcutaneously C. Intramuscularly D. Intravenously

69. D Magnesium sulfate is a severe irritant and is no longer administered subcutaneously or intramuscularly. Oral administration takes too long to achieve the desired outcome and would cause severe diarrhea.

7. Which task does the nurse delegate to the assistive personnel (AP) for clients with Alzheimer disease in a long-term care setting? A. Assist the client who has incontinence with toileting every 2 hours. B. Provide hygienic care for a client who is currently exhibiting agitation. C. Encourage the client to consume small amounts of fluid to avoid incontinence. D. Give the client a complete bed bath to conserve his or her energy.

7. A A client with AD may remain continent of bowel and bladder for a long period of time if taken to the bathroom or given a bedpan or urinal every 2 hours. Toileting may be needed more often during the day and less frequently at night. Assistive personnel (AP) or home caregivers are taught to encourage the client to drink adequate fluids to promote optimal voiding. A client may refuse to drink enough fluids because of a fear of incontinence. The care providers would assure the client that he or she will be toileted on a regular schedule to prevent incontinent episodes.

7. What will the nurse do first when a natal male client who appears to be female has an order for placement of a urinary indwelling catheter for hourly urine output measurement? A. Introduce himself or herself, ask how the client prefers to be addressed, verify the client's identity by checking the name band, and explain the procedure. B. Respectfully address the client by the name on the chart and armband, then perform catheter insertion for a male client. C. Inspect the genitalia and adapt the catheter insertion as appropriate while avoiding the use of gender-specific language. D. Politely leave and obtain advice from the charge nurse about whether to treat the client as male or female.

7. A As with any client, introduce yourself, and ask how he or she prefers to be addressed. Verify his or her identity, then explain the procedure and answer any questions before performing the catheter insertion.

7. For which client will the nurse expect extracorporeal shock wave lithotripsy (ESWL) as treatment for gallstones to be contraindicated? A. 30-year-old who is 70 inches (1.75 m) tall and weighs 325 lb (147.2 kg) B. 35-year-old who has cholesterol-based stones C. 45-year-old who has a shellfish allergy and uses hormone replacement therapy D. 55-year-old who has bilateral total knee replacements

7. A Some clients who have small, cholesterol-based stones and good gallbladder function may undergo extracorporeal shock wave lithotripsy (ESWL) to break up the stones. This procedure can be used only for patients who have a normal weight.

7. What early sign of left ventricular failure is a client most likely to report to the nurse? A. Nocturnal coughing B. Swollen legs C. Weight gain D. Nocturia

7. A The client in early HF describes a cough that is irritating, nocturnal (at night), and usually nonproductive. As HF becomes very severe, he or she may begin expectorating frothy, pink-tinged sputum, a sign of life-threatening pulmonary edema.

7. Which information is most important for the nurse to include when teaching a client and family about home care for acute pyelonephritis? Select all that apply. A. Role of nutrition and adequate fluid intake B. Need for a balance between rest and activity C. Signs and symptoms of disease recurrence D. Use of successful coping mechanisms E. Care of a permanent indwelling catheter F. Drug regimen (purpose, timing, frequency, duration, and possible side effects)

7. A, B, C, D, F All of these options are taught by the nurse to the client and family before discharge except option E. Clients are rarely discharged with a urinary catheter in place, and chronic urinary catheter care is only taught if necessary.

7. What possible causes would the nurse consider when assessing a client and finding a hyperkinetic pulse? Select all that apply. A. Sepsis B. Sedentary lifestyle C. Pain D. Fever E. Anxiety F. Thyrotoxicosis

7. A, C, D, E, F A hyperkinetic pulse is a large, "bounding" pulse caused by an increased ejection of blood. It occurs in clients with a high cardiac output (e.g., with exercise [not sedentary], sepsis, or thyrotoxicosis) and in those with increased sympathetic system activity (e.g., with pain, fever, or anxiety).

7. What is the minimum amount of urine output per day needed to excrete toxic waste products? A. 200 to 300 mL B. 400 to 600 mL C. 500 to 1000 mL D. 1000 to 1500 mL

7. B Much of the body's waste products, especially nitrogen, is excreted in the urine. Depending on body size, 400 to 600 mL/day of urine must be generated to ensure waste product excretion. This is known as the obligatory urine output. Less than this amount of urine will result in retained waste products that could lead to toxic levels.

7. Which change will the nurse expect to observe when a client's sympathetic nervous system is stimulated? A. Increased salivation B. Increased heart rate C. Myoclonus in the muscles D. Hyperactive deep tendon reflexes

7. B The SNS stimulates the functions of the body needed for "fight or flight" (e.g., increased heart and respiratory rate). It also inhibits certain functions not needed in urgent and stressful situations (e.g., inhibits stomach, pancreas and intestines).

