Hesi for me

21. The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the client should eat which of the following? 1. Bland foods. 2. High-protein foods. 3. Any foods that are tolerated. 4. A glass of milk with each meal.

. 3. Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or highprotein diet. Milk may be included in the diet, but it is not recommended in excessive amounts. CN: Basic care and comfort; CL: Apply

41. The nurse should instruct the client with a platelet count of 31,000/μL (31 × 109/L) to: 1. Pad sharp surfaces to avoid minor trauma when walking. 2. Assess for spontaneous petechiae in the extremities. 3. Keep the room darkened. 4. Check for blood in the urine.

. A client with a platelet count of 30,000 to 50,000/μL (30 to 50 × 109/L) is susceptible to bruising with minor trauma. Padding areas that the client might bump, scratch, or hit may help prevent minor trauma. A platelet count of 15,000 to 30,000/μL (15 to 30 × 109/L) may result in spontaneous petechiae and bruising, especially on the extremities. Padding measures would still be used, but the focus would be on assessing for new spontaneous petechiae. Keeping the room dark does not help the client with a low platelet count. With a count below 20,000/μL (20 × 109/L), the client is at risk for spontaneous bleeding from the mucous membranes and intracranial bleeding. CN: Reduction of risk potential; CL: Synthesize

A client who weighs 187 lb (85 kg) has a prescription to receive enoxaparin (Lovenox) 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters? _________________ mL.

0.85 mL The physician's prescription is for the client to receive enoxaparin (Lovenox) 1 mg/kg. Therefore, the client is to receive 85 mg. The desired dose in milliliters then can be calculated by using the formula of desired dose (D) divided by dose or strength of dose on hand (H) times volume (V). CN: Pharmacological and parenteral therapies; CL: Apply

A client with hypertensive emergency is being treated with sodium nitroprusside (Nipride). In a dilution of 50 mg/250 mL, how many micrograms of Nipride are in each milliliter? __________________ mcg.

200 mcg First, calculate the number of milligrams per milliliter: Next, calculate the number of micrograms in each milligram: CN: Pharmacological and parenteral therapies; CL: Apply

3. A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply. 1. Rapid pulse. 2. Decreased energy and fatigue. 3. Weight gain of 10 lb (4.5 kg). 4. Fine, thin hair with hair loss. 5. Constipation. 6. Menorrhagia.

2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze

91. The nurse is discussing medications with a client with hypertension who has a prescription for furosemide (Lasix) daily. The client needs further education when the client states which of the following? 1. "I know I should not drive after taking my Lasix." 2. "I should be careful not to stand up too quickly when taking Lasix." 3. "I should take the Lasix in the morning instead of before bed." 4. "I need to be sure to also take the potassium supplement that the doctor prescribed along with my Lasix."

1 Furosemide (Lasix) is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client's ability to drive safely. Lasix may cause orthostatic hypotension and clients should be instructed to be careful when changing from supine to sitting to standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Lasix is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals. CN: Pharmacological and parenteral therapies; CL: Evaluate

97. A client diagnosed with primary (essential) hypertension is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. "I will (Select all that apply.) 1. take my weight daily at the same time each day." 2. not drink alcoholic beverages while on this medication." 3. reduce salt intake in my diet." 4. reduce my dosage if I have severe dizziness." 5. use sunscreen if I have prolonged exposure to sunlight." 6. take the drug late in the evening."

1, 2, 3, 5. Chlorothiazide (Diuril) causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider. Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects and hence excessive table salt as well as salty foods should be avoided. Chlorothiazide (Diuril) is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the patient stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the health care provider must be notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide (Diuril) causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls. CN: Pharmacological and parenteral therapies; CL: Evaluate

76. Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply. 1. Checking urine for bright blood and a dark smoky color. 2. Walking daily as a good exercise. 3. Using garlic and ginger, which may decrease bleeding time. 4. Performing foot/leg exercises and walking around the airplane cabin when on long flights. 5. Preventing DVT because of risk of pulmonary emboli. 6. Avoiding surface bumps because the skin is prone to injury.

1, 2, 4, 5, 6. Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when a client is on anticoagulant therapy. Clients who have had previous DVTs should avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return. Instructing the client about prevention measures is important because clients with DVT are at high risk for pulmonary emboli (PE), which can be fatal. The client can be taught risk factors for DVT and PE. In addition, recommendations for prevention of these events also are standard protocol in practice and should be shared with the client for home care purposes. Older adults should be monitored closely for bleeding because the skin becomes thinner and the capillaries become more fragile with the aging process. CN: Health promotion and maintenance; CL: Create

95. A client who has diabetes is taking metoprolol (Lopressor) for hypertension. Which of the following information should the nurse include in the teaching plan? Select all that apply 1. These tablets should be taken with food at same time each day. 2. Do not crush or chew the tablets. 3. Notify the health care provider if pulse is 82 per minute. 4. Have a blood glucose level drawn every 6 to 12 months during therapy. 5. Use an appropriate decongestant if needed. 6. Report any fainting spells to the health care provider.

1, 2, 4, 6. Metoprolol (Lopressor) is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The health care provider should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued. CN: Pharmacological and parenteral therapies; CL: Create

89. A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply. 1. Dry mouth. 2. Hyperkalemia. 3. Impotence. 4. Pancreatitis. 5. Sleep disturbance.

