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Using the Parkland Formula, calculate the hourly rate of fluid replacement with LR during the first 8 hours for a client weighing 75 kg with total BSA burn of 40%. _____mL/hr

750 mL/hour - Formula: 4 mL x kg x TBSA - Give half over the first 8 hours and the second half over the next 16 hours.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.

ANS: B Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

A client with an electrical burn is being resuscitated with fluids. The nurse reports a decrease in urine output from 50 mL/hr to 15 mL/hr. Which order does the nurse question?

Furosemide 40 mg IV

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials?

Reduction of bacterial growth in the wound and prevention of systemic sepsis

The nurse is providing care for a burn patient who recently received a graft. On assessment of the patient's wound, redness, and swelling as well as some foul-swelling drainage is noted. What does the nurse suspect? a. partial thickness burn b. local infectionof burn wound c. failure of the graft d. systemic sepsis

b

Over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. Lab values include a normal platelet level. Which type of infection does the nurse suspect? a .viral b. fungal c. gram positive bacteria d. gram negative bacteria

c

During the resuscitation postburn phase, which route is used to administer morphine for pain relief?

Intravenous

A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection?

Occasional diarrhea

A client receives a prescription for collagenase (Santyl) for treatment of burns. To decrease the risk of infection, the nurse expects what else to be included on the client's plan of care?

Polysporin powder

How does the nurse determine accurate calorie requirements for a client with burns?

Using indirect calorimetry

66. Local tissue resistance to electricity varies in different parts of the body. Which tissue has the most resistance? a. Skin epidermis b. Tendons and muscle c. Fatty tissue d. Nerve tissue and blood vessels

a

70. A patient has sustained a severe burn greater than 30% TBSA. What is the best way to assess renal function in this patient? a. Measure urine output and compare this value with fluid intake. b. Weigh the patient every day and compare that to the dray weight. c. Note the amount of edema and measure abdominal girth. d. Assist the patient with a urinal or bedpan every 2 hours.

a

44. The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. The airway b. Cardiac output c. Fluid replacement d. Patient comfort

a

22. Which type of burn destroys the sweat glands, resulting in decreased excretory ability? a. Superficial b. Partial thickness c. Full thickness d. Deep full thickness

c

21. Which type of burn wound damages the epidermis, dermis, fascia, and tissues? a. Superficial b. Partial-thickness c. Full thickness d. Deep full thickness

d

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B)Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C)Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D)Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A)Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A)Ischemia B)Referred pain C)Cellulitis D)Venous thromboembolism (VTE)

A)Ischemia

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

A. In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voidin

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. d. Its going to be really hard but I will stop smoking.

ANS: A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.

A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetals angina c. Diabetes mellitus d. Chronic kidney disease

ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions would not affect the clients treatment.

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

ANS: C With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater han 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Gather appropriate equipment and prepare for an emergency airway.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this clients teaching? a. Stroke the inner aspect of your thigh to initiate voiding. b. Use a clean technique for intermittent catheterization. c. Implement digital anal stimulation when your bladder is full. d. Tighten your abdominal muscles to stimulate urine flow.

ANS: D In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the clients recovery process, they are not as important as skin closure to decrease the clients risk for infection.

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.

A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the clients cheek.

ANS: D The string should be attached to the clients cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the clients airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

ANS: D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

B. Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Range-of-motion exercises B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

C. Fluid resuscitation The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for this client? A) 100% O2 via an arousal mask B) Oxygen via nasal cannula 6L/minute C) Oxygen via nasal cannula at 15L/minute D) 100% Oxygen via a tight-fitting NRB face mask

D) 100% Oxygen via a tight-fitting NRB face mask

A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus rhythm with premature ventricular contractions

These are the characteristics of sinus tachycardia.A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

29. What is the primary reason to prevent infection with burn injuries? a. Prevent extensive scar formation b. Avoid sepsis c. Avert worsening of pain d. Avoid fever and inflammation

b

39. A patient in the burn intensive care unit weighed 80 kg (preburn weight). The provider orders titration of IV fluid to achieve 0.5 mL/kg/hr urine output. What is the minimal hourly urine output for this patient? a. 30 mL/hr b. 35 mL/hr c. 40 mL/hr d. 45 mL/hr

c

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.

ANS: A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. Reposition the client every 2 hours. b. Teach the client to perform deep-breathing exercises. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath.

ANS: A, C, D The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the clients level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

ANS: A, C, E The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full- thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

ANS: A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called battle sign and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

ANS: A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. Ill read the nutritional labels on food items for salt content. b. I will drink at least 3 liters of water each day. c. Using salt in moderation will reduce the workload of my heart. d. I will eat oatmeal for breakfast instead of ham and eggs. e. Substituting fresh vegetables for canned ones will lower my salt intake.

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day.

A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

ANS: A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow- up care for victims of rape, child abuse, and domestic violence e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow- up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching? a. Walk until you become short of breath, and then walk back home. b. Gather everything you need for a chore before you begin. c. Pull rather than push or carry items heavier than 5 pounds. d. Take a walk after dinner every day to build up your strength.

ANS: B A client who has heart failure should be taught to conserve energy. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. The client should not walk until becoming short of breath because he or she may not make it back home. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

ANS: B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. A low-protein diet will help the liver rest and will restore liver function. b. Less protein in the diet will help prevent confusion associated with liver failure. c. Increasing dietary protein will help the client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the clients dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)

ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries

A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

ANS: B Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such.

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

ANS: B Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

ANS: B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the clients support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the clients obligations

ANS: B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home

ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.

ANS: B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the clients family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen The nurse would be violating privacy laws by sharing the clients status with the brother.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an Ask the nurse booth at the pet store.

ANS: B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

ANS: B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with highe blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

ANS: B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control

ANS: B Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching? a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache. b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches. c. This drug will relieve the pain during the aura phase soon after a headache has started. d. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.

ANS: B Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client

ANS: B By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the clients neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

ANS: B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. Are you taking a nonsteroidal anti-inflammatory drug? b. Do you have a mental health disorder? c. Are you able to swallow medications? d. Do you smoke cigarettes or any illegal drugs?

ANS: B Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching? a. Ill be able to carry heavy loads after 6 months of rest. b. I will have my teeth cleaned by my dentist in 2 weeks. c. I must avoid eating foods high in vitamin K, like spinach. d. I must use an electric razor instead of a straight razor to shave.

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this clients postoperative instructions? a. Only lift items that are 10 pounds or less. b. Wear your brace whenever you are out of bed. c. You must remain in bed for 3 weeks after surgery. d. You are prescribed medications to prevent rejection.

ANS: B Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure? a. Do you have trouble breathing or chest pain? b. Are you able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurseneeds to determine whether the clients activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the clients heart failure.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

ANS: B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

A home health care nurse is visiting an older client who lives alone after being discharged from the hospita after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

ANS: B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the clients medication lists.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95 F (35 C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky; most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the clients chart. d. Notify the surgeon immediately.

ANS: B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the clients perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

ANS: B Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night. b. My shoes fit really tight lately. c. I wake up coughing every night. d. I have trouble catching my breath.

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion

ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond? a. The prosthetic valve places you at greater risk for a heart attack. b. Blood clots form more easily in artificial replacement valves. c. The vein taken from your leg reduces circulation in the leg. d. The surgery left a lot of small clots in your heart and lungs.

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

ANS: B The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication.

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this clients temperature or improve the clients symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching? a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.

ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.

ANS: B The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

ANS: B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the clients chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the clients position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

ANS: B The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this clients inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching? a. Use a soft-bristled toothbrush and avoid flossing. b. Avoid large crowds and people who are sick. c. Change positions slowly to avoid hypotension. d. Check your heart rate before taking the medication.

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the clients magnesium level. b. Assess the clients sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information: Feels frightened/Cant catch my breath. Shortness of breath for 20 minutes Laboratory Analysis/Physical Assessment pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

ANS: B This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the clients presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

ANS: B This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the clients cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self- management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.

ANS: B Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

ANS: B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are no related.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

ANS: B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the clients spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the clients spouse to the hospitals crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

ANS: B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

ANS: B, C, D The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I can continue to take antacids to relieve heartburn. b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

ANS: B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

ANS: B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says Strenuous? Whats that? d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia

ANS: B, D, E Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

ANS: B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the clients blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.) a. Increase your intake of caffeinated beverages. b. Incorporate physical exercise into your daily routine. c. Avoid all alcoholic beverages. d. Participate in a smoking cessation program. e. Increase your intake of fruits and vegetables.

ANS: B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respiration f. decreased urinary output

ANS: B, D, F Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

ANS: B, E The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years experience on this floor

ANS: C The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104 F

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

A nurse is triaging clients in the emergency department. Which client should be considered urgent? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102 F d. A 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative- pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation.

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

ANS: C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

ANS: C A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%

ANS: C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching? a. Place a warm compress on your forehead at the onset of the headache. b. Wear dark sunglasses when you are in brightly lit spaces. c. Lie down in a darkened room when you experience a headache. d. Set your alarm to ensure you do not sleep longer than 6 hours at one time.

ANS: C At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

ANS: C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the clients previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond? a. You should make peace with your family. b. This is not unusual. My family hates me too. c. I will help you identify a support system. d. You must attend Alcoholics Anonymous.

ANS: C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the clients concerns by brushing off the clients comment. Attending AA may be appropriate, but this response doesnt address the clients concern. Making peace with the clients family may not be possible. This statement is not client-centered.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond? a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the clients question.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure? a. I have been drinking more water than usual. b. I am awakened by the need to urinate at night. c. I must stop halfway up the stairs to catch my breath. d. I have experienced blurred vision on several occasions.

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or catching their breath. This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

ANS: C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the clients creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

ANS: C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

ANS: C During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It means it is caused by another disease. b. It means it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension.

ANS: C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

ANS: C For the nurses safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140 F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

ANS: C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.

ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self- worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. I should leave the drainage bag above the level of my abdomen. b. I could flush the tubing with normal saline if the flow stops. c. I should take a stool softener every morning to avoid constipation. d. My diet should have low fiber in it to prevent any irritation.

ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

ANS: C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a smart pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs: HR: 110BPM, BP:112/68, RR: 20, Oxygen SAT: 94%, Pain: 3/10 LAB: RBC:5,000,000; WBC: 10,000; Platelet: 200,000 Wound assessment: Left chest burn wound 3cm X 2.5cm X 0.5cm wound bed pale with surround tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the clients skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

ANS: C Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond? a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this clients needs.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. If my climbing partner cant think straight, we should descend to a lower altitude. b. I will ask my provider about medications to help prevent acute mountain sickness. c. My partner and I will plan to sleep at a higher elevation to acclimate more quickly. d. I will drink plenty of fluids to stay hydrated while on the mountain.

ANS: C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation.

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM) The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

ANS: C The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Wound Assessment Bilateral leg burns present and leather- like appearance. No blisters or bleeding are present. Client rates pain at 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

ANS: C The characteristics of the clients wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tigh clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

ANS: C The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a persons risk for developing liver cancer.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale

ANS: C This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the clients vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, bu calling the Rapid Response Team takes priority over positioning.

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings.

ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the clients belongings and personal space.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

ANS: C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinalfluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. A good abrasive pumice stone will keep my feet soft. b. Ill always wear shoes if I can buy cheap flip-flops. c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

ANS: C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip- flops may not fit well and wont offer much protection against injury.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. I will explore other ways besides intercourse to please my partner. b. I will not be able to have an erection because of my injury. c. Ejaculation may not be as predictable as before. d. I may urinate with ejaculation but this will not cause infection. e. I should be able to have an erection with stimulation.

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the clients partner will not get an infection.

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

ANS: D A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

ANS: D ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical ventilator. How should the nurse respond? a. You should discuss this with your family and health care provider. b. Why are you afraid of being placed on a breathing machine? c. Using the incentive spirometer each hour will delay the need for a ventilator. d. What would you like to be done if you begin to have difficulty breathing?

ANS: D ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client mus indicate in the advance directive what is to be done when breathing is no longer possible without intervention.

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

ANS: D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease? a. His mask-like face makes it difficult to communicate, so I will use a white board. b. He should not socialize outside of the house due to uncontrollable drooling. c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions.

ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

ANS: D Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if youd like.

ANS: D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes. b. Im glad I get energy assistance so my house isnt so cold. c. My daughter makes sure I have plenty of lotion for my feet. d. My hands shake when I try to do things requiring coordination.

ANS: D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching? a. Avoid drinking more than 3 quarts of liquids each day. b. Eat six small meals daily instead of three larger meals. c. When you feel short of breath, take an additional diuretic. d. Weigh yourself daily while wearing the same amount of clothing.

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching? a. Avoid taking aspirin or aspirin-containing products. b. Increase your intake of foods that are high in potassium. c. Hold this medication if your pulse rate is below 80 beats/min. d. Do not take this medication within 1 hour of taking an antacid.

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

ANS: D Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the clients chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the clients anxiety.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical ventilation.

ANS: D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on- scene personnel regarding the ability to take more clients.

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

ANS: D The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you. c. Do you want to come off the transplant list? d. Would you like information about advance directives?