7. Which questions will the nurse ask to provide effective screening for urinary incontinence by asking clients to respond "always," "sometimes," or "never"? Select all that apply. A. Do you ever leak urine after drinking two cups of coffee? B. Do you ever leak urine or water when you don't want to? C. Do you ever leak urine or water when you cough, sneeze, laugh, or exercise? D. Do you ever leak urine or water on the way to the toilet? E. Do you ever use pads, tissue, or cloth in your underwear to catch urine? F. Do you ever talk about leaking urine with your health care provider?

7. B, C, D, E Incontinence may be underreported because health care professionals do not ask clients about urine loss. Many clients are hesitant to initiate the subject. Effective screening includes asking clients to respond "always," "sometimes," or "never" to these questions: • Do you ever leak urine or water when you don't want to? • Do you ever leak urine or water when you cough, sneeze, laugh, or exercise? • Do you ever leak urine or water on the way to the toilet? • Do you ever use pads, tissue, or cloth in your underwear to catch urine?

7. Which information does the community health nurse include when preparing an information packet about a potential pandemic influenza outbreak? Select all that apply. A. In the event of an outbreak, do not eat any cooked or uncooked meat from exotic animals. B. Have on hand a minimum of 2 weeks' supply of food, water, and routine prescription drugs. C. Listen to public health announcements and early warning signs for disease outbreaks. D. Avoid traveling to areas where there has been a suspected outbreak of disease. E. Obtain a supply of antiviral drugs such as oseltamivir. F. In the event of an outbreak, avoid going to public areas such as churches or schools.

7. B, C, D, F When a pandemic influenza appears in a community, it is announced at large and containment actions are instituted. Containment recommendations include staying home and avoiding public areas for at least 2 weeks. Thus, people should have a 2-week supply of food, water, and their usual prescription drugs in order to stay home and avoid coming into contact with infected individuals. Influenza in pandemic form is a respiratory illness that spreads through person-to-person contact and not through the intestinal tract. Unless a person has influenza symptoms or lives with a person who actually has influenza, antiviral drugs are not prescribed.

7. Which changes in a 60-year-old client's assessment findings over the past 4 weeks indicate to the nurse the need for a nutrition status evaluation? Select all that apply. A. Sprained a wrist 2 weeks ago B. Initiation of a strict vegan diet C. Unintentional weight loss of 6% D. Initiation of a regular exercise program E. Reports starting counseling for depression F. Reduced cigarette smoking from two packs/day to one pack/day

7. B, C, E The changes that could alter nutrition status the most for this 60- year-old client are the start of a strict vegan diet, unintentional weight loss greater than 5% in a month, and the presence of depression. Many people who decide to begin a strict vegan diet are unaware of what types of plant-based foods will be needed to maintain an adequate intake of micronutrients and protein. Many, but not all, people with depression often lose interest in maintaining an adequate nutritional intake.

7. Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? Select all that apply. A. Anorexia B. Infection C. Opioids D. Diarrhea E. GI bleeding F. High-protein diet G. Diabetes mellitus H. Chronic confusion

7. B, C, E, F Factors that may contribute to or worsen hepatic encephalopathy in patients with cirrhosis include high-protein diet, infection, hypovolemia (decreased fluid volume), hypokalemia (decreased serum potassium), constipation, GI bleeding (causes a large protein load in the intestines), and some drugs, especially hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs.

7. Which grade of infiltration (based on Infusion Nurses Society [INS] criteria) would the nurse document after observing a client's IV site to have skin that is blanched and translucent, gross edema more than 6 inches in any direction, area cool to touch, moderate pain, and site numbness? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

7. C According to INS criteria, Grade 3 infiltration includes the following symptoms: skin blanched, translucent, gross edema more than 6 inches in any direction, cool to touch, mild-to- moderate pain, and possible numbness.

7. Which laboratory results will the nurse monitor when a client is receiving IV gentamicin? Select all that apply. A. Platelet count B. Hemoglobin and hematocrit C. Blood urea nitrogen (BUN) D. Prothrombin time E. Creatinine F. Gentamicin peak and trough levels

7. C, E, F If a client is receiving a known nephrotoxic drug, the nurse will closely monitor laboratory values, including BUN, creatinine, and drug (gentamicin) peak and trough levels, for indications of reduced kidney function.