1, 3, 5. Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug. CN: Pharmacological and parenteral therapies; CL: Apply

84. Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include instructing the client to do which of the following? Select all that apply. 1. Brush the teeth at least twice a day. 2. Avoid use of an electric toothbrush. 3. Take an antibiotic prior to oral surgery. 4. Floss the teeth at least once a day. 5. Have regular dental checkups. 6. Rinse the mouth with an antibiotic mouthwash once a day.

1, 4, 5. Daily dental care including brushing the teeth twice a day and flossing once a day and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. The client can use a regular tooth brush; it is not necessary to avoid use of an electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash. CN: Reduction of risk potential; CL: Create

32. After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? 1. Dark brown. 2. Bile green. 3. Bright red. 4. Cloudy white.

1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown, which indicates digested blood. Bile green or cloudy white drainage is not expected during the first 12 to 24 hours after a subtotal gastrectomy. Drainage during the first 6 to 12 hours contains some bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the physician promptly. CN: Reduction of risk potential; CL: Apply

55. Platelets should not be administered under which of the following conditions? 1. The platelet bag is cold. 2. The platelets are 2 days old. 3. The platelet bag is at room temperature. 4. The platelets are 12 hours old.

1. Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days. CN: Pharmacological and parenteral therapies; CL: Synthesize

93. The nurse is teaching a client with hypertension about taking atenolol (Tenormin). The nurse should instruct the client to: 1. Avoid sudden discontinuation of the drug. 2. Monitor the blood pressure annually. 3. Follow a 2-g sodium diet. 4. Discontinue the medication if severe headaches develop.

1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician's prescription. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension. CN: Pharmacological and parenteral therapies; CL: Synthesize

40. After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan? 1. Nutritional intake. 2. Management of alopecia. 3. Exercise and activity levels. 4. Access to community resources.

1. Clients who have had gastric surgery are prone to postoperative complications, such as dumping syndrome and postprandial hypoglycemia, which can affect nutritional intake. Vitamin absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as well as access to community resources are important teaching areas, but nutritional intake is a priority need.

82. For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? 1. Ensure a liberal fluid intake. 2. Provide an alkaline-ash diet. 3. Prevent constipation. 4. Enrich the client's diet with dairy products.

1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi. CN: Physiological adaptation; CL: Synthesize

81. The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. Observe careful handwashing procedures. 2. Clean the incisional area with an antiseptic. 3. Use prepackaged sterile dressings to cover the incision. 4. Place soiled dressings in a waterproof bag before disposing of them.

1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections. CN: Reduction of risk potential; CL: Synthesize

51. When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should recommend which of the following? 1. Take the prednisone with food. 2. Take over-the-counter drugs as needed. 3. Exercise three to four times a week. 4. Eat foods that are low in potassium.

1. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the physician who prescribed the prednisone. The client should ask the physician about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia. CN: Pharmacological and parenteral therapies; CL: Synthesize

100. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II. CN: Pharmacological and parenteral therapies; CL: Apply

87. Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is: 1. Decrease in heart rate. 2. Lessening of fatigue. 3. Improvement in blood sugar levels. 4. Increase in urine output.

1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output. CN: Pharmacological and parenteral therapies; CL: Evaluate

4. Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? 1. Sore throat. 2. Painful, excessive menstruation. 3. Constipation. 4. Increased urine output.

1. The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. CN: Pharmacological and parenteral therapies; CL: Synthesize

48. The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for which of the following? 1. Tachycardia. 2. Bradycardia. 3. Decreased PaCO2. 4. Narrowed pulse pressure.

1. The nurse observes tachycardia in the hemorrhaging client because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells (RBCs). The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pressure is not an early sign of hemorrhage. CN: Physiological adaptation; CL: Analyze

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 AM, the client has sharp midchest pain after having a bowel movement. What should the nurse do first? 1. Assess the client's vital signs. 2. Administer a bolus of lactated Ringer's solution. 3. Assess the client's neurologic status. 4. Contact the physician.

1. The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer's solution would require a physician's prescription. CN: Physiological adaptation; CL: Synthesize

86. Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision and the incision seems to becoming larger. The nurse's response should reflect the understanding that the client may be experiencing which of the following? 1. Anxiety related to altered body image. 2. Anxiety related to altered health status. 3. Altered tissue perfusion. 4. Lack of knowledge regarding the postoperative course. The Client with Hypertension

1. Verbalized concerns from this client may stem from anxiety over the changes in the body after open heart surgery. Although the client may experience anxiety related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion. CN: Psychosocial integrity; CL: Analyze The Client with Hypertension

28. The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which of the following? Select all that apply. 1. Dry, flushed skin. 2. Decreased urine output. 3. Tachycardia. 4. Widening pulse pressure. 5. Rapid respirations. 6. Thirst.

2, 3, 5, 6. The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure. CN: Physiological adaptation; CL: Analyze

92. In teaching the client with hypertension to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions? Select all that apply. 1. Plan regular times for taking medications. 2. Arise slowly from bed. 3. Avoid standing still for long periods. 4. Avoid excessive alcohol intake. 5. Avoid hot baths.

2, 3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation. CN: Reduction of risk potential; CL: Create

54. A client has been on long-term prednisone therapy. The nurse should instruct the client to consume a diet high in which of the following? Select all that apply. 1. Carbohydrate. 2. Protein. 3. Trans fat. 4. Potassium. 5. Calcium. 6. Vitamin D.

