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The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding?

It indicated dilute urine

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response?

1 Abdominal girth decrease 2 Mucous membranes becoming drier Correct3 Heart rate increases from 80 to 135 Incorrect4 Blood pressure rises from 130/70 to 190/80 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

Which complication should the nurse assess in a client who had a bilateral herniorrhaphy?

1 Hydrocele 2 Paralytic ileus Correct3 Urinary retention 4 Thrombophlebitis Because of pain and the proximity of the operative site to the lower urinary tract, voiding problems are common. Hydrocele is not a complication of herniorrhaphy. The abdomen was not entered, and interference with peristalsis should not occur. Thrombophlebitis should not be a complication of herniorrhaphy because early ambulation is encouraged.

Which content should the nurse emphasize in a prepared childbirth class?

1 Birth as a family experience 2 Labor without the use of analgesics Correct3 Education, exercise, and breathing techniques 4 Hydration, relaxation, and pain control during labor The objective of childbirth classes is to adequately prepare parents for childbearing. Birth as a family experience is only part of the class content. Labor without the use of analgesics is not an absolute; in most childbirth methods parents are informed that analgesics are available if necessary. Hydration, relaxation, and pain control during labor is only part of the class content.

A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude is the purpose of the T-tube?

1 Decrease edema Correct2 Permit drainage of bile 3 Insert antibiotic medication 4 Provide for irrigation of the gallbladder The T-tube provides a passageway for bile to move through the common bile duct in the presence of edema; it does not reduce edema. When the common bile duct is explored, the T-tube maintains patency until edema subsides. The T-tube will not reduce edema. Antibiotics usually are not necessary postoperatively unless infected bile or pus is in the ducts (cholangitis). The gallbladder has been excised and therefore cannot be irrigated.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider?

1 Passage of pink-tinged urine 2 Pink drainage on the dressing 3 Intake of 1750 mL in 24 hours Correct4 Urine output of 20 to 30 mL/hr Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage on the dressing may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

Administer oxygen using a face mask The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis. Topics

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder?

Burning pain after exposure to cold Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation. As a result of impaired circulation, burning pain and intermittent claudication occur. General blanching of the skin, easy fatigue of extremities, and presence of Homans sign when ambulating are not related to thromboangiitis obliterans.Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply.

Correct1 A midline trachea Correct2 Pink nasal mucosa 3 Deviated nasal septum Correct4 Nonlabored respirations of 14 breaths/min 5 Anteroposterior to lateral chest diameter (2:1) The normal findings of a chest examination include a midline trachea, pink-colored nasal mucosa, and non-labored respirations of 14 breaths/min. The nasal septum should be straight; a deviated nasal septum is an abnormal finding. The anteroposterior diameter should be less than the side-to-side or transverse diameter by a ratio of (1:2).

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client?

Exercise the triceps, finger flexors, and elbow extensors. The triceps, finger flexors, and elbow extensors are used in crutch walking and therefore need strengthening. Although back muscles keep the person erect, the most important muscles for walking with crutches are the triceps, elbow extensors, finger flexors, and the muscles in the unaffected leg. Keeping the unaffected leg in extension and abduction will do nothing to promote crutch walking. A pushing, not a pulling, motion is used with crutches; the triceps, not the biceps, are used.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session?

Increased blood viscosity Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first?

Record the temperature reading and continue to monitor it. Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2° F (37.9° C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2° F (37.9° C) is an expected response and is not an emergency requiring notification of the primary healthcare provider.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. What should be the nurse's first action?

Stop the transfusion. Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.

When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid?

Using a heating pad to warm the extremities The client's extremities are less sensitive to thermal stress because of peripheral vascular problems, and burns may occur. Applying heat to the abdomen causes reflex dilation of the arteries in the extremities and increases blood flow without untoward effects. Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment is an effort to prevent cold, chilling, and further constriction of peripheral vasculature.

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What should the nurse assess in the client as an early sign of decreased arterial pressure?

Weak radial pulses Hypovolemia occurs with decreased cardiac output; the resulting decreased arterial pressure is reflected in weak, thready peripheral pulses. The skin will be cool and pale because of vasoconstriction. Lethargy with confusion will occur later as a result of hypovolemic shock. The pulse pressure will be decreased, not increased, with decreased cardiac output associated with hypovolemic shock.Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition?

"I have abnormal hemoglobin." The client with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. While it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

A client has untreated stage 2 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140 mm Hg According to the 2017 guidelines of the American College of Cardiology, systolic blood pressure associated with stage 2 hypertension is greater than or equal to 140 mm Hg. Optimal systolic blood pressure is less than 120 mm Hg. Systolic blood pressure is between 120 and 129 mm Hg for prehypertension and between 130 and 139 for stage 1 hypertension.STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

A nurse is weighing a client with heart failure. The client weighed 175 lb (79.4 kg) on the last visit and has had a 5% weight gain since then. The nurse suspects that the client is retaining fluid. How many liters of fluid has the client retained? Record your answer using a whole number. ___ liters

4 One liter of fluid is equal to 1 kg of weight. The client has had a 5% weight gain since the previous visit; the nurse feels this weight gain is fluid retention.79.4 kg X 5% = 3.97 kg = 3.97 L = 4 LTest-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature?