7. Which condition or factor will the nurse consider as the most likely cause of a client's loss of bone density in the L-1 to L-5 vertebrae? A. Swims an hour every day at an indoor pool B. Has worked as a data entry technician 40 hours weekly for the past 25 years C. Takes 1300 mg of acetaminophen daily for pain relief from osteoarthritis of the left knee D. Has had five epidural injections of cortisol into the lower back during the past year for severe pain

7. D Cortisol, a corticosteroid, causes bone density loss generally when taken orally or given parenterally. When it is administered in an epidural, it is present in a high concentration surrounding the vertebrae in the area for weeks with each administration. This high local concentration causes local bone density loss without inducing loss anywhere else.

7. What priority teaching will the nurse provide to prevent harm when a client with gastritis reports taking ibuprofen regularly for discomfort related to arthritis? A. "Do not take ibuprofen more than twice a day." B. "Ibuprofen can interfere with the action of the drugs you take for gastritis." C. "This drug is excellent for pain relief related to arthritis." D. "Avoid taking ibuprofen because it can cause gastritis."

7. D Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). The nurse teaches the client that long-term NSAID use creates a high risk for acute gastritis. NSAIDs inhibit prostaglandin production in the mucosal barrier. Use of this drug may have caused the gastritis and continued use will cause it to worsen.

7. How will the nurse respond to the client newly diagnosed with type 2 diabetes who asks, "What does having metabolic syndrome and diabetes mean for me?" A. "Metabolic syndrome is helpful to anyone with diabetes because it increases the sensitivity of your cells to the presence of insulin." B. "People with diabetes and metabolic syndrome usually need to use insulin rather than oral antidiabetic drug to manage their blood glucose levels." C. "Metabolic syndrome is a problem in eliminating drugs from your body, so you will need to be on lower doses of your antidiabetic drugs to prevent severe side effects." D. "Your risk for having cardiovascular disease and a possible heart attack is higher and will require good control of your diabetes, blood pressure, and cholesterol to prevent them."

7. D Metabolic syndrome is the simultaneous presence of metabolic factors that increase risk for developing type 2 DM and cardiovascular disease. Features include insulin resistance, higher blood lipid levels, abdominal obesity, and hypertension. The risk for atherosclerosis, along with heart disease and strokes is greatly increased. The two disorders together make blood glucose levels harder to control.

7. How will the nurse document the assessment observation in which the client's spinal thoracic vertebrae curve sideways to the right and then return to midline? A. Dextrosis B. Lordosis C. Kyphosis D. Scoliosis

7. D Scoliosis is an abnormal lateral curvature of the spine. In lordosis, the abnormal spinal curvature is inward and occurs in the lumbar spinal area. Kyphosis is an outward curvature of the thoracic spine causing a "humped back" appearance. Dextrosis is not a spinal curvature.

7. Which question will the nurse ask a client to determine whether the drug tamsulosin is achieving the desired therapeutic effect? A. "Do you have a green or yellow discharge from your penis?" B. "Are you having any problems achieving an erection?" C. "Does your urine have a strong odor or appear cloudy?" D. "Are you continuing to have difficulty passing urine?"

7. D Tamsulosin is an alpha1 adrenergic antagonist drug. These drugs act to relax smooth muscle in the bladder neck, which will help make urination less difficult.

70. Which assessment findings does the nurse expect to see in a client who has severe hypermagnesemia? A. Bradycardia and hypotension B. Tachycardia and weak palpable pulse C. Hypertension and irritability D. Irregular pulse and deep respirations

70. A Magnesium is a membrane stabilizer that decreases depolarization of all excitable membranes. As a result, heart rate is slower and the client can become hypotensive.

8. Which activity of a nutritional screening will the nurse assign to an assistive personnel (AP)? A. Obtaining an accurate height and weight B. Asking about the client's usual food intake C. Reviewing the client's laboratory results D. Performing a psychosocial assessment

8. A Accurately measuring height and weight are within the AP's scope of practice. Collecting information about a client's nutrition history, reviewing laboratory findings, and performing a psychosocial assessment require greater knowledge and skill and are not within an AP's scope of practice.

8. Based on the Kidney Disease: Improving Global Outcomes classification (KDIGO), how will the nurse interpret this client data (serum creatinine increases 1.5 times over baseline with urine output of less than 0.5 mL/kg/hr for 6 hours or longer)? A. Stage 1 B. Stage 2 C. Stage 3 D. End-stage kidney disease

8. A Based on the Kidney Disease: Improving Global Outcomes classification (KDIGO), a value of serum creatinine increases 1.5 times over baseline with urine output of less than 0.5 mL/kg/hr for 6 hours or longer indicates stage 1. See Table 63.2 in your text for information on the other stages for this system.