2, 4, 5, 6. Adverse effects of prednisone are weight gain, retention of sodium and fluids with hypertension and cushingoid features, a low serum albumin level, suppressed inflammatory processes with masked symptoms, and osteoporosis. A diet high in protein, potassium, calcium, and vitamin D is recommended. Carbohydrate would elevate glucose and further compromise a client's immune status. Trans fat does not counteract the adverse effects of steroids such as prednisone. CN: Pharmacological and parenteral therapies; CL: Synthesize

22. The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from a briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: 1. Involvement with the job will keep the client from becoming bored. 2. A relaxed environment will promote ulcer healing. 3. Not keeping up with the job will increase the client's stress level. 4. Setting limits on the client's behavior is an important nursing responsibility.

2. A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes. CN: Basic care and comfort; CL: Apply

5. A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? 1. "Your behavior is caused by temporary confusion brought on by your illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." 3. "Your behavior is caused by your worrying about the seriousness of your illness." 4. "Your behavior is caused by the stress of trying to manage a career and cope with illness."

2. A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. CN: Psychosocial integrity; CL: Synthesize

96. An older adult with a history of hypertension is admitted with diagnosis of dehydration. The client is becoming increasingly confused and weak. The client reports taking one tablet of hydrochlorothiazide (HydroDIURIL) daily, and the prescription is written for 1/2 tablet. The nurse should obtain additional information about: 1. Decreased drug half-life of the HydroDIURIL. 2. Decreased hepatic blood flow. 3. Increased GI activity. 4. Increased urinary elimination.

2. Aging causes decreased hepatic blood flow. Decreased drug metabolism, which occurs with aging, along with more drug in circulation means the drug will remain in the body longer and produce greater drug effects. The client has also taken more drug than prescribed increasing the opportunity for more drug action to occur. When there is decreased metabolism of drugs, an increase in the half-life will occur most especially in the older adult. In older adults transit time (GI motility) is slower, allowing more drug to be absorbed. Increased urinary elimination would mean that drug elimination could be higher not lower and accumulating in the body. CN: Physiological adaptation; CL: Analyze

27. Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate engaging in contact sports. The Client with Cancer of the Stomach

2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress inducing. CN: Reduction of risk potential; CL: Evaluate The Client with Cancer of the Stomach

36. After a subtotal gastrectomy, the nurse is developing a plan with the client to assist the client to gain weight. To help the client meet nutritional goals at home, the nurse should: 1. Instruct the client to increase the amount eaten at each meal. 2. Encourage the client to eat smaller amounts more frequently. 3. Explain that if vomiting occurs after a meal, nothing more should be eaten that day. 4. Inform the client that bland foods are typically less nutritional and should be used minimally.

2. Because of the client's reduced stomach capacity, frequent small feedings are recommended. Early satiety can result, and large quantities of food are not well tolerated. Each client should progress at his or her own pace, gradually increasing the amount of food eaten. The goal is three meals daily if possible, but this can take 6 months or longer to achieve. Nausea can be episodic and can result from eating too fast or eating too much at one time. Eating less and eating more slowly, rather than not eating at all, can be a solution. Bland foods are recommended as starting foods because they are easily digested and are less irritating to the healing mucosa. Bland foods are not less nutritional.

1. The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: 1. Anorexia. 2. Tachycardia. 3. Weight gain. 4. Cold skin.

2. Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism. CN: Physiological adaptation; CL: Analyze

44. The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client makes which of the following statements? 1. "Petechiae are large, red skin bruises." 2. "Ecchymoses are large, purple skin bruises." 3. "Purpura is an open cut on the skin." 4. "Abrasions are small pinpoint red dots on the skin."

2. Large, purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called purpura. An abrasion is a wound caused by scraping. CN: Health promotion and maintenance; CL: Evaluate

10. A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The expected outcome of using this drug is that it helps: 1. Slow progression of exophthalmos. 2. Reduce the vascularity of the thyroid gland. 3. Decrease the body's ability to store thyroxine. 4. Increase the body's ability to excrete thyroxine.

2. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine. CN: Pharmacological and parenteral therapies; CL: Apply

65. Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. The nurse should first: 1. Offer analgesics as prescribed and apply the compression devices. 2. Leave the compression devices off and contact the physician to report the assessment findings. 3. Massage the area of discomfort before applying the compression devices. 4. Leave the compression devices off and report assessment findings to the oncoming shift.

2. Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the physician; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the physician as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus. CN: Reduction of risk potential; CL: Synthesize

85. Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon? 1. Showering. 2. Lifting anything heavier than 10 lb (4.5 kg). 3. A program of gradually progressive walking. 4. Light housework.

2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge. CN: Safety and infection control; CL: Evaluate

6. The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which of the following statements from the client indicates the desired outcome of the drug? 1. "I have excess energy throughout the day." 2. "I am able to sleep and rest at night." 3. "I have lost weight since taking this medication." 4. "I do perspire throughout the entire day."

2. PTU is a prototype of thioamide antithyroid drugs. It inhibits production of thyroid hormones and peripheral conversion of T4 to the more active T3. A client taking this antithyroid drug should be able to sleep and rest well at night since the level of thyroid hormones is reduced in the blood. Excess energy throughout the day, loss of weight and perspiring through the day are symptoms of hyperthyroidism indicating the drug has not produced its outcome. CN: Pharmacological and parenteral therapies; CL: Evaluate.