A fever increases the cardiac workload. Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.

A nurse is completing the admission assessment of a client with peripheral arterial disease. Which assessments will the nurse expect to observe? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. A superficial ulcer with irregular edges is associated with venous insufficiency; the ulcer associated with arterial insufficiency is deep and well demarcated. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency. Topics

A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease?

Cardiovascular Tertiary syphilis is the last stage, affecting several body systems: skin, cardiovascular, and neurological. Aortic valvular disease and aortic aneurysms can occur. Although lesions occur on the genitalia during primary and secondary syphilis, the reproductive system is not the major body system affected in tertiary syphilis. Structures of the lower respiratory tract and gastrointestinal are not the major structures involved in tertiary syphilis.

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. The nurse notifies the primary healthcare provider to have the packing removed. What is the primary reason that the packing needs to be removed immediately?

Correct1 The radioactive packing will injure healthy tissue. 2 Removal of the packing will prevent excessive blood loss. 3 The exposure of radium to the environment will diminish its effectiveness. 4 Removal of the packing will minimize life-threatening contact with the radiation. Packing maintains a radium implant in its correct placement; correct placement minimizes the effect on healthy tissue. There should not be active bleeding with a radium implant; cellular sloughing is expected. Although exposure to the radioactive packing damages healthy tissue, it is not life threatening.Test-Taking Tip: Look for answers that focus on the client or are directed toward feelings.

A nurse identifies that the client is experiencing a hypoglycemic reaction. Which intervention should the nurse implement to relieve the symptoms associated with this reaction?

Give 4 oz of juice Liquids containing simple carbohydrates are most readily absorbed and thus increase the blood glucose level quickly. Although a solution of 50% dextrose may be given if the client is comatose, 5% dextrose does not supply sufficient carbohydrates. Withholding a subsequent dose of insulin will not alter the current situation. Complex carbohydrates and protein take longer to increase the blood glucose level, so they should be administered after a simple carbohydrate.

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

Inflammation in the myocardium causes a rise in the systemic body temperature. Temperature may increase within the first 24 hours as a result of the inflammatory response to tissue destruction and persist as long as a week. Diaphoresis is caused by activation of the sympathetic, not parasympathetic, nervous system and may indicate cardiogenic shock. Pain is persistent and constant, not intermittent; it is caused by oxygen deprivation and the release of lactic acid. The blood pressure increases initially but then drops because there is a decrease in cardiac output.

A client is found unconscious and unresponsive. What should the nurse do first?

correct1 Initiate a code 2 Check for a radial pulse 3 Compress the lower sternum 4 Give four full lung inflations Additional help and a cardiac defibrillator must be obtained immediately. The carotid, not radial, pulse is used. Compressing the mid-lower sternum is done after the nurse summons help. The ratio is two lung inflations to 30 chest compressions.

A nurse is assessing a client with diabetes insipidus. Which signs indicative of diabetes insipidus should the nurse identify when assessing the client? Select all that apply.

excessive thirst dry mucous membranes decreased urine specific gravity As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Diabetes mellitus affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.

Which clinical manifestation occurs in a client with vasopressin deficiency?

hypotension Vasopressin regulates fluid level and blood pressure. A vasopressin deficiency causes hypotension. Impotence, amenorrhea, and decreased libido in both men and women are clinical manifestations of luteinizing and follicle-stimulating hormone deficiencies.

A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis. Which component is increased in the blood and a direct cause of acidosis?

ketones The ketones produced excessively in diabetes are a by-product of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.

Which hormone is released from the posterior pituitary gland?

oxytocin Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.

Which joint in the human body is an example of a condyloid joint?

the wrist The wrist joint is an example of a condyloid joint. It is a joint between the radial and carpals. The elbow joint is an example of a hinge joint. The shoulder joint is an example of a ball and socket joint. The sacroiliac joint is an example of a gliding joint.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A registered nurse is providing information to a group of student nurses regarding the actions of parathyroid hormone (PTH). Which statement made by the student nurse indicates a need for further teaching? Select all that apply.

"It allows reabsorption of phosphorus in the kidney tubules." "It decreases serum calcium levels by increasing bone resorption." Parathyroid hormone (PTH) allows calcium to be reabsorbed in the kidney tubules. PTH increases bone resorption, thus increasing serum calcium levels. PTH activates vitamin D in the kidneys, which increases the absorption of calcium and phosphorous from the intestines. Secretion of PTH increases serum calcium levels. PTH regulates calcium and phosphorous metabolism by acting on the GI tract, bones, and kidneys.

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?

"The results from the monitor will be used to determine the size and shape of my heart." "The monitor will record any abnormal heart rhythms while I go about my usual activities." The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

A multipara who is admitted to the hospital for repair of a rectocele and cystocele asks a nurse why these problems happened to her. How should the nurse respond?