8. How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 91 mg/dL (5.1 mmol/L) and an A1C of 8.2%? A. The client's glucose control for the past 24 hours has been good but the overall control is poor. B. The client's glucose control for the past 24 hours has been poor but the overall control is good. C. The values indicate that the client has poorly managed his or her disease. D. The values indicate that the client has managed his or her disease well.

8. A Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM for the previous 24 hours. This client's FBG is well within the normal range. A1C provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client's A1C level is outside the desirable range, indicating chronic hyperglycemia and poor long-term glucose control despite good short-term control.

8. Which client will the nurse recognize as having the greatest risk for nonacoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb (13.9 kg) overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old black woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

8. A Obesity and type 2 diabetes with metabolic syndrome are risk factors for NAFLD. In addition, a genetic variation in the PNPLA3 gene increases the risk. This variation is much more common among Latinos.

8. Which advantages of minimally invasive surgery (MIS) laparoscopic cholecystectomy will the nurse reinforce to a client after the surgeon has provided information for informed consent? Select all that apply. A. Bile duct injuries are rare. B. Complications are uncommon. C. Postoperative pain is less severe. D. Mortality is about equal to that of traditional cholecystectomy. E. IV antibiotics are not needed because infection does not occur. F. Depending on the nature of the job, some clients can return to work within 1 to 2 weeks.

8. A, B, C, F Injuries and complications are much lower than with traditional cholecystectomy and the postoperative pain is less severe. Many clients can resume their normal activies within 1 week. The mortality rate is very low, much lower than traditional cholecystectomy. Although the infection rate is low, there is still an infection risk anytime an incision is made.

8. What information must the nurse know before giving any IV drug to a client? Select all that apply. A. Indications and proper dosage B. Contraindications and precautions C. Percentage of adverse events for the drug D. Compatibility with other IV medications E. Rate of infusion and osmolarity F. Potential for irritant and vesicant effects

8. A, B, D, E, F For all drug administration, nurses must be knowledgeable about drug indications, proper dosage, contraindications, and precautions. IV administration also requires knowledge of appropriate dilution, rate of infusion, pH and osmolarity, compatibility with other IV medications, appropriate infusion site (peripheral versus central circulation), potential for vesicant/irritant effects, and specific aspects of client monitoring because of its immediate effect.

8. Which important information will the nurse gather when a client reports a change in bowel habits? Select all that apply. A. Presence of abdominal distention or gas B. Intentional weight gain C. Occurrence of diarrhea or constipation D. Color and consistency of feces E. Occurrence of heartburn or reflux F. Presence of bloody or tarry stools

8. A, C, D, F Changes in bowel habits are commonly reported by clients. Important information for the nurse to gather from the client includes: pattern of bowel movements, color and consistency of the feces, occurrence of diarrhea or constipation, effective action(s) taken to relieve diarrhea or constipation, presence of frank blood or tarry stools, and presence of abdominal distention or gas.

8. Which clients will the nurse collaborate with a registered dietitian nutritionist to assist in modifying their nutritional risk for osteoporosis? Select all that apply. A. 25-year-old female who drinks six cups of coffee daily B. 30-year-old female who is overweight for height C. 35-year-old male who is on the high-protein Atkins diet D. 45-year-old female who drinks unfortified almond milk E. 55-year-old male who drinks one carbonated beverage every day F. 65-year-old male with chronic alcoholism

8. A, C, D, F High caffeine intake increases calcium loss and increases the risk for osteoporosis. High-protein diets reduce the levels of free calcium in the blood by keeping it bound to plasma proteins. Almond milk may contain calcium but if it is unfortified, it does not also contain vitamin D, which is needed to absorb calcium in the GI tract. Chronic alcoholism often results in a variety of nutritional deficits that increase the risk for osteoporosis. Drinking one carbonated beverage daily or being overweight does not increase osteoporosis risk.

8. Which symptom will the nurse expect when caring for an older male client with an enlarged prostate? A. Passing a large amount of dilute urine B. Difficulty starting the urine stream C. Inability to sense the urge to urinate D. Burning sensation when voiding

8. B As male clients age, an enlarged prostate gland makes starting the urine stream difficult and may cause urinary retention.

8. For which pathophysiological conditions can a normal healthy heart adapt to maintain perfusion to the body tissues? A. Menses and gastroesophageal reflux disease B. Stress and infection C. Kidney stones and peripheral vascular disease D. Bleeding and shortness of breath

8. B The healthy heart can adapt to various pathophysiologic conditions (e.g., stress, infections, hemorrhage) to maintain perfusion to the various body tissues.