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the clients concerns instead of pushing the clients issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the persons next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

ANS: D The clients swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a. That feeling will gradually go away as you get used to the treatment. b. You probably need to see a psychiatrist to see if you are depressed. c. Do you need help from social services to discuss financial aid? d. Tell me more about your feelings regarding hemodialysis treatment.

ANS: D The nurse needs to explore the clients feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the clients feelings first. Telling the client his or her feelings will go away is dismissive of the clients concerns.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion.

ANS: D The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The clients headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

ANS: D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the clients record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.

ANS: D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

ANS: D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the familys trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the clients death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

ANS: D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

ANS: D, E The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

An older client has suffered a 45% body surface area burn from a house fire. Which complication is the client at greater risk of developing because of age-related changes?

Acute kidney injury

The triage nurse has a suggestion for improving response in the next mass casualty event. Which option does the nurse use to introduce this idea? Administrative review Hospital suggestion box Medical Reserve Corp Supervisor

Administrative review The triage nurse uses the Administrative review committee to present suggestions to improve responses in the next mass casualty event. The goal of the administrative review is to discern what went right and what went wrong during activation and implementation of the emergency preparedness plan. In this way, changes can be made.The hospital suggestion box and the supervisor are not the most effective ways to implement change in this situation. The purpose of the Medical Reserve Corp is to help with staffing and providing care, not revising policy or protocol.

How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? The patient states he is dizzy and weak. The nurse notes dyspnea. The patient has a heart rate of 42 beats/min. The monitor shows an increase in heart rate.

An expected outcome after the administration of atropine is an increased heart rate. By definition, the bradydysrhythmia has resolved when the heart rate is greater than 60 beats/min.Dizziness and weakness indicate symptoms of decreased cerebral perfusion and intolerance to the bradydysrhythmia. Dyspnea indicates intolerance to the bradydysrhythmia. A heart rate of 42 beats/min after atropine has been given indicates that bradycardia is unresolved.

An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? 1. An incision is made through the burn eschar. 2. Anesthesia is administered to the client for pain. 3. Analgesia is not administered with this procedure. 4. The procedure is performed in the surgical suite.

An incision is made through the burn eschar. - Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the client with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relive the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the client as the nerve endings are destroyed due to the injury. The client is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing auto-contamination? A. Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area. B. Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings. C. Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D. Warning the client's family not to bring fresh fruit and vegetables or house plants into the client's environment.

Answer: A Rationale: Auto-contamination is the movement of organisms from one body area on a client to another body area. The use of sterile versus clean gloves for routine wound care varies by agency and is a matter of debate. Regardless of sterility, change gloves when handling wounds on different areas of the body and between handling old and new dressings. So, if the nurse changed to fresh gloves after removing old dressings but kept the fresh gloves on while dressing all the burn wound areas, he or she greatly increases the risk for translocating organisms from one burn wound to another, resulting in auto-contamination. Responses C and D address cross-contamination that occurs between people.

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury? A. Hot liquid scald burn B. Liquid chemical burn C. Electrical burn D. Dry heat burn

Answer: D Rationale: Direct injury to the lung from contact with flames, scalding hot liquids, liquid chemicals, or electrical current rarely occurs. Rather, respiratory problems are caused by superheated air, steam, toxic fumes, or smoke. Although it is possible for an electric current to pass through the lungs, it seldom causes injury.

A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? Assessment Communication Priority setting Technical and procedural skills

Assessment The first core competency that is essential in this situation is assessment and is the foundation of the ED nurse's skill base to determine normal from abnormal client findings.Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation. Until the client has been accurately assessed, care can begin.

A client was brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to get out of a car fire. The nurse should implement which nursing actions for this client? A) Restrict fluids B) Assess for airway patency C) Administer oxygen as prescribed D) Place a cooling blanket on the client E) Elevate extremities if no fractures are present F) Prepare to give oral pain medication as prescribed

B) Assess for airway patency C) Administer oxygen as prescribed E) Elevate extremities if no fractures are present

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Base on this level, the nurse would anticipate noting which sign in the client? A) Coma B) Flushing C) Dizziness D) Tachycardia

B) Flushing

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide most reliable indicator for determining the adequacy? A) vital signs B) UOP C) Mental status D) Peripheral pulses

B) UOP

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A)Silver sulfadiazine 1% (Silvadene) water-soluble cream B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C)Silver nitrate 0.5% aqueous solution D)Acticoat

B)Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L (3.2 mmol/L) Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) Chest x-ray report showing right middle lobe consolidation

B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) A BNP of 760 pg/ml (760 ng/dL) is consistent with a diagnosis of heart failure. BNP is produced and released by the ventricles when the client has fluid overload as a result of HF. A normal BNP value is less than 0-99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L).Hypokalemia (serum potassium level of 3.2 mEq/L [3.2 mmol/L]) may occur in response to diuretic therapy for HF, but may also occur with other conditions. It is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

B. "Burn wound conditions promote the growth of Clostridium tetani." Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital. Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

The nurse is caring for a client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much now as in the beginning."

B. "I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem. The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse doesn't stare at the scars as much all indicate that the client is coping effectively. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

B. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" Smoke inhalation and facial burns are associated with airway inflammation and obstruction; the client with difficulty breathing needs immediate assessment and intervention. Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

B. Intravenous During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? A. Black-brown coloration B. Painful C. Moderate to severe edema D. Absence of blisters

B. Painful Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters. A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply.) A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B. Performs frequent handwashing D. Performs gloved dressing changes E. Uses disposable dishes Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible. Cushions and rugs are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first? Bee sting on the jawline with an inability to swallow Bite on the hand from a stray dog with minimal bleeding Severe muscle cramps after running Suspected spider bite with a red and swollen forearm

Bee sting on the jawline with an inability to swallow The nurse would first assess the client who was stung by a bee and is unable to swallow. This client is showing potential signs of respiratory compromise and needs immediate assessment and intervention.Neither the client with the spider bite nor the dog bite client have life-threatening injuries. The current tetanus immunization status would be checked for each client and administered if needed. The client bitten by the dog might also require rabies vaccination follow-up. The client with muscle cramping after running would need to be assessed thoroughly for the potential of heat-related injury although this does not appear to be a life threat at this time.

A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety? Blood and body fluid precautions Metal detector screening of the client Placement of a security guard Use of a positive air-purifying respirator (PAPR)

Blood and body fluid precautions The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids.Screening of the client with a metal detector, appointing a security guard, and use of a PAPR, although beneficial are not minimum Standard Precautions issues.

An adult client was burned in an explosion. The burn initially affected the client's entire face. and the upper of of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would bet the extent of the burn injury? A) 18% B) 24% C) 36% D) 48%

C) 36%

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm/Hg, a pulse rate of 110/beats per minute, and a urine output of 20ml over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A) Transfusing 1 unit of packed RBCs B) Administering a diuretic to increase urine output C) Increasing the amount of IV fluid D) Changing the IV LR to 5% dextrose

C) Increasing the amount of IV fluid

The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A)Emergent B)Immediate resuscitative C)Acute D)Rehabilitation

C)Acute

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A)Instruct the patient to keep the wound site in a dependent position. B)Administer PRN analgesia as ordered. C)Assess the patients peripheral pulses distal to the dressing. D)Assist with passive range of motion exercises to set the new dressing.

C)Assess the patients peripheral pulses distal to the dressing.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A)Obtain an order to reduce the rate of the patients IV fluid infusion. B)Report the patients early signs of acute kidney injury (AKI). C)Recognize that the patient is experiencing an expected onset of diuresis. D)Administer sodium chloride as ordered to compensate for this fluid loss.

C)Recognize that the patient is experiencing an expected onset of diuresis.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A)To prevent neuropathies B)To prevent wound breakdown C)To prevent contractures D)To prevent heterotopic ossification

C)To prevent contractures

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of respiratory complications but will not decrease pressure on the clients hips and sacrum.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

C. "How have you handled similar situations before?" Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective. "Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A. "Do you want to pray about it?" B. "I know, and you will have to learn to adapt to a new body image." C. "Tell me more." D. "There must be a reason."

C. "Tell me more." Asking the client to tell the nurse more encourages therapeutic grieving. Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving; the nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason" minimizes the grieving process by not allowing the client to express his or her concerns.

Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room? A. Use space heaters to reduce electrical costs. B. Check water temperature before bathing. C. Do not smoke in bed. D. Wear sunscreen.

C. Do not smoke in bed. Smoking in bed increases the risk for fire because the person could fall asleep. Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet. Sunscreen is advised to prevent sunburn.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Intense pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

C. Reduced self-image In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

C. Scar tissue formation Indicators of wound healing include the presence of granulation, re-epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A. Bowel sounds are absent. B. The pulse oximetry level is 91%. C. The serum potassium level is 6.1 mEq/L. D. Urine output since admission is 370 mL.

C. The serum potassium level is 6.1 mEq/L. An elevated serum potassium level can cause cardiac dysrhythmias and arrest, and so is of the most concern. Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. Urine output, 40 mL/hr Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.

Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? Select all that apply. Change the decorations in the home according to the season. Put the bed close to the window. Write out detailed instructions, and have the client read them over before performing a task. Ask the client what time he or she prefers to shower or bathe. Mark off the days of the calendar, leaving open the current date.

Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule.Directions to the client need to be short and uncomplicated, and not detailed.

What precautionary measure must individuals take to prevent fires? 1. While drinking alcohol, smoking must be done in an open area. 2. Space heaters must be placed on a cotton cloth. 3. Chimneys must be cleaned once in a year. 4. One smoke detector must be placed in the house.

Chimneys must be cleaned once in a year. - Chimneys must be cleaned once a year to avoid creosote accumulation, which is a highly flammable material. Clients must be advised not to smoke while drinking alcohol, as alcohol can cause drowsiness and a lit cigarette could be dropped. Clothing, bedding, and other materials should be kept away from space heaters. Smoke detectors must be placed in each bedroom and in stairwells.

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? Carry out artificial respirations. Clear the airway. Place a cervical collar. Realign the leg and check for pulse.

Clear the airway. The airway should first be cleared of any secretions or debris with a suction catheter or manually, if necessary. The primary survey for a trauma client is based on the mnemonic "ABCDE", with "A" being airway.A cervical collar will need to be applied and respiration will need to be assisted with a bag-valve-mask (BVM) connected to 100% oxygen source. Although the leg does not have a pulse, life threats must be addressed before limb threats.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? 1. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care 2. Recently admitted client with a high-voltage electrical burn 3. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed 4. Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr - An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% total body surface burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow. A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Which of these clients could be delegated to an unlicensed assistive personnel (UAP)? Client who has multiple left rib fractures and reports dyspnea Client who reports severe left anterior chest pain Client who has a femoral fracture with palpable distal pulses Client who is unconscious with massive aortic bleeding from the chest

Client who is unconscious with massive aortic bleeding from the chest The client who is unconscious and has massive aortic bleeding is unlikely to survive and would be "black-tagged" and assigned to a UAP for comfort.The client with rib fractures and dyspnea, the client with chest pain, and the client with a femoral fracture with palpable pulses are likely to survive and would not be delegated to licensed staff members.

The nurse is assigned to care for four clients. Which client does the nurse assess first? Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring, and is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated.Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with heart failure who is receiving dobutamine (Dobutrex) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Client with pericarditis who has a paradoxical pulse and distended jugular veins Client with rheumatic fever who has a new systolic murmur

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042

Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.

A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? Remove all lines and indwelling tubes. Cover the client with a sheet, leaving the face exposed. Call a chaplain or social worker to accompany the family. Tell the family that the client "is in a better place now." Dim the lights in the client's room.

Covering the client with a sheet, leaving the face exposed, and dimming the lights in the client's room are steps the ED nurse would take prior to the viewing. Sometimes by leaving the hands out from underneath the sheet it allows the family more "permission" to touch the client if they desire. The nurse's response needs to be one of empathy and dignity in all interactions.This death may be reportable as a medical examiner's case therefore, IV lines and tubes may need to be maintained. The nurse may ask the family if they want a chaplain or social worker. Statements to the effect that the client "is in a better place now" are inappropriate.

A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A)13% B)25% C)9% D)18%

D)18%

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A)Pain B)Fluid balance C)Anxiety and fear D)Airway management

D)Airway management

The nurse caring for a patient who is recovering from full-thickness burns is aware of the patients risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? A)Apply skin emollients as ordered after granulation has occurred. B)Keep injured areas immobilized whenever possible to promote healing. C)Administer oral or IV corticosteroids as ordered. D)Encourage physical activity and range of motion exercises.

D)Encourage physical activity and range of motion exercises.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A)Superficial partial-thickness B)Deep partial-thickness C)Full partial-thickness D)Full-thickness

D)Full-thickness

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A)Maintenance of bed rest to aid healing B)Choosing appropriate splints and functional devices C)Administration of beta adrenergic blockers D)Prevention of venous thromboembolism

D)Prevention of venous thromboembolism

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 150 mL/hr

D. Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr. The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

D. Planning additions to the standard nutritional pattern Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

D. Titrate fluid replacement. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Cardiopulmonary resuscitation (CPR) Administration of epinephrine Administration of oxygen

Defibrillation Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over. In asystole, there is no rhythm to interrupt. Therefore, this intervention is not used.If drug therapy fails to restore effective rhythm, CPR is initiated. Epinephrine is used to increase heart rate in asystole. Hypoxia may be a cause of cardiac arrest, so the administration of oxygen would be appropriate.