1 "Did you have a bladder infection?" 2 "You probably have a malformation of your uterus." Correct3 "You have relaxation of the muscles in your lower pelvis." Incorrect4 "Did you have problems when your episiotomy was healing?" Relaxation of the pelvic musculature causes the uterus to drop, with subsequent relaxation of the vaginal walls, most often as a result of childbirth. A rectocele is a protrusion of the rectal wall into the vagina, whereas a cystocele is a protrusion of the bladder into the vaginal wall. A bladder infection, malformation of the uterus, and episiotomy healing problems do not cause either a rectocele or a cystocele.

The nurse is assessing a client with worsening preeclampsia. What is the most significant clinical manifestation of severe preeclampsia?

1 Polyuria 2 Vaginal spotting Correct3 Proteinuria of 3+ 4 Blood pressure of 130/80 mm Hg As preeclampsia worsens, blood pressure and edema increase and degenerative changes of the kidney cause increasing proteinuria (3+). With worsening preeclampsia, oliguria, not polyuria, is expected. Vaginal spotting is not a sign of worsening preeclampsia. A blood pressure of 130/80 mm Hg is within acceptable limits; however, there is insufficient information to determine whether it is increased in this client.STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy?

Active participation in providing self-care Listing the indicators of recovery after Listing the indicators of recovery after a myocardial infarction Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.

A nurse is caring for a client with hypoglycemia. Which nursing intervention would be appropriate in managing the client's condition? Select all that apply.

Administering glucagon Administering IV glucose Administering oral hydrocortisone A client with hypoglycemia suffers with weakness and vision disturbances due to low glucose levels. Glucagon is the hormone secreted by the pancreas that helps with increasing the blood glucose levels. Administering IV glucose would immediately improve the blood glucose levels. Hydrocortisone is a glucocorticoid that prevents hypoglycemia by increasing liver gluconeogenesis and inhibiting peripheral glucose use. Insulin is administered when glucose levels are high as it increases the glucose reuptake, thereby reducing blood glucose levels. Somatostatin is a hormone released by delta cells of the pancreas that inhibits insulin and glucagon.

client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. Which sign or symptom leads the nurse to determine that the client has Raynaud disease and not Raynaud phenomenon?

Bilateral involvement Raynaud phenomenon has unilateral involvement, whereas Raynaud disease has bilateral involvement. A tingling sensation indicates return of blood flow and is characteristic of both Raynaud phenomenon and Raynaud disease. Skin color changes indicate blood return and are characteristic of both Raynaud phenomenon and Raynaud disease. Changes in skin temperature indicate lack of blood supply and are characteristic of both Raynaud phenomenon and Raynaud disease.

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

Chronic obstructive pulmonary disease (COPD) COPD causes destruction of capillary beds around the alveoli, interfering with blood flow to the lungs from the right side of the heart. As the heart continues to strain against this resistance, heart failure eventually results. Renal disease causes stress on the left side of the heart. Hypovolemic shock will not cause stress on the right side of the heart. Severe systemic infection probably will produce greater stress on the left side of the heart. Topics

A client at 26-weeks' gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86 mm Hg. She tells the nurse that she has gained 5 lb (2.3 kg) in the last 2 weeks. What is the priority nursing action?

Correct1 Testing the client's urine for albumin 2 Taking the client's body temperature 3 Preparing the client for a vaginal examination 4 Scheduling the client for an appointment in a week Albumin (a protein made by the liver) in the urine is an indication of preeclampsia, as are increased blood pressure and weight gain of more than 2 lb (0.9 kg) per week. Changes in body temperature are not associated with preeclampsia. These signs indicate preeclampsia; treatment does not require a vaginal examination. Scheduling the client for an appointment in a week is premature. More data must be collected and documented first.

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient?

Fats Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse notifies the surgeon. What is the rationale for the nurse's action?

Graft is leaking or ruptured. Hypertension increases pressure on the suture lines, which can affect the integrity of the graft causing leaking or rupture. A compromised venous return is evidenced by lower extremity edema, not an increase in blood pressure. Compartment syndrome is associated with circulatory, sensory, and motor alterations related to excessive interstitial fluid, the presence of which is not indicated in the question. Occluded femoropopliteal arteries were the reason that the client had the surgery; the graft bypasses the occluded area.

A nurse is caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings does the nurse expect when assessing this client? Select all that apply. Correct

Heachache palpitations Diaphoresis A pounding headache is secondary to the severe hypertension associated with excessive amounts of catecholamines. Palpitations are associated with stimulation of the sympathetic nervous system caused by catecholamines (epinephrine and norepinephrine). Diaphoresis is associated with stimulation of the sympathetic nervous system because of excessive catecholamines. Tachycardia, not bradycardia, is associated with stimulation of the sympathetic nervous system caused by catecholamines. Hypertension, not hypotension, is the principal clinical manifestation associated with pheochromocytoma because of stimulation of the sympathetic nervous system

A primary healthcare provider prescribes verapamil to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil?