8. Which types of ulcers does the nurse teach a client about when discussing peptic ulcer disease (PUD)? Select all that apply. A. Pressure ulcers B. Gastric ulcers C. Duodenal ulcers D. Stress ulcers E. Esophageal ulcers F. Colon ulcers

8. B, C, D Three types of peptic ulcers may occur in PUD: duodenal ulcers, gastric ulcers, and stress ulcers (less common). Duodenal ulcers are most common, gastric ulcers occur in the antrum of the stomach, and stress ulcers are acute gastric mucosal lesions occurring after an acute medical crisis or trauma, such as sepsis or a head injury.

8. The nurse will collaborate with which members of the interprofessional team to determine the needs of a client with Alzheimer disease for adaptive devices? Select all that apply. A. Social services B. Occupational therapist C. Surgeon D. Physical therapist E. Registered dietitian nutritionist F. Speech language therapist

8. B, D The nurse would collaborate with the occupational and physical therapists to provide a complete evaluation and assistance in helping the client remain as independent as possible. Adaptive devices, such as grab bars in the bathtub or shower area, an elevated commode, and adaptive eating utensils, may enable him or her to maintain independence in grooming, toileting, and feeding. The physical therapist prescribes an exercise program to improve physical health and functionality.

8. Which measure will the nurse recommend to prevent harm when a client with MS is discharged home? A. Avoid exercising outside. B. Immediately adapt the home for wheelchair access. C. Keep the home free of clutter. D. Install a ramp to the door of the home.

8. C Before the client is discharged, it is important to assess the client's home for hazards. Any items that might interfere with mobility (e.g., scatter rugs, stacks of magazines) are removed. In addition, care must be taken to prevent injury resulting from vision problems. Teach the client and family to keep the home environment as structured and free from clutter as possible.

8. Which client will the nurse recognize as having the greatest risk for developing chronic osteomyelitis? A. 25-year-old who performs heavy manual labor B. 35-year-old who stepped on a rusty nail 10 years ago C. 45-year-old with diabetes who has a recurrent foot ulcer D. 55-year-old with osteoporosis who has sprained the same wrist twice

8. C Clients who have diabetes have poor wound healing and a high risk for infection in any open wound. An injury to the foot is difficult to heal and can progress inward through the soft tissue to the bone. Infection can spread to the bone this way, resulting in chronic osteomyelitis.

8. Based on the etiology and main cause of heart failure, the nurse knows that which client has the greatest need for health promotion measures to prevent heart failure? A. Client with asthma B. Client with renal insufficiency C. Client with hypertension D. Client with Parkinson disease

8. C Heart failure (HF) is caused by systemic hypertension in most cases. Some clients experiencing myocardial infarction (MI, "heart attack") also develop HF. The next most common cause is structural heart changes, such as valvular dysfunction, particularly pulmonic or aortic stenosis, which leads to pressure or volume overload on the heart.

8. What is the nurse's best action after inadvertently making an error when addressing a transgender client by not using their preferred name or pronoun? A. Apologize and explain that working with transgender clients is a new experience. B. Assume that the client is used to this type of error and continue providing care. C. Self-correct and continue providing care rather than making a prolonged apology. D. Observe the client's nonverbal behavior to determine whether the error was noticed.

8. C Occasionally nurses recognize the cues and know their client's preferred name or pronoun, but accidentally say the wrong one. Transgender clients encounter this situation often and typically anticipate an occasional error. When this error occurs, simply self-correct and continue with care rather than make a prolonged apology. Focusing too much on the error may make the client more uncomfortable because more attention has been drawn to the situation.

8. Which teaching strategy is best for the nurse to use when instructing an older adult about medications and lifestyle changes? A. Relate the information to recent events. B. Provide teaching late in the afternoon. C. Allow extra time for teaching and questions. D. Give limited and simplified information.

8. C Older adults develop slower cognitive time as they age. The nurse provides sufficient time for the affected older adult to respond to questions and/or direction. Allowing adequate time for processing helps differentiate normal findings from neurologic deterioration. See the box labeled Patient-Centered Care: Older Adult Considerations Changes in the Nervous System Related to Aging in your text.

8. How will the nurse document the pack-year smoking history for a client who reports smoking a pack of cigarettes a day for 10 years, quitting for 4 years, and then smoking 2 packs a day for the last 25 years? A. 30 years B. 35 years C. 45 years D. 60 years

8. D Pack-years are calculated by multiplying the number of packs smoked per day by the number of years of smoking at that rate. One pack per day X 10 years = 10 pack-years, plus 2 packs per day X 25 years = 50 years. Total is 50 plus 10 for 60 pack-years.