Which assessment does the nurse perform first on a client who has been admitted after an electrical injury with contact sites on the right hand and left foot?

Electrocardiography

Which dietary guideline must be followed for a client with a large burn area?

Feeding can be started within 4 hours of fluid resuscitation.

An occupational health nurse arrives at the scene where a client suffered a burn from a chemical splash. What is the priority intervention? Cover the client with a blanket. Apply gloves and remove the client from the scene. Flush the area with copious amounts of water. Call 911.

Flush with water - The priority is to flush with water to neutralize the chemicals and to decrease a heat reaction. This also decreases the chemical contact time, which is directly related to the degree of injury. It is important to call 911 after beginning the flush of the affected area, because the client has other needs that cannot be managed at the scene. Covering the client or removal from the area will not stop the burn process, so the priority action is to flush the burned area.

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? Forensic nurse examiner Physician or health care provider Psychiatric crisis nurse Police officer

Forensic nurse examiner The forensic nurse examiner is the best and most appropriate team member able to recognize evidence of abuse and to intervene on the client's behalf.Although the forensic nurse examiner is the best team member to provide care for this client, physicians or other health care providers or a psychiatric crisis nurse may also play a role in the client's care. Law enforcement may or may not be involved dependent on local laws.

The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? 1. Furosemide (Lasix) 2. Digoxin (Lanoxin) 3. Dopamine (Inotropin) 4. Morphine sulfate

Furosemide (Lasix) - Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. Digoxin may be used to strengthen the force of myocardial contractions in older adult clients. Dopamine may be given to increase cardiac output in older adult clients. Morphine sulfate may be indicated for pain management.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I need to avoid eating hamburgers." "I must cut out bacon and canned foods." "I won't put the salt shaker on the table anymore." "I need to avoid lunchmeats but may cook my own turkey."

Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first? Apply an ice pack to the stinger. Gently scrape out the stinger with a credit card. Inject the child with an epinephrine pen (EpiPen auto-injector). Remove the bee and save it for identification.

Gently scrape out the stinger with a credit card. The nurse first needs to quickly remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle.Once the stinger is removed, applying an ice pack to the area may decrease the pain in the area as well as venom distribution. Unless the child has had an allergic reaction in the past, an epinephrine pen would not be used. The bee does not need to be saved for identification.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? Give oxygen per facemask. Infuse lactated Ringer's solution at 150 mL/hr. Give morphine sulfate 4 to 10 mg IV for pain control. Insert a 14 Fr retention catheter.

Give oxygen per facemask. The nurse needs to first administer oxygen per face mask to the client. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first?

Give oxygen per nonrebreather mask at 100% Fio2.

Which factors are possible transmission routes for human immune deficiency virus (HIV)?Select all that apply. Breast-feeding Anal intercourse Mosquito bites Toileting facilities Oral sex

HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions.HIV is not spread by mosquito bites or by other insects. It is not transmitted by casual contact. Sharing toilet facilities does not cause transmission of HIV.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema

Heart failure The nurse will contact the health care provider if the client's history reveals specific information about cardiac or kidney problems, chronic alcoholism, substance abuse, or diabetes mellitus. Any of these problems can influence fluid resuscitation. A client's health history, including any preexisting illnesses, must be known for appropriate management. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction.Diverticulitis, hypertension, and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.

Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and get a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

An adolescent who experienced major burns two months ago is ready for discharge. Which statement best reflects that the child and family understand the discharge care? "I will apply cold packs to my arms three times a day for at least half an hour." "I really need to stick to the high-carbohydrate, high-calorie diet that I had in the hospital." "I will be so glad to be home and not need to wear this pressure covering on my arms anymore." "I will call my doctor if I have a fever or my arms have any drainage."

I will call my doctor if I have a fever or my arms have drainage. - The discharged client and family must be alert to signs and symptoms of infection and know to notify the physician if they occur. Pressure garments may need to be worn for up to two years. A high-protein diet rather than a high-carbohydrate diet is recommended to promote healing and recovery. Cold packs can damage new skin, so they would not be appropriate.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)

Ibuprofen (Motrin) The nurse questions an 82-year-old client with exacerbation of heart failure if the client is taking ibuprofen. Long-term use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism. It does not cause HF.

An HIV positive client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? Therapeutic highly active antiretroviral therapy (HAART) level Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot Positive Papanicolaou (Pap) test Improved CD4+ T-cell count and reduced viral load

Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication.Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? 1. Improved distal pulses 2. Reduced edema 3. Improved blood pressure 4. Reduced fluid resuscitation needs

Improved distal pulses - When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? Intramuscular Intravenous Sublingual Topical

Intravenous During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.When these agents (opioid drugs) are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

A client's burn injury was caused by a gasoline-fueled explosion. Which laboratory result does the nurse monitor closely for possible signs of organ injury?

Liver function tests

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight and turned as a unit.The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? The pacemaker spike falls on the T wave. Pacemaker spikes are noted, but no P wave or QRS complex follows. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. The patient demonstrates hiccups.

Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode.Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly. Demand pacing would cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker? Acetazolamide sodium (Diamox) Dexamethasone (Decadron) Lower altitude Oxygen therapy

Lower altitude The most effective intervention to manage serious altitude-related illness is gradual descent to a lower altitude.Diamox needs to be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Decadron can be administered during descent to help with symptoms, but is not the most effective treatment at this time. Oxygen is not the most effective treatment.

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)? 1. Moderate burn 2. Major burn 3. Minor burn 4. Severe burn

Moderate burn - Deep partial-thickness burns affecting 15% to 25% TBSA are classified as moderate burns. Partial-thickness burns affecting more than 25% of TBSA are classified as major burns. Deep partial-thickness burns affecting less than 15% of TBSA are considered minor burns. Burns are categorized as three types: major, minor, and moderate; there is no "severe" burn category.

A health care provider admitted a client with second and third degree burns over 60% of the body. Fourteen hours later, the client is receiving lactated Ringer's at 200 mL/hr. Which intervention is the priority at this time? Begin hourly range of motion. Monitor hourly urine output. Administer morphine sulfate prn. Assess burned areas for signs and symptoms of infection.

Monitor hourly urine output - Fluid resuscitation is a priority in the first 24 hours after a burn to prevent the onset of shock and system collapse. Urine output is the most readily available and reliable indicator for determining the adequacy of fluid replacement. Assessing for infection is important as are pain control and range of motion; however, during the shock phase, adequacy of fluid resuscitation should be the priority. Pain is a high priority after fluid resuscitation has begun.

A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? Allows the client to go home Checks blood alcohol levels Prepares the client for surgery Monitors the client

Monitors the client Blunt force injuries are from acceleration/deceleration forces, and can cause trauma to bones, blood vessels, and soft tissue. An injury may not be evident right away. A seat belt abrasion across the chest would alert the nurse to monitor closely for signs of potential internal injuries.While the nurse is monitoring the client, routine labs, including blood alcohol levels, may be obtained as well as computerized tomography (CT) scans. Based on these results, a decision regarding disposition will be made. Allowing the client to go home or preparing for surgery are not appropriate actions in this situation.

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

NS: A These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

NS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

NS: B Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

Which method must be employed during hydrotherapy for the debridement of a wound in the client with acid burns?

Nonviable tissue must be removed by forceps.

A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action?

Notify the Rapid Response Team.

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? Obtain a 12-lead electrocardiogram (ECG). Call for a portable chest x-ray. Obtain blood cultures from two sites. Give cefazolin (Kefzol) 500 mg IV.

Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic.A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit? Determine the usual alcohol intake for a client with cardiomyopathy. Monitor the pain level for a client with acute pericarditis. Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis.

Obtain daily weights for several clients with class IV heart failure. The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

What is the main role of the incident commander in a disaster? Call in extra staff Contact other facilities to arrange transfers Oversee the movement of clients through the system Notify the media of hospital capacity

Oversee the movement of clients through the system The main role of the incident commander in a disaster is to oversee the movement of clients through the system and assist in the organization of hospital-wide services. This activity rapidly expands hospital capacity, recruits paid or volunteer staff, and ensures the availability of medical supplies.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? Black-brown coloration Painful blisters Moderate to severe edema Absence of blisters

Painful blisters Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters.A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

Which factors indicate that a client's burn wounds are becoming infected? Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia

Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection.Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? Select all that apply. "I am 78 years old, and I was treated and cured of syphilis many years ago." "In 1986, I received a transfusion of platelets." "Seven years ago, I was released from a penitentiary." "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." "At 68, I am going to get married for the fourth time."

People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV.HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

When caring for a client after an escharotomy, how should the nurse explain to the client the reason for the procedure? The procedure permits blood to flow more easily. A skin graft will prevent scarring of the area. The procedure does not remove any tissue. The procedure will prevent infections.

Permits blood to flow more easily. - An escharotomy is performed to prevent arterial occlusion and resulting gangrene in a circumferential burn. Skin grafting will probably be necessary and scarring will result. Dead tissue may be excised and scrupulous wound care is necessary to prevent infection.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.

Place the client in high-Fowler's position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern

Planning additions to the standard nutritional pattern Consultation with the dietitian is required to help the client achieve the correct nutritional balance. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing.It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea

Positions the client to alleviate dyspnea The ICU nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

Which essential item is added to a personal-readiness supplies "go bag?" Fruits and vegetables Laptop computer Potable water Television

Potable water The "go bag" would contain 1 gallon of potable water per person per day. Potable water is drinking water and is required to prevent dehydration.Any foods included in a "go bag" would be nonperishable. Fruits and vegetables are perishable. A television would not be practical. A radio (battery-powered or hand-crank generated) would be better. A laptop computer would also not be practical. A "go bag" is a disaster supply kit for the home and automobile with clothing and basic survival supplies. It allows for a rapid response for disaster staffing coverage (Table 10-3). "Go bags" are needed for all members of the family, including pets, in the event the disaster requires evacuation of the community or for people to take shelter in their own homes.

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency Potential for infection transmission related to recurring opportunistic infections High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Secondary immune deficiencies are common and acquired as part of another disease or as a consequence of certain medications. The most common secondary immune deficiencies are caused by aging, malnutrition, certain medications, and some infections, such as HIV. The most common medications associated with secondary immune deficiencies are chemotherapy agents and immune suppressive medications, cancer, transplanted organ rejection, or autoimmune diseases.Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be secondary concern because Candida Albicans causes the mouth sores. Nutrition will be affected because of Candida Albicans; however, it is not a priority.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain

Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected.Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? Reduction of bacterial growth in the wound and prevention of systemic sepsis Prevention of cross-contamination from other clients in the unit Enhanced cell growth Reduced need for a skin graft

Reduction of bacterial growth in the wound and prevention of systemic sepsis The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection in burn wounds.Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury?

Scar tissue formation

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation Sloughing of grafts

Scar tissue formationIndicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation.Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts. INCORRECT

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L) The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? 1. Serum sodium levels 2. Hemoglobin levels 3. Alanine aminotransferase 4. Serum cholesterol levels

Serum sodium levels - Renal failure is caused due to the accumulation of large amounts of proteins and myoglobin in the kidneys as a result of muscle damage. Fluid resuscitation must be provided to the client in order to maintain a rate of 30 to 50 mL of urine output. Serum sodium levels, serum creatinine levels, and specific gravity of the urine must be monitored every hour after providing fluid resuscitation to the client—it helps to assess kidney function. Hemoglobin levels can be monitored in case of anemia; hemoglobin levels are not an indicator of kidney function. Alanine aminotransferase is an enzyme that is secreted by the liver and is an indicator of hepatic functioning.

Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Obtaining informed consent Setting the defibrillator to the synchronized mode Removing oxygen

Setting the defibrillator to the synchronized mode Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation.Cardioversion is usually performed starting at a lower rate of 120-200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.

What assessment data would lead the nurse to suspect that an inhalation injury may have occurred in a client with a severe burn? (Select all that apply.) Singed hair and eyebrows Decreased level of consciousness Decreased sputum production Excessive thirst Hoarse voice

Singed hair and eyebrows Decreased sputum production Hoarse voice

During a mass casualty, which injury receives care first? Abdominal evisceration Open fracture of the left forearm Sprained ankle Sucking chest wound

Sucking chest wound A sucking chest wound receives care first during a mass casualty. This type of injury is a red tag, or emergent, injury because it can be quickly resolved until further help can be given. Remember the A,B,Cs. Airway, breathing, and circulation always come first.The abdominal evisceration would be considered a black tag because of the amount of time it would require to provide adequate care. The open fracture of the left forearm would be yellow tagged. The injury requires care but can wait. The sprained ankle would be green tagged and considered "walking wounded."

The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Select all that apply. Palpitations Increased energy Chest discomfort Flushing of the skin Hypotension

Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? Analyze the ED response to the mass casualty incident. Follow up with survivors to determine the need for additional referrals. Initiate critical incident stress debriefing (CISD) for staff members. Take inventory and restock the ED with supplies and equipment.

Take inventory and restock the ED with supplies and equipment. The most important priority for the ED charge nurse at this time is to take inventory and restock the ED to return to normal operation.Analysis of the ED response, CISD debriefing, and follow-up with survivors and referrals can occur after the ED is restored to operational status.

Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 71-year-old patient admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min The 88-year-old patient admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min The 92-year-old patient admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min

The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 64-year-old has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training.The 71-year-old is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.

Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? The dietary worker hands the disposable meal trays to the LPN assigned to the client. The social worker encourages the client to verbalize about stressors at home. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. The health care provider orders vital signs, including temperature, every 8 hours.

The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection.Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk of infection.

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Methylprednisolone (Solu-Medrol) Nifedipine (Procardia) Ziconotide (Prialt)

The nurse anticipates that the primary health care provider will prescribe nifedipine for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). Nifedipine (Procardia), a calcium channel blocker, can be administered to treat AD and lower blood pressure. If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? "Do not wear high-heeled shoes." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Standing for long periods of time will help to prevent low back pain."

The nurse includes the following instructions into the low back pain client's teaching plan: don't wear high-heeled shoes, begin a regular exercise program, and keep the back straight and knees bent when lifting something. Wearing high-heeled shoes can increase back strain. Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects and will help to prevent back injury.The client needs to avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight needs to be kept within 10% of ideal body weight and not 50%.

A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? Autonomic dysreflexia CSF leak Fat embolism syndrome Paralytic ileus

The nurse is concerned that fat embolism syndrome has occurred. Fat embolism syndrome (FES) is characterized by chest pain, dyspnea, anxiety, and mental status changes. Petechiae may develop around the neck, over the upper chest, buccal mucosa, and conjunctiva. This is an emergency. The nurse must notify the primary health care provider immediately.Autonomic dysreflexia is not associated with lumbar laminectomies. It is seen in spinal cord injuries. A cerebrospinal fluid (CSF) leak is a concern with laminectomy but would not present with these symptoms. Paralytic ileus may occur but is associated with abdominal pain and distention.

The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Defibrillate the patient at 200 joules. Check the patient for a pulse. Cardiovert the patient at 50 joules. Give the patient IV lidocaine.

The nurse needs to first assess the patient to determine stability before proceeding with further interventions. If the patient has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone.If the patient is pulseless or nonresponsive, the patient is unstable and defibrillation is used and not cardioversion. Also, if the patient is pulseless, lidocaine may be given after defibrillation

The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? Administer atropine. Administer digoxin. Administer clonidine. Continue to monitor.

The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs.Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide. The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin Atropine Dobutamine Magnesium sulfate

The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin [Lovenox], warfarin [Coumadin], and novel oral anticoagualants, when nonvalvular, such as dabigatran [Pradaxa], rivaroxaban [Xarelto], apixaban [Eliquis], or edoxaban [Savaysa]) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

The nurse uses a paper clip bilaterally on each limb of the client with back pain to assess sensation. Both extremities may be checked for sensation by using a paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side.Gait is assessed by having the client walk. Mobility is assessed by determining the client's ability to move on his/her own, turn or perform ADLs. Strength is measured by having the client perform bilateral grips.

In teaching patients at risk for bradydysrhythmias, what information does the nurse include? "Avoid potassium-containing foods." "Stop smoking and avoid caffeine." "Take nitroglycerin for a slow heartbeat." "Use a stool softener."

The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia.Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

The nurse's first action when a client returns to the neurosurgical floor after having an anterior cervical discectomy is to assess the airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing.Administration of pain medication, ambulation, and assessing the client's ability to void are important but are not the highest priority.

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. Serosanguineous fluid oozes onto the neck dressing. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms.

The nursing assessment finding that is the greatest concern for a postoperative anterior cervical diskectomy client is the client reporting difficulty swallowing secretions. This may indicate swelling in the neck and the potential for compromise of the client's airway.Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? The patient is semi-recumbent in bed. Chest leads are placed as for the previous ECG. The patient is instructed to breathe deeply through the mouth. The patient is instructed to lie still.

The patient is instructed to breathe deeply through the mouth. While obtaining a 12-lead ECG, remind the patient to be as still as possible in a semi-reclined position, breathing normally. Any repetitive movement will cause artifact and could lead to inaccurate interpretation of the ECG. Normal breathing is required or artifacts will be observed, perhaps leading to inaccurate interpretation of the ECG.Placing the patient in a semi-reclined position is correct and does not require the nurse to intervene. ECGs are valid when electrode placement is identical at each test. The patient must lie still to avoid artifacts and inaccurate interpretation of the ECG.

Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid talking on a cell phone. Avoid operating electrical appliances over the pacemaker. Avoid sexual activity. Do not take tub baths.

The patient needs to avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction.It is not necessary to avoid a telephone or a cell phone, but the patient would keep cellular phones at least six inches (15 centimetres) away from the generator and with the handset on the ear opposite the side of the generator. Radio transmitter towers, arc welding, and strong electromagnetic fields may pose a hazard. No hazard exists with sexual activity. Bathing and showering are permitted.

A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Synchronized cardioversion Electrophysiology studies (EPS) Anticoagulation Radiofrequency ablation therapy

The patient's rhythm has stabilized but because of the risk for thromboembolism related to AF, anticoagulation is necessary.Cardioversion is not needed at this time. EPS are indicated for recurring, symptomatic dysrhythmia. Ablation therapy is ordered for recurring and symptomatic atrial fibrillation.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm.Auscultating bowel sounds is important since paralytic ileus can develop from a SCI; however this is not the priority intervention. Beginning bladder retraining and monitoring the nutritional status will be important for adequate healing and progress to rehabilitation. However, these interventions can be delayed until major life threats are addressed.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? Bowel sounds are absent. The pulse oximetry level is 91%. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). Urine output since admission is 370 mL.

The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest.Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Dry mouth Slow heart rate Tingling feelings Warm sensation

The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol (Inderal) may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider.Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. Blurred vision Tachycardia Fatigue Serum digoxin level of 1.5 ng/ml (1.92 nmol/L) Anorexia

The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." This was caused by my child getting too many x-rays

The statement that demonstrates that the newly diagnosed client with MS correctly understands the pathophysiology of the disease is "parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system.The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

The statement that indicates the client correctly understands preoperative teaching of a microdiskectomy is "I can go home the day of the procedure." A microdiskectomy is considered minimally invasive surgery (MIS) and does not typically require an inclient hospital stay.The client who undergoes a minimally invasive surgery does not have to wait 48 hours after the procedure to return home, will not have a drain in place after the procedure, and will not need to wear special stockings after the procedure. These steps are used in the case of traditional open laminectomy, not MIS.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. Titrate fluid replacement.

Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values.A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

During the shock phase of the burn injury in a severely burned client, which assessment findings indicate that the client is receiving adequate fluid volume replacement? Restless, confused as to time and place, urine output 20 mL/ hr, and weight gain of 5 lb Bounding pulse, rales on expiration, weight gain >5 lb/24 hrs Urine output 45 mL/hr, BP 100/60, and oriented to person and place Weak pulses, BP 85/50, pulse 120, and hematocrit 50%

Urine output 45 mL/hr, BP 100/60, and oriented to person and placeFluid replacement is considered adequate when urine output is 30-50 mL/hr or 0.5 mL/kg/hr, blood pressure is stable, pulses are palpable, central venous pressure (CVP) is 7-10, and potassium level is 3.5-5.3. A clear sensorium is another positive sign of adequate fluid replacement. Weight gain is not an issue with fluid resuscitation.

The nurse is caring for a patient who has developed a bradycardia. Which possible causes does the nurse investigate? Select all that apply. Bearing down for a bowel movement Possible inferior wall myocardial infarction (MI) Patient stating that he just had a cup of coffee Patient becoming emotional when visitors arrived Diltiazem (Cardizem) administered 1 hour ago

Valsalva maneuvers such as bearing down for a bowel movement or gagging may cause excessive vagal (parasympathetic) stimulation to the heart leading to decreased rate of sinus node discharge. Bradycardia may result from carotid sinus massage, vomiting, suctioning, ocular pressure, or pain. Inferior wall MI is a cause of bradycardia and heart block. Calcium channel blockers such as diltiazem may cause bradycardia.Caffeine intake results in an increased heart rate. Stress, such as an emotional encounter, can result in tachycardia.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? "I need to know my HIV status, so I must get tested before caring for any clients." "Putting on a gown and gloves will cover up the itchy sores on my elbows." "Washing my hands and putting on a gown and gloves is what I must do before starting care." "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include hand hygiene and whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.Knowing HIV status is important for preventing transmission of HIV, but is not part of the Standard Precaution Protocol. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds (2.7 kg) since the last visit Reports sucking on ice chips all day for dry mouth

Weight loss of 6 pounds (2.7 kg) since the last visit The clinic nurse recognizes that the client has been compliant with fluid restrictions when the client has a weight loss of 6 pounds (2.7 kg) since the last visit. Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions. Alternative methods of treating dry mouth need to be explored.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum Sleeping on back without a pillow Fatigue

When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

There has been an explosion at a local refinery. Numerous injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? Child with an open fracture of the arm Man with a contusion on the head Teenager with a closed fracture of the leg Woman bleeding heavily

Woman bleeding heavily The critically injured woman with active hemorrhage is the emergent priority in this situation. This condition is potentially life threatening.The child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent and treatment can wait.

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities Older adult with thick, tan-colored sputum

Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

14. A patient sustained a superficial-thickness burn over a large area of the body. The patient is crying with discomfort and is very concerned about the long-term effects. What does the nurse tell the patient to expect? a. "Healing should occur in 3 to 6 days with no scarring or complications." b. "The pain should be less because more of the nerve endings were destroyed." c. "The wound will appear red an dry with some white areas." d. "The leathery eschar will have to be removed before healing can occur."

a

33. The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new complaint of shortness of breath. On auscultation, the nurse hears crackles throughout the lung fields. What does the nurse suspect is causing this patient's symptoms? a. Pulmonary fluid overload due to fluid resuscitation b. Exposure to carbon monoxide that was undiagnosed c. Fat emboli secondary to extensive injury d. Excessive oxygen therapy at the first facility

a

36. The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. Related to hypovolemia and hypotension b. Related to fluid overload and peripheral edema c. Related to prolonged resuscitation and hypoxia d. Related to direct blunt trauma to the kidneys

a

38. A patient who lives in a rural community sustained severe burns during a house fire at 10 AM. The rural emergency medical services (EMS) started a peripheral IV at 11:00 AM at a keep-vein-open (KVO) rate. The patient was admitted to the hospital at 1:00 PM. In calculating the fluid replacement, at what time is the fluid for the first 8-hour period completed? a. 6:00 PM b. 7:00 PM c. 8:00 PM d. 9:00 PM

a

5. The nurse is reviewing the hemoglobin and hematocrit results for a patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration? a. Hematocrit of 58% b. Hemoglobin of 14 g/dL c. Hematocrit 42% d. Hemoglobin of 10 g/dL

a

52. The nurse is applying a dressing to cover a burn on a patient's left leg. What technique does the nurse use? a. Consider the depth of the injury and amount of drainage, and work distal to proximal. b. Change the dressing every 4 hours or when the drainage leaks through the dressing. c. Consider the patient's mobility and the area of injury, and work proximal to distal. d. Use multiple gauze layers and roller gauze to pad and protect the joint areas.

a

55. The nurse is educating a patient who has sustained burns to the dominant hand. What kind of active range-of-motion exercises does the nurse instruct the patient to perform? a. Exercise the hand, thumb, and fingers every hour while awake. b. Exercise the fingers and thumb at least three times a day. c. Use the hands to perform activities of daily living. d. Squeeze a soft rubber ball several times a day.

a

67. A patient was rescued from a burning house and treated with oxygen. Initially, the patient has audible wheezing and wheezing on auscultation, but after approximately 30 minutes the wheezing stopped. The patient now demonstrates substernal retractions and anxiety. What action does the nurse take at this time? a. Recognize an impending airway obstruction and prepare for immediate intubation. b. Continue to monitor the patient's respiratory status and initiate pulse oximetry. c. Document this finding as evidence of improvement and continue to observe. d. Stay with and encourage the patient to remain calm and breathe deeply.

a

69. A patient has sustained a burn to the right ankle. The provider has applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to prevent contracture. What is the correct position the nurse uses? a. Dorsiflexion b. Adduction c. External rotation d. Hyperextension

a

71. The nurse is caring for an African-American patient with a burn injury. The patient appears to be having severe pain and discomfort that are unrelated to the burned areas. The nurse advocates that the provider order which additional test? a. Sickle cell for trait b. Drug screen for opiate abuse c. X-rays to identify bone injuries d. ECG to identify cardiac dysrhythmia

a

72. The provider has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching? a. "He doesn't do well under general anesthesia." b. "He'll be awake for the procedure." c. "He will receive medication for sedation and pain." d. "We could stay with him at the bedside during the procedure."