Keep the client in the recumbent position for 1 hour after administration Hypotension is a common side effect of intravenously administered verapamil. Keeping the client in the recumbent position for 1 hour after administration provides for the safety of the client. A prolonged PR interval may occur during extended therapy, not on initial administration of verapamil. Verapamil should be administered undiluted when given intravenously. It is administered over 2 minutes for adults and over 3 minutes for older adults. The client's heart rate and blood pressure should be assessed before administration to provide a baseline for comparison. Verapamil will decrease the blood pressure and dysrhythmias.

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse Prolonged lack of oxygen to hair follicles results in hair loss. Prolonged lack of oxygen to the toes results in thickened toenails. Arterial ulcers are painful because of the interruption of blood supply to peripheral tissues. Inadequate arterial perfusion results in diminished volume of blood flow to the lower extremities. Brown skin discoloration is characteristic of venous ulcers.STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?

Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action?

Postural hypotension After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described.

the nurse is caring for a client four days after the client had a cystectomy and formation of a continent diversion. After observing mucous threads in the client's urine, the nurse should:

Recognize that this is an expected response

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first?

Remove all jewelry. Remove medication patches on the chest. Medication patches that interfere with electrode placement must be removed before application of electrodes because of possible burn caused by electrical conduction in the area of the patch. Jewelry usually is not a problem with the function of an automated external defibrillator. Skin preparation is unnecessary. The AED is battery-operated and does not need a grounded electrical source.Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A nurse working in the diabetes clinic is evaluating a client's success with managing the medical regimen. What is the best indication that a client with type 1 diabetes is successfully managing the disease?

Stabilization of the serum glucose A combination of diet, exercise, and medication is necessary to control the disease; the interaction of these therapies is reflected by the serum glucose level. Weight loss may occur with inadequate insulin. Acquisition of knowledge does not guarantee its application. Insulin alone is not enough to control the disease.

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit?

The client may have atrial fibrillation. Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis.STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register for afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?

Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

A client receiving calcitonin therapy reports a stinging sensation in the hands and feet. The primary healthcare provider analyzes the client's laboratory results and finds the client is experiencing a side effect of calcitonin therapy. Which finding will the nurse observe to support this conclusion?

Total serum calcium of 8 mg/dL (2 mmol/L) Calcitonin therapy is associated with the risk of hypocalcemia, which is manifested by tingling or numbness in the muscles. Normal levels of total calcium lie between 9.0-10.5 mg/dL (2.25 and 2.75 mmol/L). Because the client's total serum calcium concentration is 8 mg/dL (2 mmol/L), the nurse would conclude that the client has hypocalcemia. All the other values are normal. The normal range of sodium in the serum ranges from 135 to 145 mEq/L (135-145 mmol/L). The normal level of serum creatinine ranges from 0.6 to 1.2 mg/dL (53.04-106.08 µmol/L); while 0.4 mg/dL (35.36 µmol/L) is low, it will not cause stinging sensation in the hands and feet. The normal range of blood urea nitrogen lies between 7 and 20 mg/dL (2.5-7.14 mmol/L), and 17 mg/dL (6.07 mmol/L) is considered normal.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Weight Smoking Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which clinical manifestation is seen in a male client due to deficiency of gonadotropin?

decreased fertility Deficiency of gonadotropin in males results in clinical manifestation of infertility due to impotence. There is loss of muscle mass and bone density due to gonadotropin deficiency. Clients with diabetes insipidus have decreased urine specific gravity, usually less than 1.005.

Which hormone aids in regulating intestinal calcium and phosphorous absorption?

glucocorticoid Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

A client who has degenerative joint disease of the vertebral column is taught to turn from the back to the side, while keeping the spine straight. In addition to crossing an arm over the chest, what should the nurse instruct the client to do?

1 "Pull yourself to one side by using the night table." Correct2 "Bend your top knee to the side to which you are turning." 3 "Turn with both legs straight while your ankles are crossed." 4 "Flex your bottom knee to the side to which you wish to turn." Putting the upper arm and leg toward the side to which the client is turning uses body weight to facilitate turning; the spine is kept straight. Telling the client to pull to one side by using the night table is unsafe and will result in twisting of the spinal column. Turning with both legs straight while the ankles are crossed can be done if another person is turning the client; when turning alone in this position, the client will have no leverage, and turning probably will result in twisting of the spinal column. Flexing the bottom knee to the side to which the client wishes to turn will interfere with turning, because the bent leg becomes an obstacle and provides a force opposite to the leverage needed to turn.

A client identified as having a high-risk pregnancy is about to undergo a contraction stress test (CST). Which factor would compel the nurse to question this prescription?

1 Blurred vision Correct2 Vaginal bleeding 3 Sickle cell disease 4 Increasing hypertension Bleeding may indicate placenta previa or abruptio placentae, which will be aggravated by contractions from the use of oxytocin. Although blurred vision may indicate preeclampsia, a CST is not contraindicated. Fetal tolerance of the stress of contractions should be assessed. Although sickling or arteriolar spasms could diminish oxygen perfusion to the placenta and compromise the fetus during labor, a CST is not contraindicated.

Immediately after a subtotal gastrectomy, a client is admitted to the postanesthesia care unit (PACU). The nurse irrigates the nasogastric tube and observes small blood clots in the return. Which is the best nursing intervention?