19. The nurse is instructing the client with hypothyroidism who takes levothyroxine (Synthroid) 100 mcg, digoxin (Lanoxin) and simvastatin (Zocor). Teaching regarding medications is effective if the client will take: 1. The Synthroid with breakfast and the other medications after breakfast. 2. The Synthroid before breakfast and the other medications 4 hours later. 3. All medications together 1 hour after eating breakfast. 4. All medications before going to bed. The Client with Diabetes Mellitus

2. Synthroid (levothyroxine) must be given at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Other medications may impair the action of levothyroxine (Synthroid) absorption; the client should separate doses of other medications by 4 to 5 hours. CN: Pharmacological and parenteral therapies; CL: Evaluate The Client with Diabetes Mellitus

14. One day following a subtotal thyroidectomy, a client begins to have tingling in the fingers and toes. The nurse should first: 1. Encourage the client to flex and extend the fingers and toes. 2. Notify the physician. 3. Assess the client for thrombophlebitis. 4. Ask the client to speak.

2. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs and symptoms of tetany include seizures, contraction of the glottis, and respiratory obstruction. The nurse should notify the physician. Exercising the joints in the fingers and toes will not relieve the tetany. The client is not exhibiting signs of thrombophlebitis. There is no indication of nerve damage that would cause the client not to be able to speak. CN: Physiological adaptation; CL: Synthesize

68. The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of: 1. Aortic aneurysm. 2. Deep vein thrombosis (DVT) in the left leg. 3. IV drug abuse. 4. Intermittent claudication.

2. The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg. CN: Psychosocial integrity; CL: Analyze

75. A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to: 1. Avoid exercise. 2. Lose weight. 3. Perform leg lifts every 4 hours. 4. Wear support hose, using rubber bands to hold the stockings up.

2. The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Depending on the individual, leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up. CN: Reduction of risk potential; CL: Evaluate

53. The nurse is teaching a female client with a history of acquired thrombocytopenia about how to prevent and control hemorrhage. Which statement indicates that the client needs further instruction? 1. "I can apply direct pressure over small cuts for at least 5 to 10 minutes to stop a venous bleed." 2. "I can count the number of tissues saturated to detect blood loss during a nosebleed." 3. "I can take hormones to decrease blood loss during menses." 4. "I can count the number of sanitary napkins to detect excess blood loss during menses."

2. The client needs further teaching if she thinks that the number of tissues saturated represents all of the blood lost during a nosebleed. During a nosebleed, a significant amount of blood can be swallowed and go undetected. It is important that clients with severe thrombocytopenia do not take a nosebleed lightly. Clients with thrombocytopenia can apply pressure for 5 to 10 minutes over a small, superficial cut. Clients with thrombocytopenia can take hormones to suppress menses and control menstrual blood loss. Clients can also count the number of saturated sanitary napkins to approximate blood loss during menses. Some authorities estimate that a completely soaked sanitary napkin holds 50 mL. CN: Reduction of risk potential; CL: Evaluate

43. When a client with thrombocytopenia has a severe headache, the nurse interprets that this may indicate which of the following? 1. Stress of the disease. 2. Cerebral bleeding. 3. Migraine headache. 4. Sinus congestion.

2. When the platelet count is very low, red blood cells (RBCs) leak out of the blood vessels and into the tissue. If the blood pressure is elevated and the platelet count falls to less than 15,000/μL (15 × 109/L), internal bleeding in the brain can occur. A severe headache occurs from meningeal irritation when blood leaks out of the cerebral vasculature. When a client has thrombocytopenia, the nurse should always assess for cerebral bleeding by checking vital signs and performing neurologic checks. Headaches can be caused by stress, migraines, and sinus congestion. However, the concern here is the risk of internal bleeding into the brain. CN: Health promotion and maintenance; CL: Analyze

47. A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client makes which of the following statements? 1. "I need to stop flossing and throw away my hard toothbrush." 2. "I am glad that my report turned out normal." 3. "Now I know why I have all these bruises." 4. "I shouldn't jump off that last step anymore."

2. The client who states that the test results are normal has only heard that the bone marrow is functioning. The etiology is in the destruction of circulating platelets. Further tests must be completed to determine the cause (eg, a coating of the platelets with antibodies that are seen as foreign bodies). The bone marrow result does rule out other potential diagnoses such as anemia, leukemia, or myeloproliferative disorders that involve bone marrow depression. The client needs to stop flossing and throw away his hard toothbrush, which can lead to bleeding of the gums. The destruction of the circulating platelets accounts for the easy bruising and the need to protect oneself from further bruising. The client should not jump or increase exertion of joints, which may lead to bleeding in the joints and joint pain. CN: Reduction of risk potential; CL: Evaluate

15. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? 1. Sodium phosphate. 2. Calcium gluconate. 3. Echothiophate iodide. 4. Sodium bicarbonate.

2. The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid. CN: Pharmacological and parenteral therapies; CL: Apply

80. Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 bpm, and respirations 28/min. The nurse should first: 1. Assess the urine output. 2. Place a large-bore IV 3. Position onto the left side. 4. Insert a nasogastric tube.

2. The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An IV should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with severe nausea and vomiting to decompress the stomach. CN: Physiological adaptation; CL: Synthesize

88. Which set of postural vital signs (BP and heart rate) indicate inadequate blood volume? Supine 124/76, 88. Sitting 124/74, 92. Standing 122/74, 92. Supine 120/70, 70. Sitting 102/64, 86. Standing 100/60, 92. Supine 138/86, 74. Sitting 136/84, 80. Standing 134/82, 82. Supine 100/70, 72. Sitting 100/68, 74. Standing 98/68, 80.

