HESI MEDSURG PRACTICE

A client is admitted to the hospital with severe lower left abdominal pain, nausea, vomiting, fever, and chills. Which nursing action has the highest priority? A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D. Administer IV fluids.

A Rationale: A client is showing signs of acute severe diverticulitis and is at risk for peritonitis and intestinal obstruction. The nurse should make the client NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.

A Rationale: Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client.

A Rationale: Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.

An 81-year-old client has emphysema. The client lives at home with a cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken. Which nursing action is indicated? A. Help the client determine ways to increase fluid intake. B. Obtain an appointment for the client to have an eye examination. C. Instruct the client to use oxygen at night and increase the humidification. D. Schedule the client for tests to determine his sensitivity to cat hair.

A Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization.

Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.

A Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing all care.

A Rationale: Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify the dose.

A Rationale: The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse take first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula.

A Rationale: The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.

The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? A. Around the waist B. At the inner aspect of the left stump C. At the outer aspect of the left stump D. At the left groin area

A Rationale: The waist is the anchor point for the bandage for an above the knee amputation.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to take for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions.

A Rationale: This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time.

A client is admitted to the hospital with severe lower left abdominal pain, nausea, vomiting, fever, and chills. Which nursing action has the highest priority? A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D. Administer IV fluids

A Rationale:A client is showing signs of acute severe diverticulitis and is at risk for peritonitis and intestinal obstruction. The nurse should make the client NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take? A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff.

A Rationale: Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositories to control itching. F. Use a douche with weak vinegar solution to decrease itching.

A,B,C,D Rationale:The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.

A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing actions for this client? (Select all that apply.) A. Assess lung sounds. B. Look for equal and bilateral expansion of the chest. C. Monitor skin color. D. Evaluate the need for suctioning. E. Tell the family the client is expected to fully recover. F. Make sure the ventilator alarms are set.

A,B,C,D,F Rationale: The outcome of the client is too early to relay to the family. The nurse must not offer false reassurance. The remaining actions are correct for a client on a ventilator.

The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) A. Apply heat packs to your knees as needed for pain. B. Support your knees while you are in bed with a pillow or a rolled towel. C. Take 1000 mg of acetaminophen every 4 hours, as needed for pain. D. Walk no less than 3 miles every day. E. Get 7 to 8 hours of sleep every night. F. Eat a balanced diet, including fish with Omega-3 fatty acids

A,B,E,F Rationale:The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6 g/per day. The best type of exercise does not place additional stress on the knee joints, such as biking or swimming. Apply heat to increase circulation and ice packs to decrease swelling. Support to the knees can take the strain off of the joint. Getting rest will help with coping with the pain of the disease. Eating a balanced diet may help with weight loss; additional weight places strain on the joint.

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly.

A,C,D Rationale: Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis.

The nurse is preparing teaching for nursing students who are participating in a flu vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.) A. Health care personnel B. Those who are allergic to eggs C. Individuals who are over 50 years old D. Individuals with chronic health conditions E. Those who live in nursing homes F. Infants under 6 months of age

A,C,D,E Rationale: The current recommendation is those who are allergic to eggs can receive the flu vaccine if it is administered in a healthcare environment that can quickly deliver treatment for anaphylaxis. Infants over 6 months van receive the flu shot, but not under 6 months. The remaining options are recommended to receive the flu vaccine.

For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.) A. Dyspnea B. B/P 168/92 mm Hg C. Chest pain D. Anxiety E. O2 saturation of 98% F. Blue nail beds

A,C,D,F Rationale: For the client experiencing an air embolism, the nurse will see hypotension and not hypertension. The O2 saturation will also fall with an air embolism. The remaining are signs of an air embolism.

The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. The client has a carpal spasm when taking a blood pressure. C. On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7. D. The client states that she will continue to drink alcohol after going home.

B Rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? A. Bilateral jugular venous distention B. Oral temperature of 102°F C. Intermittent focal motor seizures D. Intractable pain in the cervical region

B Rationale: Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow

B Rationale: Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.

B Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required

B Rationale: The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed

B Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D

The clinic nurse is preparing to teach a client about having a cardiac catheterization. What assessment must the nurse include in the teaching plan? A. "Do you have glaucoma?" B. "Do you take any medication for Type II diabetes?" C. "Is your advance directive in order?" D. "Do any of your family members have heart disease?"