a

73. The nurse is caring for a firefighter who was brought in for burns around the face and upper chest. Airway maintenance for this patient with respiratory involvement includes what action? a. Monitoring for signs and symptoms of upper airway edema during fluid resuscitation b. Inserting a nasopharyngeal or oropharyngeal airway when the patient's airway is completely obstructed c. Obtaining an order for as-needed (prn) oxygen per nasal cannula d. Frequently suctioning the mouth with Yankauer suction

a

83. A patient has been depressed and withdrawn since her injury and has expressed that "life will never be the same." Which nursing intervention best promotes a positive image for this burn patient? a. Discussing the possibility of reconstructive surgery with the patient b. Allowing the patient to choose a colorful scarf to cover the burned area c. Playing cards or board games with the patient d. Encouraging the patient to consider how fortunate she is to be alive

a

84. A 28-year-old male patient sustained second-and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrived at the ED in severe discomfort. What is the priority problem for this patient at this time? a. Acute pain related to damaged or exposed nerve endings b. Decreased fluid volume related to electrolyte imbalance c. Potential for inadequate oxygenation d. Diminished self-image related to the appearance of legs

a

30. The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems? (Select all that apply.) a. Patient who was in a storage room where chemicals caught fire b. Patient who was working in an area where steam escaped from a pipe c. Patient who sustained a circumferential burn to the chest area d. Patient who was burned when a firecracker exploded prematurely e. Patient who was found unconscious in a slow-burning house fire

a, b, c, e

59. What does the process of full-thickness wound healing include? (Select all that apply.) a. Healing occurs by wound contraction. b. Eschar must be removed. c. Large blisters are protective and left undisturbed. d. Skin grafting may be necessary. e. Fasciotomy may be needed to relieve pressure and allow normal blood flow.

a, b, d, e

63. A patient with burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching? (Select all that apply.) a. Signs and symptoms of infection b. Drug regimens and potential medication side effects c. Definition of full-thickness burns d. Correct application and care of pressure garments e. Comfort measures to reduce scarring f. Dates for follow-up appointments

a, b, d, f

12. A patient comes to the clinic to be treated for burns from a barbeque fire. Although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? (Select all that apply.) a. Burns to the face b. Bright cherry-red color to lips c. Singed nose hairs d. Edema of the nasal septum e. Black carbon particles around the mouth f. Sweet, sugary smell to the breath

a, c, d, e

A nurse working in a provider's office is assessing a client who has a severe sunburn. Which of the following is the proper classification of this burn? a. superficial b. superficial partial-thickness c. deep partial-thickness d. full-thickness

a. A sunburn is superficial. Superficial burns damage the top layer of the skin

A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action? a. coughing and wheezing b. bright red skin with small blisters c. thirst d. singed hair

a. coughing and wheezing may indicate the child has inhaled smoke or toxic fumes. AIRWAY

During the emergent phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? a. serum creatinine level of 2.5 mg/dL b. little fluctuation in daily weight c. hourly urine output of 60 mL d. serum albumin level of 3.8

a. fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine.

When counseling clients regarding first-line burn prevention, the nurse should plan to include which of the following items? a. temperature setting on the hot water tank b. demonstration of the use of a fire extinguisher c. assistance in the planning of an escape route d. stress the need for smoke detectors.

a. most burns occur at home and caused by hot water or steam

The nurse explains to the family that he needs to have an escharotomy. The nurse includes which of the following statements in the explanation? a. it is done to prevent ischemia and necrosis b. it is exactly the same as a faciotomy c. it is done to promote drainage of edema fluid d. it is only done on extremities

a. prevents ischemia and necrosis

A nurse is planning care for a client who has burn injuries. Which of the following interventions should be included in the plan of care? select all a. use standard precautions when performing care b. encourage fresh veggies c. increase protein intake d. 3,000 calories per day e. restrict fresh flowers in the room

a. standard precautions to decrease risk of infection c. increase protein to promote wound healing d. flowers cary bacteria, increases risk for infection b. veggies have bacteria, increases risk for infection d. 5,000 calories per day

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? select all a. An 8 year old with 3rd degree burns over 10% of his body b. A 20 year old who inhaled the smoke of the fire c. a 50 year old diabetic with first and second degree burns on his left forearm (about 5% of body surface) d. A 30 year old with 2nd degree burns on the back of his left leg e. A 40 year old with second degree burns on his right arm (about 10% of his body surface).

a.b.c. - Children under age 10Adults over age 50 with 2nd and 3rd degree burns on 10% or greater of BSA. Clients between ages 11-49 with 2nd and 3rd degree burns over 20% of their BSA.Clients of any age with 3rd degree burns on more than 5% of their BSA.Clients with smoke inhalationClients with DM, heart, or kidney disease

11. The nurse is reviewing arterial blood gas (ABG) results for a patient with 35% TBSA burn in the resuscitation phase: pH is 7.26; Pco2 is 36 mm Hg; and HCO3- is 19 mEq/L. What condition does the nurse suspect the patient has? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis

b

13. The nurse is caring for a burn patient who received rigorous fluid resuscitation in the ED for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate? a. Output will be approximately equal to fluid intake. b. Output will be decreased compared to fluid intake. c. Urine will have a very low specific gravity and a pale-yellow color. d. Output will be managed with diuretics.

b

15. The nurse is caring for a patient brought to the ED after bending over the engine of his car when it explode in his face. What is the priority for this patient? a. Initiate fluid resuscitation b. Secure the airway c. Manage pain and discomfort d. Prevent infection

b

17. For which patient would the rule of nines method of calculating burn size be most appropriate? a. Child who weighs at least 50 pounds b. Adult whose weight is proportionate to height c. Adult who weighs under 300 pounds d. Child whose weight is proportionate to height

b

20. The nurse observes peeling of dead skin on the legs of a patient with a superficial-thickness burn wound. What is the most accurate description of this assessment finding? a. Blanching b. Desquamation c. Slough d. Fluid shift

b

26. Which vaccine is routinely administered when a burn patient is admitted to the hospital? a. Hepatitis B b. Tetanus c. Influenza d. Pneumonia

b

28. A patient has sustained a burn which appears red and moist. The nurse gently applies pressure to the area to assess for what sign/symptom? a. Intensity of pain b. Blanching c. Pitting edema d. Fluid-filled blisters

b

32. The nurse has just received report on a patient admitted for steam inhalation burns. The patient is alert and conversant, but reports that his throat feels raw. His wife says the he sounds hoarse compared to usual. Considering these findings, which order should the nurse question? a. Continuous pulse oximetry b. Vital signs and airway assessment every shift c. Intubation equipment at the bedside d. Oxygen 2 L via nasal cannula to maintain saturation of greater than 90%

b

53. The nurse has just received a phone report on a burn patient being transferred from the burn intensive care unit to the step-down burn unit. Which of these tasks are appropriate to delegate to UAP in order to prepare the room? a. Place sterile sheets and a sterile pillowcase on the bed. b. Place a new disposable stethoscope in the room. c. Clear a space in the corner for the patient's flowers. d. Hang a sign on the door to prohibit entry of visitors.

b

56. A burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness, what procedure pertaining to the pressure garments is implemented? a. Changed every 24 to 48 hours to prevent infection b. Worn at least 23 hours a day until the scar tissue matures c. Removed for hygiene and during sleeping d. Applied with aseptic technique

b

62. Because of the fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. An initial increase, then normalized in 24 to 48 hours. b. Depressed up to 36 hours after the burn c. Improved with fluid restriction d. Responsive to diuretics as evidenced by urinary output

b

9. During shift report, the nurse learns that a new patient was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstem bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are absent. What does the nurse do next? a. Document these findings because they indicate that the patient is improving. b. Assess for respiratory distress because of potential airway obstruction. c. Obtain an order to discontinue oxygen therapy because it is no longer needed. d. Encourage use of incentive spirometry to prevent atelectasis.

b

68. The nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. Which laboratory results does the nurse expect to see during the resuscitation phase? (Select all that apply.) a. Potassium level of 3.2 mEq/L b. Glucose level of 180 mg/dL c. Hematocrit of 49% d. pH of 7.20 e. Sodium level of 139 mEq/L

b, c, d

Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? a. electrical burns of the hands and arms causing arrhythmias b. thermal burns to the head, face, and airway resulting in hypoxia c. chemical burn on the chest and abdomen d. secondhand smoke inhalation

b. Tracheostomy or endotracheal intubation is anticipated with significant thermal and smoke inhalation burns occur.

A client with burn injury asks the nurse what the term "full thickness" means. The nurse should respond that burns classified as full thickness involve tissue distraction down to which level? a. epidermis b. subcutaneous tissue c. internal organs d. dermis

b. subcutaneous tissue (this is below the dermis) May also include the fat

31. The nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. During the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes? a. Temporary discomfort that can be treated with sips of cool fluids b. Signs of symptoms of probable carbon monoxide poisoning c. Signs indicating a pulmonary injury and possible airway obstruction d. Expected findings considering the mechanism of injury

c

34. The nurse is caring for several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring? a. Older adult woman who spilled hot water over her legs while boiling noodles b. Teenager with facial burns that occurred when he threw gasoline on a campfire c. Young women who was struck by lightning while jogging on the beach d. Middle-aged man who fell asleep while smoking and sustained burns to the chest

c

37. The student nurse is caring for a patient who has been in the burn unit for several weeks. The patient needs assistance with the bedpan to have a bowel movement, and the student nurse notes that the stool is black with a tarry appearance. What is the most important priority action at this time? a. Report this finding to the primary nurse or the instructor. b. Ask if the patient is currently taking an iron supplement. c. Test for the presence of occult blood with a hemoccult card and reagent. d. Perform a dietary assessment to determine if the stool color is related to food.

c

40. A burn patient with which condition is most likely to have mannitol (Osmitrol) ordered as part of the drug therapy? a. Peripheral edema associated with burns on the lower extremities b. Inhalation burns around the mouth causing mucosal swelling c. Electrical burn and myoglobin in the urine d. Smoke inhalation and superficial burns to the forearms

c

42. A patient was admitted for burns to the upper extremities after being trapped in a burning structure. The patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. Which diagnostic test best monitors this patient's gas exchange? a. Complete blood count b. Myoglobin level c. Carboxyhemoglobin level d. Chest x-ray

c

45. Which statement about the resuscitation phase of a burn injury is accurate? a. It occurs in the prehospital timeframe. b. It continues about 4 hours after the burn. c. It continues for about 48 hours after the burn. d. It continues until the patient is stable.

c

48. The vasodilating effects of carbon monoxide in patients with carbon monoxide poisoning cause what clinical manifestations? a. Cyanosis around the lips b. Generalized pallor c. Cherry-red skin color d. Mottled skin color

c

57. The family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her." The nurse finds that the patient has the knowledge and the physical capacity to independently perform self-care. What is the nurse's best response? a. "What can your family do to help you feel better and stronger?" b. "You should be doing these things for yourself to increase your self-esteem." c. "What has been happening since you were discharged from the hospital?" d. "Let's review the principles of self-care that you learned in the hospital."

c

6. The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen? a. To perform a daily full head-to-toe assessment b. To assess for nausea and vomiting related to pain medication c. TO assess for a paralytic ileus secondary to reduced blood flow d. To monitor increased motility that may result in cramps and diarrhea

c

64. A patient has sustained significant burns which have created a hypermetabolic state. In planning care for this patient, what does the nurse consider? a. Increased retention of sodium b. Decreased secretion of catecholamines c. Increased caloric needs d. The decrease in core temperature

c

74. At what point does fluid mobilization occur in patients with burns? a. After the scar tissue is formed and fluids are no longer being lost. b. Within the first 4 hours after the burns were sustained. c. After 36 hours when the fluid is reabsorbed from the interstitial tissue. d. Immediately after the burns occur.

c

75. The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patient's pain? a. Nitrous oxide b. Cool room temperature to reduce discomfort c. Massaging nonburned areas d. Intravenous narcotics due to delayed tissue absorption

c

79. What is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient? a. Age b. Health history c. Preburn weight d. Current weight

c

49. The nurse is caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient? (Select all that apply.) a. Administration of IV opioid analgesics b. Allowing the patient to make decisions regarding pain control c. Playing music in the background d. Use of meditative breathing e. Use of guided imagery

c, d, e

The nurse is caring for a client with full thickness burns on 50% of his body. The spouse asks "Why does he look so different? He's all puffy." What is the best response by the nurse? a. We are giving him a great deal of IV solutions and that is causing the edema b. it is normal at this stage of a burn injury c. the burn causes his fluids to shift into his tissues and that is causing the puffiness d. when he received his diuretic, most of the puffiness will go away

c. After a burn, the blood vessels dilate and fluid leaks into the interstitial spaces. This is known as third spacing .

The nurse is caring for a client admitted to the ED following a fire. The client has a BP of 96/62 and has partial thickness burns on the chest and neck. The nurse's immediate response is to: a. hang a saline infusion wide open to keep the BP WNL b. cleanse the skin with sterile saline to prevent infection c. call the physician and prepare to intubate the client d. observe the client for evidence of distress

c. Clients with burns around the face are at risk for an inhalation injury. The edema that results can be sudden and occlude the airway almost immediately.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

c. Monitor the clients temperature.

The child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action? a. give small glass of clear liquid b. give a small glass of a full liquid c. keep the child NPO d. order a pediatric meal tray with extra liquids

c. NPOA complication of major burns is a paralytic ileum, so until that has been ruled out, oral fluids should not be provided.