9. Before administering which class of drugs would the nurse always check the client's heart rate? A. Beta blockers B. Diuretics C. Anticoagulants D. Nonsteroidal anti-inflammatories

9. A An increase in circulating catecholamines (e.g., epinephrine and norepinephrine) usually causes an increase in HR and contractility. Many cardiovascular drugs, particularly beta blockers, block this sympathetic (fight or flight) pattern by decreasing the HR. The nurse would check to be sure that the heart rate was not too slow before administering a beta blocker.

9. What is the nurse's best action when assessment of a client 2 hours after abdominal surgery reveals hypoactive bowel sounds? A. Documenting the finding and continue to monitor B. Notifying the surgeon immediately C. Putting a nasogastric (NG) tube in place D. Obtaining an immediate abdominal x-ray

9. A Bowel sounds are characterized as normal, hypoactive, or hyperactive. They are diminished (hypoactive) or absent after abdominal surgery. The most reliable way of knowing that peristalsis has returned is when the client passes flatus or stool. After surgery this may take a few hours. The nurse's best action is to document the finding and continue to monitor for flatus or stool.

9. What is the nurse's best advice to a client with urge incontinence regarding fluid intake? A. Drink 120 mL every hour or 240 mL every 2 hours and limit fluid intake after dinner. B. Drink at least 2000 mL of water every day unless you have a heart problem. C. Drinking water is especially good for bladder health so drink as much as you can. D. Drink fluid freely in the morning hours but limit fluid intake after going to bed.

9. A For urge urinary incontinence, the nurse teaches the client to avoid foods that irritate the bladder such as caffeine and alcohol. Spacing fluids at regular intervals throughout the day (e.g., 120 mL every hour or 240 mL every 2 hours) and limiting fluids after the dinner hour (e.g., only 120 mL at bedtime) help avoid fluid overload on the bladder and allow urine to collect at a steady pace.

9. Which assessment will the nurse perform to monitor a likely coexisting complication in a client with MS who has dysarthria? A. Check the client's gag reflex and ability to swallow. B. Watch the client walk and note smoothness of gait. C. Ask the client to use a pencil to write out a sentence. D. Have the client stand with eyes closed and observe for swaying.

9. A If the client experiences dysarthria as a result of muscle weakness, he or she should be evaluated by a speech-language pathologist (SLP). It is not unusual for the client with dysarthria to also have dysphagia. The SLP will perform a swallowing evaluation and further diagnostic testing as needed. Monitor the client to determine if there are problems swallowing at meal time that increase the risk of aspiration.

9. What information must be included with each prescription for IV therapy for the nurse to administer it safely to a client? Select all that apply. A. Frequency of drug administration B. Specific type of administration equipment C. Rate of administration D. Specific type of solution E. Method for diluting drugs for the solution F. Specific drug to be added to the solution

9. A, C, D, F A drug prescription should include: drug name, preferably by generic name; specific dose and route; frequency of administration; time(s) of administration; length of time for infusion (number of doses/days); purpose (required in some health care agencies, especially nursing homes). The specific type of equipment to be used is not a requirement for a valid prescription. The pharmacy determines the correct diluent based on manufacturer's recommendations or requirements.

9. Which assessment findings would the nurse expect to find in a client with left heart failure? Select all that apply. A. Wheezes or crackles B. Jugular vein distention C. S3 heart sound D. Paroxysmal nocturnal dyspnea E. Ascites F. Oliguria during the day

9. A, C, D, F Signs and symptoms of left heart failure are related to decreased cardiac output (CO) and pulmonary congestion. Those associated with decreased CO include: fatigue; weakness; oliguria during the day (nocturia at night); angina; confusion, restlessness; dizziness; tachycardia, palpitations; pallor; weak peripheral pulses; and cool extremities. Those related to pulmonary congestion include: hacking cough, worse at night; dyspnea/breathlessness; crackles or wheezes in lungs; frothy, pink-tinged sputum; tachypnea; and; S3/S4 summation gallop.

9. Which interventions will the nurse employ to prevent harm when providing care for an older client who is at risk for falls related to altered balance and decreased coordination? Select all that apply. A. Instruct the client to move slowly when changing positions. B. Encourage the client not to get out of bed unless it is really necessary. C. Advise the client to hold on to handrails when ambulating. D. Raise all four siderails and place the bed in the lowest position. E. Request that a family member or a sitter stay with the client at all times. F. Assess the need for an ambulatory aid, such as a cane or walker.