B Rationale: The iodine dye from the catheterization and metformin can cause the client to develop lactic acidosis. Metformin is held 24 hours before the procedure and up to 48 hours after the procedure. There are no risks for those who have glaucoma. Having an advance directive in place is the standard of care. History of heart disease helps establish risk factors. Since the client is preparing for a heart catheterization, the client has the disease

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

B Rationale: The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's next action? A. Note the size of the stain in the chart. B. Circle the stain with an ink pen. C. Remove the dressing to assess the source of the bleeding. D. Place a pressure dressing on the existing dressing.

B Rationale:By circling the existing stain upon admission to the unit, the nurse can then assess any increase, though subtle, in the amount of drainage over time. The size of the stain will need to be noted in the chart, but it is not the first action. The nurse removes the dressing under the prescription of the health care provider or in an emergency. Neither of those conditions exist in the question. The dressing in place is an absorbent dressing. There is no need for a further dressing until the existing dressing becomes saturated.

The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which action should the nurse take first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation.

B Rationale:Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria

B Rationale:Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia

B Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.) A. Place the client in the supine position. B. Assess airway and suction secretions as needed. C. Change the client's position every 2 hours. D. Avoid mouth care, to avoid stimulating a seizure. E. Monitor for drainage from the ears.

B,C,E Rationale: The client should be at least sitting at a 45 degree angle to avoid aspiration and increased intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time. The remaining actions are appropriate for the client with a GCS score of 5.

The clinic nurse is teaching a client newly diagnosed with Raynaud's Syndrome. What instructions will the nurse include in the client's teaching plan? (Select all that apply.) A. Place your hands in 130°F/54.4°C water until warmed through. B. Wear warm clothing and socks when you are cold. C. Use finger guards when using a knife to avoid cutting your hands. D. Take your medication only when you feel the tingling in your fingers. E. Avoid stressful situations at work and in your home life.

B,C,E Rationale: Water at 130°F/54.4°C can cause burns at 30 second exposure. Because of the numbness and tingling the client may not be able to sense burning. Vasodilators are often prescribed for these clients, especially during the cold months. The therapy needs to be continuous for the maximum effect. The remaining instructions will benefit the client with Raynaud's.

The nurse is providing care to a client admitted with asthma whose theophylline level is 25 mcg/mL. What findings will the nurse be looking for in the client's assessment? (Select all that apply.) A. Pulse of 54 bpm B. Restlessness C. Tremors D. Blue nail beds E. Palpitations

B,C,E Rationale: Theophylline toxicity occurs when the blood level exceeds 20 mcg/mL. Signs of toxicity include restlessness, nervousness, tremors, palpitations, and tachycardia. A low pulse rate and blue nail beds are not associated with theophylline toxicity.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.

C Rationale: A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin

C Rationale: All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census

C Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which action should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.

C Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years.

C Rationale: Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib

C Rationale: The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.

A 62-year-old client who lives alone tripped on a scatter rug resulting in a fractured hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment B. Renal osteodystrophy resulting from chronic kidney disease (CKD) C. Osteoporosis resulting from declining hormone levels D. Cerebral vessel changes causing transient ischemic attacks

C Rationale: The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is not a common condition of older people but is associated with CKD. Although option D may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

C Rationale:The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction

D Rationale: CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes.

D Rationale: Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse take first? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider.

D Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high-carbohydrate foods. B. Decrease intake of fat-soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake.

D Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites. Options A, B, and C will not affect fluid retention.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

D Rationale: Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery."

D Rationale: The outcome of learning is best demonstrated when the client not only verbalizes an understanding but also provides a return demonstration. A 14-year-old client may or may not follow through with option A, and there is no measurement of learning. Option B may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In option C, the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.

Which nursing action is necessary for the client with a flail chest? A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing.

D Rationale: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph.

The nurse assesses a client who has been prescribed furosemide for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave

D Rationale:A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia.

The nurse notes for the client undergoing peritoneal dialysis during the outflow phase the draining dialysate suddenly stops. The outflow is one liter less than the inflow at this time. What is the next nursing action? A. Take the client's blood pressure. B. Take the client's weight. C. Call the health care provider (HCP). D. Have the client change positions.

D Rationale:The outflow should match the inflow. With repositioning fluid trapped within the peritoneum may be repositioned to the proximity of the abdominal catheter. While the vital signs and the weight may support the additional fluid, they do not address the cause of the reduced outflow. At this time, there is no medical emergency to notify the HCP.