A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice is hoarse, and he has a brassy cough. These findings are indicative of which of the following? a. pulmonary edema b. bacterial pneumonia c. inhalation injury d. carbon monoxide poisoning.

c. Wheezing and hoarseness are indicative of inhalation injury.

Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? a. soak the dressing b. remove the dressing c. administer an analgesic d. slit the dressing with blunt scissors

c. administer an analgesic.

23. During the early phase of a burn injury there is a drastic increase in capillary permeability. What does this physiologic change place the patient at risk for? a. Acute kidney injury b. Fluid overload c. Increased cardiac output d. Hypovolemic shock

d

25. What is the most effective intervention for preventing transmission of infection to a burn patient? a. Use of personal protective equipment (PPE) for anyone entering the patient's room b. Maintaining reverse isolation during the resuscitation phase c. Equipment designated for patient use d. Performing hand hygiene correctly and when appropriate

d

27. A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a worksite furnace. Which area of the body is most vulnerable to a deep burn injury? a. Anterior chest b. Upper arms c. Palmar surface of hands d. Eyelids

d

4. The nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. Hypercalcemia b. Hypernatremia c. Hypokalemia d. Hyperkalemia

d

50. A burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate and reduced calorie intake is identified for this patient. What method does the nurse use to correctly weigh this patient? a. Weigh once a week after morning hygiene and compare to previous weight. b. Weigh daily at the same time of day and compare to preburn weight. c. Use a bed scale and subtract the estimated weight of linens. d. Weigh daily without dressings or splints and compare to preburn weight.

d

58. A patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. Which intervention is best to help the patient make the transition into the community? a. Discuss cosmetic surgery that could occur over the next several years. b. Focus on the positive aspects of going home and being with family. c. Teach the family to perform all aspects of care for the patient. d. Encourage visits from friends and short public appearances before discharge.

d

7. The nurse is interviewing and assessing an electrician who was brought to the emergency department (ED) after being "electrocuted." Bystanders report that he was holding onto the electrical source "for a long time." The patient is currently alert with no respiratory distress. During the interview, what does the nurse assess for? a. Knowledge of electrical safety b. Burn marks on the dominant hand c. Injuries based on reports of pain d. Entrance and exit wounds

d

81. A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutritional requirements may exceed how many kcal/day? a. 1500 b. 2000 c. 3000 d. 5000

d

85. Which patient has the highest risk for a fatal burn injury? a. 4-year-old child b. 32-year-old man c. 45-year-old woman d. 77-year-old man

d

The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for a. paralytic ileus b. gastric distention c. hiatal hernia d. Curling's ulcer

d. Curling's ulcer occurs in about half of the clients with a burn injury.

During the early phase of burn care the nurse should assess the client for? a. hypernatremia b. hyponatremia c. metabilic alkalosis d. hyperkalemia

d. hyperkalemia - Immediately after a burn, excessive K+ from cell destruction is released into the extracellular fluid.

The client with a major burn injury receives TPN. The expected outcome is to a. correct water and electrolyte imbalances b. allow the GI tract to rest c. provide supplemental vitamins and minerals d. ensure adequate caloric and protein intake

d. nutritional support with sufficient calories and protein is extremely important because of the loss of plasma protein through injured capillaries and an increased metabolic rate.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Impaired self-image Potential for infection

impaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same.A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? "Condoms should be used when lesions are present on the penis." "Always position the condom with a space at the tip of an erect penis." "Make sure it fits loosely to allow for penile erection." "Use adequate lubrication, such as petroleum jelly."

"Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom.Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only. Oil-based lubricants, for example, petroleum-based lubricants (such as petroleum jelly), can increase the likelihood of breakage and slipping of latex condoms due to loss of elasticity caused by these lubricants. Oil may also create tiny holes in the latex. Oil-based lubricants may be considered desirable for people who are in relationships not requiring condom use and who wish to avoid certain additives and preservatives often found in other lubricants.

A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? "This will not make any difference in the viral load." "Blood concentrations will be decreased, which will lead to increased viral replication." "If only one dose of medication is missed, this will not make a difference." "This will cause an increase in opportunistic infections."

"Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.When the inhibitory concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. It does not cause an increase in opportunistic infections but places the client at increased risk for developing one. Therefore, it does make a difference and is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? "The last tetanus injection was less than 5 years ago." "Burn wound conditions promote the growth of Clostridium tetani." "The wood in the fire had many nails, which penetrated the skin." "The injection was prescribed to prevent infection from Pseudomonas."

"Burn wound conditions promote the growth of Clostridium tetani." The nurse's best response is that burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital.Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."

"Every bedroom should have a separate smoke detector." The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home.Every room in the house does not need a smoke detector. There should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.

In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? "Have you had sex with men or women or both?" "I hope you use condoms to protect your partners." "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

"Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate."I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental. Judgmental statements to clients by healthcare providers (HCPs) can impede the collaborative relationship and communication between client and HCP.

The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? "I am getting used to looking at myself." "I don't know what I will do when people stare at me." "I know that I will never look the way I used to, even after the scars heal." "My spouse does not stare at the scars as much now as in the beginning."

"I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively. The nurse needs to assist the client in exploring coping techniques. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem.The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse does not stare at the scars as much all indicate that the client is coping effectively.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds (0.9 to 1.4 kg) in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."

"I will call the provider if I have a cough lasting 3 or more days." The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 pounds (1.4 kg) in a week or 1-2 pounds (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 meters) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery of his AIDS by his family? "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" "Is there somewhere private in the home where we can go and talk?" "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." "It is your duty to protect your family members from getting AIDS."

"Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The nurse needs to have a private conversation with the client to discover the client's wishes.The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? "I told family members they need to wash their hands when they enter and leave the room." "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." "Yes, I understand the reasons why I have to wear gloves when I bathe the client." "The client's spouse told me she got HIV from a blood transfusion."

"The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse.Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "This may be caused by a genetic trait." "Just imagine how bad it would be if you weren't in good shape."

"This may be caused by a genetic trait." The nurse's best response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? "With this treatment, I probably cannot spread this virus to others." "This treatment does not kill the virus." "This medication prevents the virus from replicating in my body." "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

"With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids.HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching? "Do not allow the victim to ingest any alcohol or caffeine." "The extremity should be kept below the level of the heart." "The first priority is to call for EMS transport to a trauma center." "You should first place a tourniquet above the bite."

"You should first place a tourniquet above the bite." The ranger trainee's statement that the first thing to do is to place a tourniquet above the bite indicates a need for further teaching. Placing a tourniquet above the bite could worsen local tissue necrosis by retaining venom in the tissues. If transportation and treatment are delayed, a constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. However, it would not be used as a tourniquet. Alcohol or stimulants such as caffeinated beverages must not be offered because they may speed up the absorption of venom. Affected extremities are kept below the level of the heart. The first priority is not to call for EMS transport although it will be important for the client to be evaluated and treated at an appropriate facility that is equipped to handle snakebites.

An adult client was severely burned in a grass fire resulting in second degree burns on the left arm, leg, and back as well as third degree burns on the right arm. Using the rule of nines, the estimated extent of burns is: 54%. 27%. 45%. 36%.

54% - The rule of nines is a quick assessment scale used to estimate the extent of burn injury. The body is divided into areas that represent 9% of the body surface area. This client had burns of the following percentages: R arm 9%, L arm 9%, L leg 18%, back 18% for a total of 54%.

Which client is at greatest risk for heat exhaustion? A 24-year-old construction worker A 34-year-old police officer A 42-year-old swimming instructor A 78-year-old gardener

A 78-year-old gardener Older adults are particularly at risk for heat-related illnesses because of decreased body fluid volume. Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse as a result of the body overheating. It's one of three heat-related syndromes, with heat cramps being the mildest and heatstroke being the most severe. Older adults may also be at risk due to medications they are taking that lead to electrolyte imbalances for treatment of medical co-morbidities.The young construction worker is at risk, but is not the one at highest risk. These workers will typically have a "thirst" response and will keep hydrated as needed. The police officer is a young adult who is probably in an acceptable state of fitness. The swimming instructor may also be at risk but has the ability to cool off rapidly by getting into the water.

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate to assign to an LPN/LVN? A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) A client reporting right forearm swelling secondary to a "bug bite" with capillary refill in the right hand of greater than 3 seconds A client who was hiking and is now confused, and has crackles throughout all lung fields A client stung by an unknown insect who reports shortness of breath

A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) It is appropriate to assign an LPN/LVN to care for the stable, heat exhaustion client who is already receiving appropriate treatment.The data from the other three clients all support the need for ongoing assessment and intervention by an RN. The client who presents with vascular instability and compromise needs quick intervention. The client who has an unclear picture at present but has the potential to deteriorate rapidly and the client with the unknown insect bite also need assessment by the RN.

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A)Sodium deficit B)Decreased prothrombin time (PT) C)Potassium deficit D)Decreased hematocrit

A)Sodium deficit

An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? A)The causative agent B)The patients preinjury health status C)The patients prognosis for recovery D)The circumstances of the accident

A)The causative agent

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A. "Every bedroom should have a separate smoke detector." B. "Every room in the house should have a smoke detector." C. "If you have a smoke detector, you don't need a carbon monoxide detector." D. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

A. "Every bedroom should have a separate smoke detector." Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.

What is the best method to prevent autocontamination for a client with burns? A. Change gloves when handling wounds on different areas of the body. B. Ensure that the client is in isolation therapy. C. Restrict visitors. D. Watch for early signs of infection.

A. Change gloves when handling wounds on different areas of the body. Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Watching for early signs of infection does not prevent contamination.

Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Edema of the skin around the wound E. Tachycardia

A. Dry, crusty granulation tissue D. Edema of the skin around the wound E. Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

A. Encouraging participation in wound care Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A. Give oxygen per facemask. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

A. Give oxygen per facemask. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? A. Heart failure B. Diverticulitis C. Hypertension D. Emphysema

A. Heart failure A client's health history, including any pre-existing illnesses, must be known for appropriate management. Obtain specific information about the client's history of cardiac or kidney problems, chronic alcoholism, substance abuse, and diabetes mellitus. Any of these problems can influence fluid resuscitation. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction. Diverticulitis, hypertension and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white wounds B. Painless, brownish yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A. Painful red and white wounds A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

A. Reduction of bacterial growth in the wound and prevention of systemic sepsis Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) mL/hr

ANS: 1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) drops/min

ANS: 333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

18. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

ANS: A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics

ANS: A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. No, women should only have one beer a day as a general rule. b. No, you should not drink any alcohol with hypertension. c. Yes, since you are larger, you can have more alcohol. d. Yes, two beers per day is an acceptable amount of alcohol.

ANS: A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The womans size does not matter.

A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

ANS: A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from righ to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching? a. Avoid using salt substitutes. b. Take your medication with food. c. Avoid using aspirin-containing products. d. Check your pulse daily.

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the clients pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

ANS: A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the clients respiratory status. b. Draw blood to assess the clients serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem- focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the clients ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.

ANS: A Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

ANS: A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond? a. Weight is the best indication that you are gaining or losing fluid. b. Daily weights will help us make sure that youre eating properly. c. The hospital requires that all inpatients be weighed daily. d. You need to lose weight to decrease the incidence of heart failure.

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using yes-or-no questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

ANS: A Damage to Brocas area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. Yes-or-no questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up words often used by clients with sensory aphasia.

A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond? a. Would you like to talk more about this? b. You are lucky to have such a devoted daughter. c. It is normal to feel as though you are a burden. d. Would you like to meet with the chaplain?

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the clients concerns and do not allow the nurse to obtain more information to provide client-centered care.

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the clients integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight.

ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowlers position. d. Ask the client to perform deep-breathing exercises.

ANS: A Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. I am thrilled that I can continue to eat fast food. b. I will cut out bacon with my eggs every morning. c. My cooking style will change by not adding salt. d. I will probably lose weight by cutting out potato chips.

ANS: A Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the clients abdomen. d. Assess the clients diet history.

ANS: A Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the clients abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.

A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the clients temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the clients daily white blood cell count

ANS: A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

ANS: A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

ANS: A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.

ANS: A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min

ANS: A Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.

The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

ANS: A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. Ill use my incentive spirometer every 2 hours while Im awake. b. Ill drink thinned fluids to prevent choking. c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I dont aspirate.

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching? a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isnt useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouses concerns and feelings.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

ANS: A Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs. The electrolyte values are not related to the protein- restricted diet.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the clients weight by 6 kg

ANS: A Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the clients record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

ANS: A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

ANS: A The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like drugs are safer today do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the clients acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the clients acceptance of the treatment should come first.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.

ANS: A The nurses presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the clients blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the clients safety. Telling a confused client that everything is being done is not the most helpful response.

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.

ANS: A The nurses priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the clients intake and output. d. Ask to have the laboratory redraw the blood specimen.

ANS: A The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

ANS: A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a. Diarrhea is expected; thats how your body gets rid of ammonia. b. You may take Kaopectate liquid daily for loose stools. c. Do not take any more of the medication until your stools firm up. d. We will need to send a stool specimen to the laboratory.

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history? a. Have you been taking any aspirin, ibuprofen, or naproxen recently? b. Do you have anyone in your family with renal failure? c. Have you had a diet that is low in protein recently? d. Has a relative had a kidney transplant lately?

ANS: A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.