1 Clamp the nasogastric tube 2 Irrigate the tube with iced saline Correct3 Document this expected response 4 Notify the healthcare provider of this finding As a result of the trauma of surgery, some bleeding is expected for several hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline is used rarely because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the healthcare provider of this finding is not necessary; bleeding during the immediate postoperative period is an expected occurrence.

A blood transfusion is initiated after a client has emergency surgery. What should the nurse do first when the client develops fever, chills, and low back pain?

1 correct Stop the blood and infuse saline 2 Administer the prescribed antipyretic 3 Obtain a prescription for an antihistamine 4 Slow the rate of the transfusion and inform the blood bank Fever, chills, and low back pain indicate an acute hemolytic reaction, which is potentially life threatening; discontinuing the transfusion immediately limits kidney damage. The vein is kept open by running the primary bottle of normal saline. Although the client has a fever, administering an antipyretic is missing the life-threatening event of a hemolytic reaction. The client's safety must be addressed first. Obtaining a prescription for an antihistamine may be done later. Although the blood bank generally is notified if a reaction occurs, slowing the transfusion rate is unsafe because the reaction will continue.

How can the nurse best describe heart failure to a client?

An inability of the heart to pump blood in proportion to metabolic needs As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram?

Assess the client's affected extremity. Because of the trauma associated with insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of the heart. A general anesthetic is not used; therefore, voiding usually is not a concern. Maintaining the high-Fowler position is unsafe because it increases pressure in the groin area, which may dislodge the clot at the catheter insertion site, resulting in bleeding; it also impedes arterial perfusion and venous return.

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart. Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus.Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs; as sodium is retained, potassium is excreted.Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

The nurse is assessing a client admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these are signs of Cushing disease? Select all that apply.

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.

A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence should the nurse list the structures, beginning with the first?

Sinoatrial node Atrioventricular node Bundle of His Bundle branches Purkinje fibers The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or SA node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally terminating in tiny fibers called Purkinje fibers that reach the myocardial muscle cells or myocytes.

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?

Sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.

Stop the transfusion. Change the intravenous (IV) administration set. Run 0.9% normal saline at a rapid rate. Notify the primary healthcare provider and blood bank. The priority is to stop the transfusion. Failure to do so will make the reaction worse. Changing the IV administration set will prevent infusing any blood product remaining in tubing. Running normal saline rapidly will help to decrease shock and hypotension. Notifying the primary healthcare provider and blood bank would be the last step because this would take longer than the first three choices.

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?

To visualize the disease process in the coronary arteries Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.

A client reporting increased thirst and increased urination arrives at the emergency department. The laboratory findings reveal deficiency of antidiuretic hormone (ADH) and urine osmolarity of 80mOsm/kg. The primary healthcare provider prescribed intravenous (IV) fluid therapy. While assessing the client receiving IV therapy, the nurse finds that the client continues to experience a fluid volume deficit. Which is the likely reason for the client's condition?

administration of IV glucose Increased thirst and increased urination along with deficiency of ADH and urine osmolarity less than 100 mOsm/kg are signs of diabetes insipidus (DI). As excess fluids are lost due to urination, fluid replacement is prescribed for clients with DI. The nurse should monitor serum glucose levels while administering glucose because the client is at risk for hyperglycemia and glycosuria, which can lead to osmotic diuresis and increase the fluid volume deficit. Normal saline is used in fluid replacement therapy to treat the condition of fluid volume deficit. Lactated ringers is an isotonic IV solution used to improve a client's fluid volume status. Hypotonic saline is administered to replace the urine output. Dextrose with water is also administered to replace the urine output. However this solution may cause hyperglycemia because of the dextrose concentration.

After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes?

Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Deficient fluid volume Decreased participation in activities The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings? Correct

Hypokalemia These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Clinical manifestations of hyponatremia include nausea, malaise, and changes in mental status. Clinical manifestations of hyperglycemia include weakness, dry skin, flushing, polyuria, and thirst. Clinical manifestations of hypercalcemia include lethargy, nausea, vomiting, paresthesias, and personality changes.

After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer?

Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair. Weight bearing on the unaffected leg will help maintain muscle strength; weight bearing on the affected leg may be limited initially by the primary healthcare provider's prescription or by the client's inability to tolerate weight bearing. Using a transfer board to slide the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription. Asking the client to put weight equally on both legs and step to the chair may be contraindicated; weight bearing on the affected leg without a prescription can disrupt the repair, or the client may not be able to fully bear weight initially because of discomfort. Having several people assist with lifting the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription.

Which is the first line treatment for Paget disease?

Oral alendronate Oral alendronate, a bisphosphonate, is the first line treatment for Paget disease. 1500 mg of calcium is given as a supplement to reduce the risk for hypocalcemia. When oral drugs are not effective, pamidronate and zoledronic acid are administered intravenously.

the laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client?

Pathological fracturesGrowth hormone deficiency results in thinning of bones and increases the risk for pathological fractures. Thyrotropin deficiency results in scalp alopecia and intolerance to cold. Marked increase in the volume of urine output is a sign of diabetes insipidus caused by vasopressin deficiency.