9. A, C, F For the older client at risk for falls due to balance alteration and/or decreased coordination, the best care strategies include: instructing the client to move slowly when changing positions; if needed, advising the client to hold on to handrails when ambulating; and assessing the need for an ambulatory aid, such as a cane or walker. The client could be out of bed with assistance from the nursing staff. Most hospitals have policies against having all four siderails in the raised position because clients try to climb over and falls are very much a risk. A sitter or family member could stay with the client, but the client is alert and responsive, so this is not one of the best responses. The client should be instructed to call for assistance whenever he or she needs to get out of bed. See the box labeled Patient-Centered Care: Older Adult Considerations Changes in the Nervous System Related to Aging in your text.

9. Which actions will the nurse suggest to a 72-year-old female client to prevent harm by reducing the rate of osteoporosis? Select all that apply. A. Walking one mile 5 to 7 days per week B. Eating a diet high in fruits and vegetables C. Swimming for 30 minutes three times weekly D. Performing isometric and isotonic exercises daily E. Taking a calcium supplement that contains vitamin D F. Performing range-of-motion exercises for the arm while sitting

9. A, D, E Performing weight-bearing exercises, such as walking, and muscle- strengthening exercises can reduce bone density loss and slow osteoporosis. Ensuring adequate intake of calcium and vitamin D is critical to bone density maintenance. Swimming, although an aerobic activity, is not a weight-bearing exercise. Fruits and vegetables are not major sources of either calcium or vitamin D. Arm range-of-motion exercises can maintain arm muscle function and shoulder joint flexibility, but do not prevent bone density loss.

9. Which topics will the nurse be sure to ask about when taking a history of a client with a change in urinary patterns? Select all that apply. A. History of chronic health problems such as diabetes and hypertension B. Status of financial resources for payment of treatments C. Likelihood of complying with treatment recommendations D. Occupational exposure to toxins and use of illicit substances E. Recent travel to geographic regions that pose infectious disease risk F. Previous kidney or urologic problems, including tumors, infections, stones

9. A, D, E, F Options A, D, E, and F contribute important information to the client's history of urinary pattern changes. Finances and likelihood of compliance, although important, do not contribute to understanding the client's urinary pattern changes. Additional topics include the client's medical and surgical history, as well as previous kidney function laboratory values (e.g., proteinuria or albuminuria). See the section on taking a client history in your text for additional suggestions.

9. Which actions help the nurse caring for a client with a pandemic influenza such as COVID-19 to prevent contracting the virus? Select all that apply. A. Wearing eye protection during suctioning B. Keeping the door of the client's room closed C. Changing the water in the oxygen nebulizer daily D. Checking results of the client's sputum cultures daily E. Washing hands after removing gowns, gloves, and masks F. Using a powered air-purifying respirator (PAPR) when in the client's room

9. A, E, F Wearing eye protection while suctioning the client protects the nurse from contact with infected droplets. Using PAPR protects the nurse from inhalation exposure to the virus. Washing hands after removing gowns, gloves, masks, and eyewear protects the nurse from direct contact with the virus. Keeping the door of the client's room closed is a good action to take but does not protect the nurse in the room with the client. Changing the water in the nebulizer protects the client, not the nurse. Testing for pandemic influenza viruses is not performed by sputum culture.

9. When a client is in the diuretic phase of acute kidney injury (AKI), what priority action will the nurse take? A. Assessing for hypertension and fluid overload B. Monitoring for hypovolemia and electrolyte loss C. Adjusting the dosage of diuretic medications D. Balancing diuretic therapy with intake and output

9. B For the client in the diuretic phase of AKI, the nurse plans care that focuses on fluid and electrolyte replacement and monitoring. Onset of polyuria can signal the start of recovery from AKI.

9. What sign or symptom does the nurse expect to see in a client whose blood osmolarity is 310 mOsm/L (mOsm/kg)? A. Body temperature below normal B. Increased thirst C. Pitting edema D. Diarrhea

9. B The normal blood osmolarity is 270 to 300 mOsm/L (mOsm/kg). The value of 310 is hyperosmolar, which will cause cells to move water into the extracellular fluid compartment and shrink slightly. When the osmoreceptor cells in the hypothalamus shrink, the thirst center is stimulated so the client will drink more to dilute the hyperosmolarity.

9. Which statements made by a client indicate to the nurse the need for additional education regarding smoking-related health risks? Select all that apply. A. "I have heard that cigarette smoking can cause both lung problems and heart problems." B. "I don't worry about lung problems because, unlike my wife, I don't smoke daily." C. "I worry about lung diseases because I borrow cigarettes when I'm out with friends." D. "I use a hookah when I smoke, but I'm trying to quit because I know it's not good for me." E. "I don't worry about lung problems because no one in my family has ever had lung cancer." F. "I am trying to get my college-age daughter to 'vape' rather than smoke because it is safer than cigarettes."