4. A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

ANS: A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

ANS: A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the clients degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full- time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. I know I can take care of all these needs by myself. b. I need to seek counseling because I am very angry. c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this.

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the clients lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns ou to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

ANS: A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below: What action by the nurse is best? a. Assess the clients ankle-brachial index. b. Elevate the clients leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

ANS: A This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the clients ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the clients dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the clients phlebostatic axis

ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the devices accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the devices accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

ANS: A To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. Use a pill organizer to ensure you take this medication as prescribed. b. Transient muscle aching is a common side effect of this medication. c. Follow up with your provider in 1 week to test your blood for toxicity. d. Take your radial pulse for 1 minute prior to taking this medication.

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.

19. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

ANS: A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

ANS: A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.

ANS: A, B, C, D The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowlers position to assist in avoiding aspiration. Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

ANS: A, B, C, D The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

ANS: A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

ANS: A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

ANS: A, B, D Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dresslers syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients risk for acute pericarditis.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

ANS: A, B, D Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. c. You will have no risk for infection with PD. d. You have flexible scheduling for the exchanges. e. It takes less time than hemodialysis treatments.

ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

ANS: A, B, D The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

ANS: A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply.) a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

ANS: A, B, D To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the clients available social support, which may include family, friends, and home health services. The clients ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the clients safety upon discharge.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: A, B, E A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the clients chest and back for skin breakdown from the halo vest.

A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos

ANS: A, B, E Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

ANS: A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therap

ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the clients stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome.

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the clients nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

76. A patient with a burn injury had an autograft. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at donor site? a. Stage 1 b. Partial thickness c. Full thickness d. Stage 4

b

77. To prevent the complication of Curling's ulcer, what does the nurse anticipate the provider will order? a. Nasogastric tube insertion b. H2 histamine blockers c. Abdominal assessment every 4 hours d. Systemic antibiotic

b

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

ANS: A The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member?

"Burn wound conditions promote the growth of Clostridium tetani."

The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? "Do you support each other?" How do you plan to manage this situation?" How have you handled similar situations?" Would you like to see a counselor?"

"How have you handled similar situations?" Asking how the client and family have handled similar situations in the past best assesses whether the client's and the family's coping strategies may be effective."Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage. Asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

The nurse is caring for a client who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the client's response to the therapy?

*Serum creatinine levels*Blood urea nitrogen levels

8. A patient was involved in a house fire and suffered extensive full-thickness burns. In the long-term, what issue may this patient have trouble with? a. Intolerance for vitamin C b. Metabolism of vitamin K c. Activation of vitamin D d. Absorption of vitamin A

c

80. Which drug therapy reduces the risk of wound infection for burn patients? a. Large doses of oral antifungal medications every 4 hours b. Silver nitrate solution covered by dry dressings applied every 4 hours c. Silver sulfadiazine (Silvadene) on full-thickness injuries every 4 hours d. Broad-spectrum antibiotics given intravenously

c

A client's jeans caught on fire while camping, inflicting deep partial-thickness burns to the anterior and posterior surface of both legs. Using the rule of nines, what percent body surface area does the nurse estimate the client's burn to be? 1. 9% 2. 18% 3. 36% 4. 40%

36% - Using the rule of nines, burns to the anterior and posterior surface of both legs would be about 36% of total body surface area. Each leg is a total of 18%, with each anterior surface being 9%, and each posterior surface being 9%.

Which waveform indicates proper function of the sinoatrial (SA) node? The QRS complex is present. The PR interval is 0.24 second. A P wave precedes every QRS complex. The ST segment is elevated.

A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead.The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.

What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "It is important to consume a diet high in green leafy vegetables." "You would take aspirin or ibuprofen for headache." "Report nosebleeds to your provider immediately." "Avoid caffeinated beverages."

A nosebleed could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot.Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A) Return of distal pulses B) Brisk bleeding from the site C) Decreasing edema formation D) Formation of granulation tissue

A) Return of distal pulses

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A)2 days B)3 days C)5 days D)1 week

A)2 days

A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patients needs? A)A patient-controlled analgesia (PCA) system B)Oral opioids supplemented by NSAIDs C)Distraction and relaxation techniques supplemented by NSAIDs D)A combination of benzodiazepines and topical anesthetics

A)A patient-controlled analgesia (PCA) system

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A)Fluid status B)Risk of infection C)Nutritional status D)Psychosocial coping

A)Fluid status

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

ANS: A A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best? a. No, it may interfere with the warfarin. b. There isnt any information about that. c. Why would you want to take that? d. Yes, it is a good supplement for you.

ANS: A Many foods and drugs interfere with warfarin, St. Johns wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.

ANS: A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

ANS: A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the clients risk for infection.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

ANS: A The nurse should first provide emotional support by encouraging relaxation, listening to the familys needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the familys needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the familys needs.

The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

ANS: A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the clients feelings.

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

ANS: A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. Even though turning hurts, I will remind you to turn me every 2 hours. b. Radiation therapy can shrink the tumor but also can cause more problems. c. Surgery will be scheduled to remove the tumor and reverse my symptoms. d. I put my affairs in order because this type of cancer is almost always fatal. e. My family is moving my bedroom downstairs for when I am discharged home.

ANS: A, B, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Consult an exterminator to control bugs in and around your home. b. Do not swat at insects or wasps. c. Wear sandals whenever you go outside. d. Keep your prescribed epinephrine auto-injector in a bedside drawer. e. Use screens in your windows and doors to prevent flying insects from entering.

ANS: A, B, E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to preven infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

ANS: A, C, D, E Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

ANS: A, C, D, E The Joint Commissions Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102 F. Antipyretics should not be administered.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings.

ANS: A, D, E Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same clients body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the clients body can prevent autocontamination.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.

ANS: B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facilitys neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I Located within remote areas and provides advanced life support within resource capabilities b. Level II Located within community hospitals and provides care to most injured clients c. Level III Located in rural communities and provides only basic care to clients d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients

ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

ANS: B Lower blood volume will decrease MAP. The other answers are not accurate.

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

ANS: B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic Decides the number, acuity, and resource needs of clients b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media

ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. I need to decrease sodium, cholesterol, and protein in my diet. b. My weight should be maintained at a body mass index of 30. c. Smoking should be stopped as soon as I possibly can. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

ANS: B, D, E Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this clients constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications.

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."

ANS: C Glatiramer is given by subcutaneous injection. The first dose is administered under medical supervision, but the nurse teaches the client how to self-administer the medication after the initial dose, reminding the client about the need to rotate injection sites. Like other immunomodulators, this drug can make the client susceptible to infection. However, flulike symptoms occur more commonly with interferons rather than glatiramer.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facilitys sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

ANS: D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

ANS: D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

Adverse effects of tizanidine include drowsiness and sedation. Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant.It does not cause hirsutism, hypertension, or tachycardia.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Alopecia Headaches Dizziness Diplopia Increased blood glucose

Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it's mechanism of action is unclear.Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? Adult who is lethargic after a generalized tonic-clonic seizure Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention.The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention.

The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I will be able to shower again soon." "I need to take my pulse every day." "I might trigger airport security metal detectors." "I no longer need my heart pills."

All prescribed medications, including heart medications, are still needed after the pacemaker is implanted.Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices. A card can be shown to authorities to indicate that the patient has a pacemaker.

The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. Respiratory rate QT interval Heart rate Heart rhythm Urine output

Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.

The RN working at a long-term-care facility places priority on providing interventions for which resident? A 65-year-old paraplegic man who is demanding to see the health care provider about insurance benefits A 76-year-old woman with a total hip replacement who is showering for the first time since entering rehabilitation after surgery An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° c An 82-year-old woman with dementia who is requesting "something" for a headache

An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) The nurse's priority would be to intervene on behalf of the elderly CHF resident. The 80-year-old resident is outside when it is 95° F (35° C) and needs to be assisted back indoors with some alternatives provided for him to receive some "fresh air." This will help him meet his personal desires as well as maintain his safety and prevent potential heat-related illness.Although the 65-year-old paraplegic man has valid concerns, these concerns are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but she is not the nurse's greatest priority resident. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action? 1. Ensure that the client remains NPO. 2. Apply oxygen and notify the Rapid Response Team. 3. Slow the IV infusion rate. 4. Raise the head of the bed.

Apply oxygen and notify the Rapid Response Team. - The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the face, neck, upper body, and hands). The wheezing and difficulty swallowing indicate possible pulmonary injury and oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation immediately.

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A. Decreasing pulse pressure B. Decreasing urine specific gravity C. Decreasing core body temperature D. Increasing respiratory rate and depth

Answer: B Rationale: Urine output is the most sensitive noninvasive measure of fluid resuscitation adequacy. An increase in urine output is a positive sign; however, so is a decreasing urine specific gravity. As urine output increases, the concentration of the urine decreases, leading to a decreased urine specific gravity. A decreasing pulse pressure often indicates a fall in systolic pressure, which would not indicate fluid resuscitation adequacy. A decreasing core body temperature is related to changes in the inflammatory response or metabolism and not an indication of fluid resuscitation adequacy. An increasing respiratory rate could indicate pulmonary edema but not fluid resuscitation adequacy. The increased respiratory depth may indicate other positive changes but not adequacy of fluid resuscitation.

A client with 32% total body surface area burns has a hematocrit of 54% 10 hours after the burn injury and 8 hours after fluid resuscitation was started. What is the nurse's best action? 1. Assess the client's blood pressure and urine output. 2. Notify the health care provider immediately. 3. Evaluate the client's electrocardiogram for dysrhythmias. 4. Increase the IV infusion rate.

Assess the client's blood pressure and urine output. - The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to evaluate the adequacy of the fluid resuscitation by assessing the client's blood pressure and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, the health care provider should be called and resuscitation volumes may be increased.

The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.

Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? Clean toothbrushes once a week. Bathe daily using an antimicrobial soap. Eat salad at least once a day. Wash dishes in cool water.

Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin.Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

As a direct result of overcrowding in emergency departments (ED), for whom must the emergency department nurse expect to provide care? A variety of age groups and cultures "Boarding" or holding inpatient clients Clients with a broad spectrum of issues, illnesses, and injuries Uninsured and underinsured clients

Boarding" or holding inpatient clients ED overcrowding has led to frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus becomes one of ongoing care instead of one-time orders.Although a variety of clients spanning all age ranges, cultures and illnesses may present to the ED for treatment, this is not a direct result of overcrowding. Overcrowding has nothing to do with clients who may be uninsured or underinsured.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

C. Signs of infection The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)

Carvedilol (Coreg)

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? Administer two acetylsalicylic acid (aspirin) tablets orally. Check the client's airway and administer high-flow oxygen therapy. Monitor the client's vital signs. Place a cooling blanket on the client.

Check the client's airway and administer high-flow oxygen therapy. The first action made by the ED nurse is to check the client's airway and give high-flow oxygen therapy. Once in a clinical setting, the nurse monitors and supports the client's airway, breathing, and circulatory status. High-concentration oxygen therapy and IV lines with 0.9% saline solution are also indicated.This client is at risk for aspiration. Nothing would be given by mouth when a client is at risk for aspiration. Vital signs must be monitored, but they are not the immediate priority in this scenario. Use of a cooling blanket is important although not a top priority, especially if ice bags are already in place.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? Burn unit client who is being discharged after 6 weeks and needs teaching about wound care Recently admitted client with a high-voltage electrical burn A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse from ICU will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr.The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? Call the police. Consult with Social Services. Discharge the client as instructed. Instruct the client to go to a safe place.

Consult with Social Services. Consulting with social workers or case managers is the best course of action to investigate resource needs for this client and to plan accordingly.Contacting law enforcement, discharging the client, or telling the client to go to a safe place as instructed may not be in this client's best interest.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? A)Apply ice to the site of the burn for 5 to 10 minutes. B)Wrap the patients affected extremity in ice until help arrives. C)Apply an oil-based substance or butter to the burned area until help arrives. D)Wrap cool towels around the affected extremity intermittently.

D)Wrap cool towels around the affected extremity intermittently.

A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Establish IV access. Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR).

Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols.After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

Which is the priority nursing intervention for maintaining mobility in a client with burns to the head and neck? 1. Maintain the client in a supine position for several hours a day. 2. Do not allow the use of pillows under the head or neck. 3. Encourage the client to logroll during position changes. 4. Use foam wedges to maintain trunk alignment.

Do not allow the use of pillows under the head or neck. - Maintaining optimal mobility is essential to the recovery process of the client with burns. Correct positioning to reduce the development of contractures is an important nursing intervention. Therefore, for clients with burn injuries to the head and neck, pillows should not be allowed. Supine positioning and logrolling will assist with clients who have burns to the chest and abdomen. Foam wedges are often used to maintain hip alignment.