Which type of joint is present in the client's shoulders?

Spheroidal The spheroidal joint is a ball and socket joint that provides flexion, extension, adduction, abduction, and circumduction in the shoulders and hips. The pivotal joint provides rotation in the atlas and axis, and at the proximal radioulnar joint. The saddle joint, which is at the carpometacarpal joint of the thumb, provides flexion, extension, abduction, adduction, and circumduction of the thumb-finger. The condyloid joint is a wrist joint between the radial and carpals; it provides flexion, extension, abduction, adduction, and circumduction.

A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse?

"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort." The response "As soon as you can climb one flight of stairs without fatigue or discomfort" addresses the client's request for information. The energy required for sexual intercourse is equivalent to that of climbing one flight of stairs. Each client is different and may require longer or shorter than 6 weeks. The response "You will need to talk that over with your surgeon before you leave" avoids the client's question and cuts off communication. The nurse has a responsibility to teach. The answer "When you feel you have recovered enough and when your chest no longer hurts" is too vague and may be dangerous because the client has no basis to make a safe decision.

An older client experiences urinary frequency and nocturia. While ambulating, the client develops severe back pain and is found to have a vertebral compression fracture. When planning care, the nurse will focus interventions on which type of fracture?

Correct1 Collapse of vertebral bodies 2 Demineralization of the spinal cord 3 Wear and tear of the spinous processes 4 Bulging of the spinal cord from the vertebra Osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting. Bones, not the spinal cord, demineralize in osteoporosis. Wearing and tearing of the spinous processes occur in osteoarthritis. The spinal cord does not bulge; the nucleus pulposus bulges toward the spinal cord.Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement?

Fear Fear of a recurrent myocardial infarction or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy, and it usually becomes more evident after discharge from the hospital. Dependency is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate this.STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

A client diagnosed with adrenal gland hypofunction is receiving fludrocortisone therapy. Which nursing intervention would help the client reduce the risk of complications?

Instruct the client to regularly monitor blood pressure Fludrocortisone, prednisone, and cortisone are the drugs prescribed for the treatment of adrenal gland hypofunction. During fludrocortisone therapy, the blood pressure of the client should be regularly monitored because fludrocortisone has a potential to cause hypertension. Reporting of severe diarrhea, fever, and vomiting is required during the administration of prednisone. During the administration of cortisone, the client should take the drug with meals to reduce the risk of gastrointestinal irritation.

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do?

Keep a record of the day's activities. The purpose of monitoring is to correlate dysrhythmias with the client's reported activity. Laser-activated doors have no effect on a Holter monitor and will not affect the readings. Recording the pulse and blood pressure every 4 hours is not required for interpretation of the test. The client should take medication as prescribed and note it in the activities diary.

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?

Remove the clothing. Clothing retains body heat; clothing must be removed before other cooling methods are employed to reduce body temperature. Offering fluids is contraindicated because the client is unresponsive. There are no data to indicate a need for suctioning. Although intubation may become necessary, it is not the initial action.

A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results?

Correct1 Conduct a complete nutritional assessment of the client 2 Nothing, because these are expected values for this client's age 3 Advise the client to come back to the clinic to have the test repeated in three months 4 Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process A nutritional assessment starts the investigation for a cause of the client's anemia and is an independent function of the nurse. These are not expected values; an intervention is indicated. Medical treatment should be initiated first, and then the test should be repeated to determine the client's response to therapy; it is not within the legal function of the nurse to give medical advice. Anemia is not an expected response to the aging process.

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider?

Second degree AV block Mobitz I (Wenckebach) Also called Mobitz I or Wenckebach heart block, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care?

Small, frequent intake of juices, broth, or milk Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are presented to indicate that the client cannot take fluids orally; an NG tube is not necessary when the client can take fluids by mouth. A rapid IV infusion of an electrolyte and glucose solution is unsafe; rapid correction of a fluid and electrolyte imbalance is dangerous. Therapy should promote a gradual correction.Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the entire question and all answer choices before answering the question. Do not assume that you know what the question is asking without reading it entirely.

A man with benign prostatic hyperplasia is scheduled for a transurethral incision of the prostate (TUIP). As he is being admitted to the surgical unit, he tells the nurse he is concerned that the operation will result in impotence. Which is the best response by the nurse?

"I can understand your concern, but this operation usually does not cause impotence." The response "I can understand your concern, but this operation usually does not cause impotence" recognizes the concern and provides accurate information that may reduce anxiety. The response "It's understandable that you are worried; it is a very real possibility" is inaccurate information; impotence usually does not result. The reply "Most men worry about their ability to function; you should speak with your primary healthcare provider" closes off communication and transfers responsibility to the primary healthcare provider. The reply "You may be impotent for a while, but normal functioning probably will return within a few months" does not recognize feelings and provides inaccurate information; impotence rarely, if ever, occurs with this operation.

A client who is diagnosed as having a myocardial infarction is admitted to the coronary care unit with prescriptions for bed rest and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit. What is the nurse's best initial response?