2. There was a significant change in both blood pressure and heart rate with position change. This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a possible slight decrease of less than 5 mm Hg in the systolic blood pressure, and a possible slight increase of less than 5 mm Hg in the diastolic blood pressure. CN: Management of care; CL: Analyze

16. A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? 1. Tachycardia. 2. Weight gain. 3. Diarrhea. 4. Nausea.

2. Typical signs and symptoms of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and tingling in the fingers. Tachycardia is a sign of hyperthyroidism, not hypothyroidism. Diarrhea and nausea are not symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze

45. The nurse should instruct the client with a platelet count of less than 150,000/μL (150 × 109/L) to avoid which of the following activities? 1. Ambulation. 2. Valsalva's maneuver. 3. Visiting with children. 4. Semi-Fowler's position.

2. When the platelet count is less than 150,000/μL (150 × 109/L), prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae. CN: Health promotion and maintenance; CL: Synthesize

A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/h. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/h? ____________ gtt/min.

25 gtt/min. To administer IV fluids at 100 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula: 100 mL/60 minutes × 15 gtts/1 mL = 25 gtt/min. CN: Pharmacological and parenteral therapies; CL: Apply

39. What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply. 1. Consume three regularly spaced meals per day. 2. Eat a diet with high-carbohydrate foods with each meal. 3. Reduce fluids with meals, but take them between meals. 4. Obtain adequate amounts of protein and fat in each meal. 5. Eat in a relaxing environment.

3, 4, 5. Dumping syndrome results in excessive, rapid emptying of gastric contents. The nurse should instruct the client to avoid dumping syndrome by eating small, frequent meals rather than three large meals, having a diet high in protein and fat and low in carbohydrates, reducing fluids with meals but taking them between meals, and relaxing when eating. The client should eat slowly and regularly and rest after meals. CN: Health promotion and maintenance; CL: Create

12. Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of which of the following? 1. Internal hemorrhage. 2. Decreasing level of consciousness. 3. Laryngeal nerve damage. 4. Upper airway obstruction.

3. Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern. CN: Reduction of risk potential; CL: Analyze

2. When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle? 1. Dysmenorrhea. 2. Metrorrhagia. 3. Oligomenorrhea. 4. Menorrhagia.

3. A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a symptom of hypothyroidism. CN: Physiological adaptation; CL: Analyze

35. Following a gastrectomy, the nurse should position the client in which of the following positions? 1. Prone. 2. Supine. 3. Low Fowler's. 4. Right or left Sims.

3. A client who has had abdominal surgery is best placed in a low Fowler's position postoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory and cardiovascular function. The prone, supine, or Sims position would not be tolerated by a client who has had abdominal surgery, nor do those positions support respiratory or cardiovascular functioning. CN: Physiological adaptation; CL: Synthesize

99. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? 1. Review the negative effects of smoking on the body. 2. Discuss the effects of passive smoking on environmental pollution. 3. Establish the client's daily smoking pattern. 4. Explain how smoking worsens high blood pressure.

3. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior. CN: Psychosocial integrity; CL: Synthesize

60. The client's family asks why the client who had a splenectomy has a nasogastric (NG) tube. An NG tube is used to: 1. Move the stomach away from where the spleen was removed. 2. Irrigate the operative site. 3. Decrease abdominal distention. 4. Assess for the gastric pH as peristalsis returns.

3. A splenectomy may involve manipulation of the upper abdominal organs, such as diaphragm, stomach, liver, spleen, and small intestines. Manipulation of these organs and resulting inflammation lead to a slowed peristalsis. An NG tube is placed to decrease abdominal distention in the immediate postoperative phase. The stomach does not need to be manipulated away from the spleen postoperatively, nor would an NG tube accomplish this. The NG tube drains gastric contents and air in the stomach; it is not in the operative site, and therefore cannot be used to irrigate it. The gastric juices are not checked as an indicator that peristalsis has returned; instead, bowel sounds are auscultated in all four quadrants to indicate the return of peristalsis. CN: Physiological adaptation; CL: Apply

59. When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess next after obtaining vital signs? 1. Nasogastric drainage. 2. Urinary catheter. 3. Dressing. 4. Need for pain medication.

3. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communicated in the exchange report. Checking for hemorrhage is a greater priority than assessing pain level. CN: Physiological adaptation; CL: Analyze

58. A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has: 1. Voided completely. 2. Signed the consent. 3. Vital signs recorded. 4. Name band on wrist.

3. An elective surgical procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. The first assessment that will be completed in the preoperative holding area or operating room will be the client's vital signs. The client should have emptied the bladder before receiving preoperative medications so that the bladder is empty when it is time for transport into the operating room. The client should have signed the consent before the transport time so that if there were any questions or concerns there was time to meet with the surgeon. Also, the consent form must be signed before any sedative medications are given. The client's name band should be placed as soon as the client arrives in the perioperative setting, and it remains in place through discharge. CN: Physiological adaptation; CL: Analyze

61. A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is: 1. Arteriosclerosis. 2. Aneurysm formation. 3. Deep vein thrombosis (DVT). 4. Varicose veins.

3. DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered causes of pulmonary embolism. CN: Physiological adaptation; CL: Apply

20. The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following? 1. "How much does your family need to be involved in learning about your condition?" 2. "What is required for your family to manage your symptoms?" 3. "What activities are most important for you to be able to maintain control of your diabetes?" 4. "What do you know about your medications and condition?"

3. Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their selfmanagement practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment. CN: Health promotion and maintenance; CL: Synthesize

83. The nurse should teach the client who is receiving warfarin sodium that: 1. Partial thromboplastin time values determine the dosage of warfarin sodium. 2. Protamine sulfate is used to reverse the effects of warfarin sodium. 3. International Normalized Ratio (INR) is used to assess effectiveness. 4. Warfarin sodium will facilitate clotting of the blood.