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine Telling the client that these feelings are normal

Encouraging participation in wound care Encouraging participation in wound care is most helpful in providing the client some sense of control.Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" The nurse first needs to assess the firefighter recently admitted with smoke inhalation. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? Fluconazole (Diflucan) Trimethoprim/sulfamethoxazole (Bactrim) Rifampin (Rifadin) Acyclovir (Zovirax)

Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Candidiasis is a fungal infection.Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? Range-of-motion exercises Emotional support Fluid resuscitation Sterile dressing changes

Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury.Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

Which factor relates most directly to a diagnosis of primary immune deficiency? History of viral infection Full-term infant surfactant deficiency Contact with anthrax toxin Corticosteroid therapy

Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Primary immunodeficiencydiseases (PI) are a group of more than 250 rare, chronic disorders in which part of the body'simmunesystem is missing or functions improperly.Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

A patient was burned on the forearm after tripping and falling against a wood-burning stove. There are currently severe small blisters over the burn area. What does the nurse advise the patient to do about the blisters? a. Leave the blisters intact because they protect the wound from infection. b. Use a sterile needle to open a tiny hole in each blister to drain the fluid. c. Allow blisters to increase in size; then open them to prevent immunosuppression. d. Leave the blisters intact unless the pain and pressure increase.

a

Which factors in the older adult increase the risk of complications from a burn injury? (SATA) a. slower healing time b. thinner skin c. increased inflammatory compliance d. increased pulmonary compliance e. . altered glucose metabolism f. history of heart failure

a b e f

The nurse is caring for a patient with 45% TBSA burns. Which are priority medical surgical concepts for this patient? (SATA) a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange

a c e

The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider?

Hold omeprazole (Prilosec)

Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury?

Hyperkalemia

19. The nurse is assessing a patient with a burn wound to the back and chest area. Which assessment findings are consistent with a superficial-thickness burn wound? (Select all that apply.) a. Redness b. Pain c. Mild edema d. Moisture e. Eschar

a, b, c

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow?

In a neutral position

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed Slightly hyperextended

In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development.Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

Which alteration observed in a client rescued from a fire indicates pulmonary injury?

Inability to swallow fluids

54. The nurse is monitoring the nutritional status of a burn patient. Which indicators will the nurse use? (Select all that apply.) a. Amount of food the patient eats b. Weight to height ratio c. Serum albumin d. Amount of water the patient drinks e. Blood glucose f. Serum potassium

a, b, c, e

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the ABC's are intact, what does the team nurse do first? Give salt tablets. Move the player to the shade. Place ice packs under the arms. Provide a cool electrolyte fluid drink.

Move the player to the shade. After ensuring the ABC's are intact, the nurse would first move the player into the shade.After the player is in the shade, the nurse would place ice packs under the arms as well as in the groin to cool the client. Due to a diminished level of consciousness, nothing would be given by mouth to prevent aspiration. Salt tablets are not given.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control

Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client?Select all that apply. Provides cushions for comfort Performs frequent hand washing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes

Performs frequent hand washing, performs gloved dressing changes, uses disposable dishes. Frequent hand washing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible.Cushions are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

47. A burn patient in the fluid resuscitation phase is experiencing dyspnea. What are the priority interventions for this patient? (Select all that apply.) a. Elevate the head of bed to 45 degrees. b. Maintain patient in the supine position. c. Notify the Rapid Response Team d. Administer an analgesic to calm the patient. e. Apply humidified oxygen.

a, c, e

51. The student nurse is preparing to assist with hydrotherapy for a burn patient. The supervising nurse instructs the student to obtain the necessary equipment before beginning the procedure. What equipment does the student nurse obtain? (Select all that apply.) a. Scissors and forceps b. Hydrogen peroxide c. Mild soap or detergent d. Pressure dressings e. Washcloths and gauze sponges f. Chlorhexidine sponges

a, c, e

61. As a result of third-spacing, during the acute phase, which electrolyte imbalances may occur? (Select all that apply.) a. Hyperkalemia b. Hypokalemia c. Hypernatremia d. Hyponatremia e. Hypercalcemia

a, d

A client with severe burns is receiving ranitidine hydrochloride (Zantac) 50 mg IV every 6 hours. What is the rationale for this therapy? Management of moderate pain Vitamin supplementation Prevention of Curling's ulcers Ongoing treatment for a client history of gastritis

Prevention of Curling's ulcers - Clients with burns or any significant degree of stress are very susceptible to the development of Curling's ulcers (stress ulcers). Ranitidine is an H2 receptor antagonist and will decrease acid secretion, thereby preventing formation of stress ulcers. It is not used for treatment of gastritis or pain, nor is it a vitamin supplement.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? Collaborate with the client to select foods that are high in calories. Provide oral care to the client before meals to enhance appetite. Assess the perianal area every 8 hours for signs of skin breakdown. Discuss the need to avoid foods that are spicy or irritating.

Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants.Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice, and would be done by licensed staff.

Which risk factors are known to contribute to atrial fibrillation? Select all that apply. Use of beta-adrenergic blockers Excessive alcohol use Advancing age High blood pressure Palpitations

Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans.Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.

Which are expected outcomes when evaluating the care of a patient with burn injuries? (SATA) a. Patients infection was treated rapidly b. patients airway remained patent c. patients pain was decreased or relieved d. patient's perception of self is positive e. patient's weight loss was only 10% f. patient's wounds are all in the process of healinh

b c d

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? "Birth control is not needed while taking sumatriptan." "I must report any chest pain right away." "St. John's wort can also be taken to help my symptoms." "Sumatriptan can be taken as a last resort."

The client comment that shows that she understands the discharge instructions is that any chest pain must be reported right away. Chest pain must be reported immediately with the use of sumatriptan because triptans cause vasoconstriction.Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans would not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression. Sumatriptan must be taken as soon as migraine symptoms appear.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg.

The client's weight decreases by 2.5 kg. The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 pounds (2.5 kg) in one day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

18. Which criterion describes a full-thickness burn wound? (Select all that apply.) a. The wound is red and moist and blanches easily. b. There is destruction to the epidermis and dermis. c. There are no skin cells for regrowth. d. The burned tissue is avascular. e. The burn wound will not be painful.

b, c, d

35. A patient is transported to the ED for severe and extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress and the resuscitation team must immediately begin multiple interventions. Which task is delegated to unlicensed assistive personnel (UAP)? a. Position the patient's head to open the airway and assist with intubation. b. Assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation. c. Prepare the intubation equipment and set up the oxygen flowmeter. d. Elevate the head of the bed to achieve a high-Fowler's position.

b

41. A patient was admitted to the burn unit approximately 6 hours ago after being rescued from a burning building. In the ED, he reported a dry, irritated throat "from breathing in the fumes," but otherwise had no airway complaints. During the shift, the nurse notes that the patient has suddenly developed marked stridor. The nurse anticipates preparing the patient for which emergency procedure? a. Bronchoscopy b. Intubation c. Needle thoracotomy d. Escharotomy

b

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? ST segment Heart rate Troponin Myoglobin

The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

43. A patient in the burn intensive care unit is receiving vecuronium (Norcuron). What is the priority nursing intervention for this patient? a. Have emergency intubation equipment at the bedside. b. Ensure that all the equipment alarms are on and functional. c. Closely monitor the patient's urinary output every hour. d. Ensure that daily drug levels and electrolyte values are obtained.

b

46. The release of myoglobin form damaged muscle in patients with major burns can result in which potential complication? a. Paralytic ileus b. Acute kidney injury c. Limited mobility d. Hypovolemia

b

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway

The nursing priority when assessing a client with a spinal cord injury is a patent airway. Clients with injuries at or above T6 are at risk for respiratory complications. Assessing for a patent airway is essential.Asking the client about current medications and allergies is part of every trauma assessment. Assessing the level of consciousness utilizing the Glasgow Coma Score (GCS) is an important part of the trauma assessment. Determining the level of loss of sensation will be included in the neurological evaluation.

60. Which statement about the third spacing or capillary leak syndrome in a patient with severe burns is accurate? a. It usually happens in the first 36 to 48 hours. b. It is a leak of plasma fluids into the interstitial space. c. It is present only in the burned tissues. d. It can usually be prevented with diuretics.

b

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests

The risk for hypotension At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A client arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury?

Thrombosed blood vessels are visible beneath the skin surface.

Why is positive end-expiratory pressure (PEEP) provided to the clients with major burns? 1. To increase the lung volume 2. To decrease the exchange of gases 3. To increase the vascular supply 4. To increase the respiratory rate

To increase the lung volume - Clients with major burns have acute respiratory distress syndrome due to hypoxia. In end-expiratory pressure (PEEP), continuous positive pressure is applied in the alveoli and the airways to increase lung volume. It helps to increase oxygen permeability across the alveoli and capillaries. PEEP does not affect vascular supply, as it is an external pressure applied in the lung. PEEP is not used to increase respiratory rate.

The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? Administer antibiotics as prescribed. Transfuse ordered packed red blood cells. Teach pursed-lip breathing. Encourage increased fluid intake.

Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules and increases sites at which oxygen can attach and improves gas exchange.Antibiotics treat infection and do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement? Communications officer Hospital incident commander Medical command physician Triage nurse

Triage nurse When the triage officer is incapacitated, the triage nurse is the best choice for replacement. When physician resources are limited, an experienced nurse may assume this role.The communications officer serves as the liaison between the health care facility and the media. Typically, the hospital incident commander and the medical command physician are too busy to serve as triage officer as well.

78. Several patients are transported from an industrial fire to a local ED. Which factors increase the risk of death for these patients? (Select all that apply.) a. Male gender b. Age greater than 60 years c. Burn greater than 40% TBSA d. Presence of an inhalation injury e. Presence of contact burns

b, c, d

65. The nurse is reviewing the laboratory results for several burn patients who are approximately 24-to 36 hours postinjury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see? a. Anemia b. Metabolic alkalosis c. Hypernatremia d. Hyperkalemia

a

3. The home health nurse is visiting an older couple for the initial visit. In observing the household, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and/or household fires? (Select all that apply.) a. Several potholders hanging within easy reach of the stove b. Ashtray with old cigarette butts on the bedside table c. Space heater very close to the bed d. Single smoke detector in the kitchen e. Back exit hall of the house used as a storage space

b, c, d, e

82. Which feelings are most typically expressed by the burn patient? (Select all that apply.) a. Suspicion b. Regression c. Apathy d. Denial e. Suicidal ideations f. Anger

b, d, f

10. The nurse is caring for several patients who have sustained burns. The patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. Severe sunburn after lying in the sun for several hours b. Deep full-thickness burn from an electrical accident c. Partial-thickness burn from picking up a hot pan d. Deep partial-thickness burn after a motorcycle accident

b

The rate at which IV fluids are infused is based on the burn client's a. lean muscle mass and body surface area burned b. total body weight and BSA burned c. total BSA and BSA burned d. height and weight and BSA burned

b. During the first 24 hours, fluid replacement is calculated on total body weight and BSA burned.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? a. oral OTC analgesics b. IV opioids c. IM opiods d. Oral antianxiety agents

b. IV opiods client will be in severe pain

16. The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What assessment finding does the nurse anticipate? a. Patient will be cyanotic because of hypoxia. b. Blood gas value of PaO2 will be very low. c. Patient will report a headache. d. Patient will report a dry and irritated throat.

c

2. The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. Bradycardia and pitting edema b. Hypertension and decreased urine output c. Tachycardia and hypotension d. Respiratory depression and lung crackles

c

24. An adult patient is admitted to the burn unit after being burned in a house fire. Assessment reveals burns to the entire face, back of the head, anterior torso, and circumferential burns to both arms. Using the rule of nines, what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

c. Administering intravenous fluids through the AV fistula

A client is receiving fluid replacement with LR after 40% of his body was burned 10 hours ago. The assessment reveals: Temp 36.2, HR 122, BP 84/42, CVP 2 mm, and urine output 25 mL for the last two hours. The IV rate is currently at 375 mL/hr. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for a. furosemide b. fresh frozen plasma c. IV rate increase d. dextrose 5%

c. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement.

A nurse is caring for a client who was admitted 24 hours ago with deep partial thickness and full thickness burns to 40% of his body. Which of the following are expected findings in this client? (select all) a. hypertension b. bradycardia c. hyperkalemia d. hyponatremia e. decreased hematocrit

c. hyperkalemia occurs when a client is in shock as a result of leakage of fluid from the intracellular space. d. hyponatremia occurs as a result in sodium retention in the interstitial space. a. hypotension b. tachycardia e. increased hematocrit

The nurse in the immediate care clinic is assessing an 80 year old client who lives with his son's family and has scald burns on his hands and both forearms (first and second degree burns on 10% of his body). What should the nurse do first? a. clean the wounds with warm water b. apply antibiotic cream c. refer the client to a burn center d. cover the burns with a sterile dressing

c. refer the client to a burn center - The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for injection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

d. Prepare protamine sulfate for administration.

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective? "I should try to exercise between noon and 3 PM." "I will limit my fluids to drinking 'sports' drinks after I exercise." "Taking frequent rests is important when in a hot environment." "Wearing dark-colored clothing to deflect the sun away from me will help me stay cooler."

"Taking frequent rests is important when in a hot environment." The statement that demonstrates that the teaching about heat exhaustion is effective is the comment that stresses the importance of frequent rest periods when in a hot environment. Frequent rest periods will decrease the risk of heat exhaustion.Exercising during times of peak sun exposure (midday) will increase the risk of heat exhaustion. Fluids, particularly water, have to be consumed throughout the exercise period and not be limited to a certain type. Light colored clothing, not dark, reflects the sun away from the individual.

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) The nurse would first assess the 46-year-old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.