"You need to rest. You should get back into bed." The response "You need to rest. You should get back into bed" addresses the client's behavior and explains the rationale for bed rest. "Tell me what you are doing out of bed" is a demeaning response. The response "It must be frustrating to be confined in bed" identifies feelings but does nothing to reduce the oxygen demands on the heart, which is a priority at this time. The response "Please get back into bed immediately. The primary healthcare provider wants you to rest" is an authoritarian response, which may precipitate negative feelings in the client.Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect?

1 Candidiasis 2 Trichomoniasis Correct3 Bacterial vaginosis 4 Group B Streptococcus Signs of bacterial vaginosis include a milky gray vaginal discharge that has a characteristic fishy odor. "Clue cells" noted on wet smear are indicative of bacterial vaginosis. Clue cells are vaginal epithelial cells coated with bacteria. Candidiasis is a yeast infection caused by the organism Candida albicans. The most common symptom of a yeast infection is vulvar and vaginal pruritus. Vaginal discharge in a candidal infection is thick, white, and lumpy. A woman with a trichomoniasis infection may present with a frothy yellowish-green vaginal discharge. Vulvar irritation, pruritus, and dyspareunia are usually present. Group B Streptococcus may be considered part of the normal vaginal flora in a woman who is not pregnant, and no treatment is necessary.Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.

Two hours after a client gives birth, her physical assessment findings include a blood pressure of 86/40 mm Hg; temperature of 98 °F (36.7 °C); pulse rate of 100 beats/min; respirations of 22 breaths/min; a firm fundus, four fingerbreadths above the umbilicus; small spots of lochia rubra on the perineal pad; and a distended bladder. After a urinary catheterization the client's fundus remains firm and four fingerbreadths above the umbilicus. What should the nurse do next?

1 Catheterize the client again 2 Palpate the client's fundus every 2 hours Correct3 Notify the client's primary healthcare provider immediately 4 Recheck the client's vital signs in 30 minutes The primary healthcare provider should be notified, because the increased height of the uterus may be the result of accumulation of blood in the uterus caused by internal hemorrhaging. Also, the blood pressure is low and the pulse is rapid, possibly indicating impending shock. Any other intervention will delay the immediate, urgent response that is needed, because the client may be hemorrhaging.

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. What is the nurse's priority action immediately postoperative?

1 Check the neck dressing and behind neck for excessive bleeding. Correct2 Monitor the trachea for deviation to the right or left. 3 Assess the client's level of discomfort and medicate as prescribed. 4 Encourage coughing and deep breathing to prevent atelectasis. A deviated trachea is an imminent sign of airway compromise which requires immediate intervention. The client is at high risk for bleeding within the first 24 hours postoperative. Bleeding can accumulate at the incision site as well as in the neck causing tracheal compression with swelling that may compromise the client's ability to breath. Checking for bleeding may alert the nurse of an increasing risk of airway compromise. Pain management and breathing exercises are standard postoperative interventions.

A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention?

1 Describing the proposed surgery to the client 2 Proceeding with the preoperative plan Correct3 Notifying the surgeon that the client needs more information 4 Explaining gently to the client that she should have asked more questions Legally the person performing the surgery is responsible for informing the client adequately; the nurse may clarify information, witness the client's signature, and co-sign the consent form. Describing the proposed surgery to the client is beyond the scope of nursing practice. The nurse could face criminal charges of assault and battery for proceeding when there is a lack of informed consent. Explaining gently that she should have asked more questions places blame on the client; it is the responsibility of the surgeon to impart the vital information required for consent.

When obtaining the history of a client recently diagnosed with type 1 diabetes, what will the nurse expect to discover?

1 Edema 2 Anorexia Correct3 Weight loss 4 Hypoglycemic episodes Protein and lipid catabolism occur because carbohydrates cannot be used by the cells; this results in weight loss and muscle wasting. Dehydration, not edema, is more likely to occur because of the polyuria associated with hyperglycemia. Polyphagia, not anorexia, occurs with diabetes as the client attempts to meet metabolic needs. Hyperglycemia, not hypoglycemia, is present in both type 1 and type 2 diabetes.Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?

1 Increased blood pressure Incorrect2 Prolonged edema in the thigh 3 Increased skin temperature of the foot Correct4 Prolonged reperfusion of the toes after blanching Damage to the blood vessels may decrease circulatory perfusion of the toes. Damage to the major blood vessels will more likely cause a decrease in blood pressure. The fracture is between the knee and the ankle, not in the thigh. Decreased circulatory perfusion of the foot causes the skin temperature to decrease.Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the entire question and all answer choices before answering the question. Do not assume that you know what the question is asking without reading it entirely.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?

1 Increased blood urea nitrogen (BUN) and hypotension 2 Hyperkalemia and poor skin turgor Correct3 Hyponatremia and decreased urine output 4 Polyuria and increased specific gravity of urine Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

A client develops increased respiratory secretions because of radiation therapy to the lung, and the healthcare provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective?