9. B, E, F Anyone who lives with a smoker has passive exposure to smoke and has a greater risk for lung problems than those who never experience exposure to cigarette smoke. Passive smoking contributes to health problems, especially when chronic exposure occurs in small, confined spaces. Lung cancer is an environmentally acquired malignancy. Current evidence does not associate any genetic mutation with an increased risk for lung cancer. New evidence from the Centers for Disease Control and Prevention indicate that vaping as a form of nicotine delivery is at least as problematic for lung disease as cigarette smoking is. Statements B, E, and F are recognized by the nurse as gaps in the client's knowledge of the health risk. The other three statements indicate the client is aware of health risks.

9. Which client will the nurse identify as most at risk for the marasmic-kwashiorkor form of protein-energy malnutrition (PEM)? A. 48-year-old with rheumatoid arthritis who has worn dentures for 6 years B. 58-year-old who suffered a traumatic amputation of the left arm 15 years ago C. 68-year-old vegan who is 10 lb (4.5 kg) underweight and has bacterial pneumonia with a high fever D. 78-year-old who has type 2 diabetes mellitus and lives with his 50-year-old daughter

9. C Marasmus is an energy (caloric) malnutrition with some degree of starvation in which body fat and muscle proteins are wasted although serum proteins may be normal. The client appears thin. Kwashiorkor malnutrition occurs with a severe protein deficiency although overall caloric intake may be adequate to maintain a normal weight, but serum proteins are low. Marasmic-kwashiorkor is a more severe malnutrition in which both protein and caloric intake are inadequate and the client is seriously underweight. It is most common when a client already is malnourished and develops a health problem that greatly increases the metabolic need for nutrients.

9. Which statement by a client indicates to the nurse that teaching about the action of sucralfate has been successful? A. "The main side effect of sucralfate is diarrhea." B. "I will take my sucralfate with each meal." C. "Sucralfate will work to heal my ulcer." D. "I will take my sucralfate with my antacid."

9. C Sucralfate is a mucosal barrier fortifier. It helps ulcers to heal by coating and protecting the inner lining of the stomach. It should be given 1 hour before and 2 hours after meals and at bedtime because food may interfere with drug's adherence to mucosa. Sucralfate is not given within 30 minutes of giving antacids or other drugs because antacids may interfere with its effects.

9. What is the nurse's next action after assessing a client with glomerulonephritis (GN) who reports mild shortness of breath and finding crackles in all lung fields, distended neck veins? A. Obtaining a urine sample to check for proteinuria B. Checking for costovertebral angle tenderness or flank pain C. Assessing carefully for additional signs of fluid overload D. Alerting the health care provider about the respiratory symptoms

9. C The nurse assesses for fluid overload and pulmonary edema that may result from fluid and sodium retention occurring with acute GN. He or she asks about any difficulty breathing or shortness of breath. Assessment for crackles in the lung fields, an S3 heart sound (gallop rhythm), and neck vein distention would also be completed. With this information, the nurse would then notify the health care provider of the findings.

9. Which action does the nurse teach a client with BPH to perform that can help relieve obstructive symptoms? A. Urinate before going to bed and immediately upon waking. B. Consume fluids regularly throughout the day. C. Increase the frequency of sexual intercourse. D. Urinate forcefully after drinking a large glass of water.

9. C The nurse teaches the client that frequent sexual intercourse can reduce obstructive symptoms because it causes the release of prostatic fluid. This approach is helpful for a client whose obstructive symptoms result from an enlarged prostate with a large amount of retained prostatic fluid.

9. Which statement does the nurse recognize as accurate with regard to drugs used to treat a client with Alzheimer disease? A. If started early enough, cholinesterase inhibitors may cure AD. B. All clients with AD are treated with antidepressants. C. No drugs can cure AD but some may improve symptoms. D. A family member should know how to check pulse because of tachycardia.

9. C There are no drugs that can cure or slow the progression of Alzheimer disease, but a few drugs may improve symptoms associated with the disease for some clients. Cholinesterase inhibitors work to improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme cholinesterase. This action may slow the onset of cognitive decline in some clients, but none of these drugs alters the course of the disease. Memantine blocks excess amounts of glutamate that can damage in some clients.

9. Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the client's abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

9. D Although measuring abdominal girth can show increases in girth that can be interpreted as more ascites, weighing the client provides more accurate information of water retention in the abdominal and dependent areas.