3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots. CN: Pharmacological and parenteral therapies; CL: Apply

25. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? 1. The client has not been including enough fiber in the diet. 2. The client needs to increase the daily exercise. 3. The client is experiencing an adverse effect of the aluminum hydroxide. 4. The client has developed a gastrointestinal obstruction.

3. It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction. CN: Pharmacological and parenteral therapies; CL: Analyze

33. A client has a nasogastric (NG) tube following a subtotal gastrectomy. The nurse should: 1. Irrigate the tube with 30 mL of sterile water every hour, if needed. 2. Reposition the tube if it is not draining well. 3. Monitor the client for nausea, vomiting, and abdominal distention. 4. Turn the machine to high suction if the drainage is sluggish on low suction.

3. Nausea, vomiting, or abdominal distention indicates that gas and secretions are accumulating within the gastric pouch due to impaired peristalsis or edema at the operative site and may indicate that the drainage system is not working properly. Saline solution is used to irrigate NG tubes. Hypotonic solutions such as water increase electrolyte loss. In addition, a physician's prescription is needed to irrigate the NG tube because this procedure could disrupt the suture line. After gastric surgery, only the surgeon repositions the NG tube because of the danger of rupturing or dislodging the suture line. The amount of suction varies with the type of tube used and is prescribed by the physician. High suction may create too much tension on the gastric suture line. CN: Reduction of risk potential; CL: Synthesize

94. The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? 1. Mixed green salad with blue cheese dressing, crackers, and cold cuts. 2. Ham sandwich on rye bread and an orange. 3. Baked chicken, an apple, and a slice of white bread. 4. Hot dogs, baked beans, and celery and carrot sticks.

3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, lowsalt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic. CN: Basic care and comfort; CL: Apply

24. A client is to take one daily dose of ranitidine (Zantac) at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug at which of the following times? 1. Before meals. 2. With meals. 3. At bedtime. 4. When pain occurs.

3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs. CN: Pharmacological and parenteral therapies; CL: Evaluate

11. The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should: 1. Pour the solution over ice chips. 2. Mix the solution with an antacid. 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. 4. Disguise the solution in a pureed fruit or vegetable.

3. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth. CN: Pharmacological and parenteral therapies; CL: Apply

74. Which of the following clients is at risk for varicose veins? 1. A client who has had a cerebrovascular accident. 2. A client who has had anemia. 3. A client who has had thrombophlebitis. 4. A client who has had transient ischemic attacks.

3. Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins. CN: Health promotion and maintenance; CL: Analyze

56. The nurse is preparing to administer platelets. The nurse should: 1. Check the ABO compatibility. 2. Administer the platelets slowly. 3. Gently rotate the bag. 4. Use a whole blood tubing set.

3. The bag containing platelets needs to be gently rotated to prevent clumping. ABO compatibility is not a necessary requirement, but human leukocyte antigen (HLA) matching of lymphocytes may be completed to avoid development of anti-HLA antibodies when multiple platelet transfusions are necessary. Platelets should be administered as fast as can be tolerated by the client to avoid aggregation. Most institutions use tubing especially for platelets instead of tubing for blood and blood products. CN: Pharmacological and parenteral therapies; CL: Synthesize

9. After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to: 1. Monitor for signs and symptoms of hyperthyroidism. 2. Rest for 1 week to prevent complications of the medication. 3. Take thyroxine replacement for the remainder of the client's life. 4. Assess for hypertension and tachycardia resulting from altered thyroid activity.

3. The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. CN: Pharmacological and parenteral therapies; CL: Synthesize

50. A client is to be discharged on prednisone. Which of the following statements indicates that the client understands important concepts about the medication therapy? 1. "I need to take the medicine in divided doses at morning and bedtime." 2. "I am to take 40 mg of prednisone for 2 months and then stop." 3. "I need to wear or carry identification that I am taking prednisone." 4. "Prednisone will give me extra protection from colds and flu."

3. The client needs to wear or carry information containing the name of the drug, dosage, physician and contact information, and emergency instructions because additional corticosteroid drug therapy would be needed during emergency situations. Prednisone should be taken in the morning because it can cause insomnia and because exogenous corticosteroid suppression of the adrenal cortex is less when it is administered in the morning. Prednisone must never be stopped suddenly. It must be tapered off to allow for the adrenal cortex to recover from drug-induced atrophy so that it can resume its function. Prednisone suppresses the immune response and masks infections. It does not provide extra protection against infection. CN: Pharmacological and parenteral therapies; CL: Evaluate

66. A client is receiving an IV infusion of 5% dextrose in water (D5W). The skin around the IV insertion site is red, warm to touch, and painful. The nurse should first: 1. Administer acetaminophen (Tylenol). 2. Change the D5W to normal saline. 3. Discontinue the IV. 4. Place a warm compress on the area.

3. The first action should be to discontinue the IV. The nurse should restart the IV elsewhere and then apply a warm compress to the affected area. The nurse should administer acetaminophen or an anti-inflammatory agent only if prescribed by the physician. The type of infusion cannot be changed without a physician's prescription, and such a change would not help in this case. CN: Reduction of risk potential; CL: Synthesize

31. Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." Based on this information, the nurse should understand that the client: 1. Is having difficulty coping. 2. Has a sleep disorder. 3. Is grieving. 4. Is anxious.