1 Is free of crackles Correct2 Has a productive cough 3 Is able to expectorate saliva 4 Can breathe deeply through the nose A productive cough indicates that mucus is being raised from the lungs, which is an expected outcome. Crackles are unaffected by postural drainage or coughing. Saliva comes from the mouth; it does not indicate that the lungs are clear. Depth of respirations may not be altered by postural drainage.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L (0.30 mmol/L). What is the next nursing action?

1 Stopping the infusion 2 Assessing the client's deep tendon reflexes 3 Assessing the client's level of consciousness Correct4 Documenting the level in the client's electronic medical record Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEq/L (0.28 to 0.44 mmol/L). The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear.Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.

A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery?

Impaired swallowing Impaired swallowing may occur as a result of cranial nerve damage during surgery. Slight edema of the neck is expected from the trauma of surgery; it is not a complication. Decreased appetite, change in bowel habits, and slight edema of the neck are not complications of a carotid endarterectomy.

A nurse is assessing the needs of a client who just learned that a tumor is malignant and has metastasized to several organs and that the illness is terminal. What behavior does the nurse expect the client to exhibit during the initial stage of grieving?

Asking for a second opinion Seeking other opinions to disprove the inevitable is a form of denial employed by individuals who have illnesses with a poor prognosis. If the client is crying, the client is aware of the magnitude of the situation and is past the stage of denial. Criticism that is unjust often is characteristic of the stage of anger. Refusing to receive visitors is most common during the depression experienced as one moves toward acceptance or during the acceptance stage.Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, the nurse has established that the client has no pulse when cardiopulmonary arrest was determined. Therefore, chest compressions should be initiated immediately. Never leave the client to call for assistance; either call the emergency medical services (EMS) by dialing 911 in the US or 112 in Canada on a cellular phone (and leave the phone on so that EMS can find you) or shout out to others in the area for assistance in seeking EMS. The longer the client goes without circulation, the higher the risk of death, so initiating chest compressions has highest priority when cardiopulmonary arrest has been established. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving warfarin therapy after a myocardial infarction?

Blood-clotting function of vitamin k A neonate lacks the ability to produce vitamin K because of a lack of bacteria in the intestine. After a cholecystectomy a client experiences interference with absorption of the fat-soluble vitamin K because of disruption in bile flow. A client who is receiving warfarin experiences inhibition of vitamin K-dependent activation of clotting factors. Neuromuscular function of vitamin B1, calcium-absorbing function of vitamin D, and hemoglobin-forming function of vitamin B12 are not common nutritional problems for these clients.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply.

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes, and the other client has type 2 diabetes. When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes what clinical presentation about type 1?

Complications are not present at the time of diagnosis Clinical presentation of type 1 diabetes is characterized by acute onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease; 20% of newly diagnosed clients with type 2 diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time. Clinical presentation of type 1 diabetes is rapid, not slow, as pancreatic beta cells are destroyed by an autoimmune process; in type 2 diabetes, the body is still producing some insulin, and therefore the onset of signs and symptoms is slow. In type 1 diabetes, clients are generally lean or have an ideal weight; 80% to 90% of clients with type 2 diabetes are overweight. Type 1 diabetes requires diet control, exercise, and subcutaneous administration of insulin, not oral medications; oral medications are used for type 2 diabetes because some insulin is still being produced.

The nurse is caring for a client who is in the taking-in phase of the postpartum period. What area of health teaching will the client be most responsive to?

Correct1 Perineal care 2 Infant feeding 3 Infant hygiene 4 Family planning During the taking-in phase a woman is primarily concerned with self-care needs and being cared for. The taking-in phase generally occurs during the first 24 hours after delivery and may last up to 2 days. Infant feeding and infant hygiene are best taught during the taking-hold phase of postpartum adjustment. Family planning is not a primary concern during the immediate postpartum period.

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Crackles Coughing Orthopnea Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.

A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take?

Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. A low potassium level with the administration of digoxin can cause digitalis toxicity, resulting in life-threatening dysrhythmias. Doubling the dose of potassium chloride and administering it with the prescribed digoxin has the potential of causing digitalis toxicity. In addition, changing the dose of a medication is not within the legal role of the nurse and requires a primary healthcare provider's prescription. Giving the digoxin and potassium chloride as prescribed and reporting the laboratory results to the primary healthcare provider has the potential of causing digitalis toxicity, especially when the potassium level is less than 3 mEq/L (3 mmol/L). Administering the prescribed digoxin and potassium chloride with a glass of orange juice and continuing to monitor the client has the potential of causing digitalis toxicity. One glass of orange juice and one dose of potassium chloride will not change the potassium level significantly.Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

A client develops ventricular fibrillation in a coronary care unit. Which action is priority?

Initiate defibrillation Ventricular fibrillation is a lethal dysrhythmia and, once identified, must be terminated immediately by defibrillation so the sinus node can act again as the heart's pacemaker. Oxygen is administered to correct hypoxia, but if the heart is not pumping, oxygen will not be delivered to the tissues; it does not take priority over defibrillation. Cardioversion is not effective in ventricular fibrillation. Bicarbonate is administered to correct acidosis; it does not take priority over defibrillation.

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm?

Normal sinus rhythm Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.