3. The information presented indicates the client is grieving about the changes that will occur as a result of the diagnosis of gastric cancer. The information does not indicate the client is having difficulty coping, or experiencing insomnia. The client is not demonstrating signs of anxiety. CN: Psychosocial adaptation; CL: Analyze

29. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? 1. The client has a sore throat. 2. The client displays signs of sedation. 3. The client experiences a sudden increase in temperature. 4. The client demonstrates a lack of appetite.

3. The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process. CN: Reduction of risk potential; CL: Analyze

62. A client with a cerebral embolus is receiving streptokinase. The nurse should evaluate the client for which of the following expected outcomes of this drug therapy? 1. Improved cerebral perfusion. 2. Decreased vascular permeability. 3. Dissolved emboli. 4. Prevention of cerebral hemorrhage.

3. Thrombolytic agents such as streptokinase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or increase vascular permeability, nor do they prevent cerebral hemorrhage. CN: Pharmacological and parenteral therapies; CL: Evaluate

7. The nurse should teach the client with Graves' disease to prevent corneal irritation from mild exophthalmos by: 1. Massaging the eyes at regular intervals. 2. Instilling an ophthalmic anesthetic as prescribed. 3. Wearing dark-colored glasses. 4. Covering both eyes with moistened gauze pads.

3. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased. CN: Reduction of risk potential; CL: Synthesize

30. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate? 1. The procedure will result in enlargement of the pyloric sphincter. 2. The procedure will result in anastomosis of the gastric stump to the jejunum. 3. The procedure will result in removal of the duodenum. 4. The procedure will result in repositioning of the vagus nerve.

30. 2. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to the jejunum. The pyloric sphincter is removed, along with some of the stomach fundus. CN: Physiological adaptation; CL: Apply

A client diagnosed with a deep vein thrombosis has heparin sodium infusing at 1,500 units/h. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12-hour shift, how many milliliters of fluid will infuse? __________________________-mL.

360 mL CN: Pharmacological and parenteral therapies; CL: Apply

17. The nurse should assess a client with hypothyroidism for which of the following? 1. Corneal abrasion due to inability to close the eyelids. 2. Weight loss due to hypermetabolism. 3. Fluid loss due to diarrhea. 4. Decreased activity due to fatigue.

4. A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism. CN: Basic care and comfort; CL: Analyze

42. A client with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent: 1. Quality and quantity of food intake. 2. Type and amount of fluid intake. 3. Weakness, fatigue, and ability to get around. 4. Length and amount of menstrual flow.

4. A recent viral infection in a female client between the ages of 20 and 30 with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic thrombocytopenic purpura. It is important to ask whether the client's recent menses have been lengthened or are heavier. Determining her ability to clot can help determine her risk of increased bleeding tendency until a platelet count is drawn. Petechiae are not caused by poor nutrition. Because of poor food and fluid intake or weakness and fatigue, the client may have gotten bruises from falling or bumping into things, but not petechiae. CN: Reduction of risk potential; CL: Analyze

26. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? 1. "I should take my antacid before I take my other medications." 2. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." 3. "My antacid will be most effective if I take it whenever I experience stomach pains." 4. "It is best for me to take my antacid 1 to 3 hours after meals."

4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain. CN: Pharmacological and parenteral therapies; CL: Evaluate

46. A client who is taking acetylsalicylic acid (ASA) caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first? 1. Place the forearm under a running stream of lukewarm water. 2. Pat the injury with a dry washcloth. 3. Wrap the entire forearm from the wrist to the elbow. 4. Apply an ice pack for 20 minutes.

4. Aspirin has an antiplatelet effect, and bleeding time can consequently be prolonged. Intermittent use of ice packs to the site may stop the bleeding; ice causes blood vessels to vasoconstrict. Use of lukewarm water, patting the injury, and wrapping the entire forearm do not promote vasoconstriction to stop bleeding. CN: Pharmacological and parenteral therapies; CL: Synthesize

37. To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following? 1. Sit upright for 30 minutes after meals. 2. Drink liquids with meals, avoiding caffeine. 3. Avoid milk and other dairy products. 4. Decrease the carbohydrate content of meals.

4. Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine. CN: Basic care and comfort; CL: Synthesize

13. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: 1. Begin total parenteral nutrition. 2. Start a cutdown infusion. 3. Administer tube feedings. 4. Perform a tracheotomy.

4. Equipment for an emergency tracheotomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set, oxygen and suction equipment, and a suture removal set (for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not an expected possible treatment after thyroidectomy. Tube feedings are not anticipated emergency care. CN: Reduction of risk potential; CL: Synthesize

69. A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: 1. Administering aspirin as prescribed. 2. Encouraging green leafy vegetables in the diet. 3. Monitoring the client's prothrombin time (PT). 4. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR).

4. Heparin dosage is usually determined by the physician based on the client's aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium (Coumadin). CN: Pharmacological and parenteral therapies; CL: Create

18. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: 1. The effects of thyroid hormone replacement therapy and will diminish over time. 2. Related to thyroid hormone replacement therapy and will not diminish over time. 3. A normal part of having a chronic illness. 4. Most likely related to low thyroid hormone levels and will improve with treatment.

4. Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking serum thyroid hormone and thyroid-stimulating hormone levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not "normal." CN: Psychosocial integrity; CL: Analyze

49. The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why it is necessary to take steroids. Which is the nurse's best response? 1. Steroids destroy the antibodies and prolong the life of platelets. 2. Steroids neutralize the antigens and prolong the life of platelets. 3. Steroids increase phagocytosis and increase the life of platelets. 4. Steroids alter the spleen's recognition of platelets and increase the life of platelets.

4. ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the antibody-coated platelets, which are recognized as foreign bodies, so that the platelets live longer. The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis. CN: Pharmacological and parenteral therapies; CL: Apply

23. A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? 1. Conduct physical activity in the morning in order to be able to rest in the afternoon. 2. Have the family agree to perform the necessary yard work at home. 3. Give up jogging and substitute a less demanding hobby. 4. Incorporate periods of physical and mental rest in the daily schedule.

4. It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful. CN: Psychosocial adaptation; CL: Synthesize

77. A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care? 1. Administer pain medication. 2. Draw blood for laboratory studies. 3. Regulate the IV infusion. 4. Monitor the pulses. 5. Inspect the dressing.

4. Monitor the pulses. 5. Inspect the dressing. 3. Regulate the IV infusion. 1. Administer pain medication. 2. Draw blood for laboratory studies. The nurse should first monitor the popliteal and the pedal pulses in the affected extremity after arterial embolectomy. Monitoring peripheral pulses below the site of occlusion checks the arterial circulation in the involved extremity. The nurse should next inspect the dressing to be sure that the client is not bleeding at the surgical site. The nurse should next regulate the IV infusion to prevent fluid overload. Then the nurse should assess pain and administer pain medications as prescribed. Last, the nurse can obtain blood for laboratory studies. CN: Physiological adaptation; CL: Synthesize The Client with an Aneurysm

8. A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? 1. "The RAI stabilizes the thyroid hormone levels before a thyroidectomy." 2. "The RAI reduces uptake of thyroxine and thereby improves your condition." 3. "The RAI lowers the levels of thyroid hormones by slowing your body's production of them." 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced."

4. Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI. CN: Pharmacological and parenteral therapies; CL: Synthesize

98. Which intervention would be most likely to assist the client with hypertension in maintaining an exercise program? 1. Giving the client a written exercise program. 2. Explaining the exercise program to the client's spouse. 3. Reassuring the client that he or she can do the exercise program. 4. Tailoring a program to the client's needs and abilities.

4. Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program. CN: Psychosocial integrity; CL: Synthesize

52. The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? 1. Floor exercises. 2. Stretching. 3. Running. 4. Walking.

4. The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding. CN: Pharmacological and parenteral therapies; CL: Synthesize

73. The nurse observes that an older female has small-to-moderate, distended, and tortuous veins running along the inner aspect of her lower legs. The nurse should: 1. Apply a half-leg pneumatic compression device. 2. Suggest the client contact her physician. 3. Assess the client for foot ulcers. 4. Encourage the client to avoid standing in one position for long periods of time.

4. The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the physician at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time. CN: Health promotion and maintenance; CL: Synthesize

57. Which of the following indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: 1. Breathes in through the nose and out through the mouth. 2. Breathes in through the mouth and out through the nose. 3. Uses diaphragmatic breathing in the lying, sitting, and standing positions. 4. Takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

4. The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene. CN: Reduction of risk potential; CL: Evaluate

72. The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of: 1. Atherosclerosis. 2. Diabetes. 3. Vasospastic disorder (Raynaud's disease). 4. Thrombophlebitis.

4. The data suggest an increased risk of thrombophlebitis. The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for atherosclerosis include genetics, older age, and a highcholesterol diet. Risk factors for diabetes include genetics and obesity. Risk factors for vasospastic disorders include cold climate, age (16 to 40), and immunologic disorders. CN: Reduction of risk potential; CL: Analyz

38. A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which of the following responses by the nurse is most appropriate? 1. "Eating six meals a day is time-consuming, isn't it?" 2. "You will have to eat six small meals a day for the rest of your life." 3. "You will be able to tolerate three meals a day before you are discharged." 4. "Most clients can resume their normal meal patterns in about 6 to 12 months."

4. The symptoms related to dumping syndrome that occur after a gastrectomy usually disappear by 6 to 12 months after surgery. Most clients can begin to resume normal meal patterns after signs of the dumping syndrome have stopped. Acknowledging that eating six meals a day is time-consuming does not address the client's question and makes an assumption about the client's concerns. It is not necessarily true that a sixmeal- a-day dietary pattern will be required for the rest of the client's life. Clients will not be able to eat three meals a day before hospital discharge. CN: Physiological adaptation; CL: Synthesize

The Client with an Aneurysm The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan? 1. Food intake. 2. Fluid volume. 3. Skin integrity. 4. Tissue perfusion.

4. The underlying pathophysiology in this client is atherosclerosis. The findings from the assessment indicate the risk factors of smoking and high blood pressure. Therefore, tissue perfusion is a priority for health promoting education. The data do not support education that focuses on food or fluid intake. Although edema is a potential problem and could contribute to poor skin integrity, the edema will likely be resolved by the aneurysm repair. CN: Physiological adaptation; CL: Synthesize

70. In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should: 1. Restrict fluids. 2. Encourage deep breathing. 3. Assist the client to remain sedentary. 4. Use pneumatic compression stockings.

4. The use of pneumatic compression stockings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid intake, and administering anticoagulant medication as prescribed. Deep breathing would be encouraged postoperatively, but it does not prevent DVT. CN: Health promotion and maintenance; CL: Synthesize

67. The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following: 1. Turning every 2 hours. 2. Passive and active range-of-motion exercises. 3. Use of thromboembolic disease (TED) support hose. 4. Maintaining the client in the supine position.

4. Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities. CN: Reduction of risk potential; CL: Create

64. A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications? 1. Air embolus. 2. Fat embolus. 3. Stress fractures. 4. Thrombophlebitis.

4. Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system. CN: Health promotion and maintenance; CL: Analyze