Med surg Final

After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?

Absent Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.

The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents?

Administer factor VIII intravenously at the first sign of bleeding Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, however, playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided because they will interfere with platelet aggregation. Nasal packing is avoided because when the nasal packing is removed, bleeding may occur.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?

6 to 12 Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?

Increasing difficulty in swallowing The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order?

CBC Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered.

A nurse is teaching a client about asthma. What symptoms should be included with the teaching? Select all that apply.

Chest tightness Wheezing Dyspnea Productive cough The common symptoms of asthma are productive cough, chest tightness, dyspnea, and wheezing. In some instances, cough may be the only symptom. Crackles are not seen with clients with asthma.

Which electrolyte is a major anion in body fluid?

Chloride Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are cations.

A nurse is admitting a client with emphysema. What are presenting findings the nurse should assess? Select all that apply.

Chronic cough Dyspnea The clinical manifestations for emphysema is grouped with COPD and includes chronic cough, sputum production, and dyspnea. Chest pain, wheezing, and tachypnea are not common findings.

A nurse is monitoring the client's progression of human immunodeficiency virus (HIV). What debilitating gastrointestinal condition found in up to 90% of all AIDS clients should the nurse be aware of?

Chronic diarrhea Chronic diarrhea is believed related to the direct effect of HIV on cells lining the intestine. Although all gastrointestinal manifestations of acquired immune deficiency syndrome (AIDS) can be debilitating, the most devastating is chronic diarrhea. It can cause profound weight loss and severe fluid and electrolyte imbalances.

A nursing student is preparing a teaching plan for a client with an immunodeficiency disorder. The student is going to include the cardinal symptoms in teaching. Which of the following would the student include? Choose all that apply.

Chronic diarrhea Chronic or recurrent severe infections Poor response to treatment of infections Regardless of the underlying cause, the cardinal symptoms of immunodeficiency include chronic or recurrent and severe infections, infections caused by unusual organisms or by organisms that are normal body flora, poor response to standard treatment for infections, and chronic diarrhea.

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition?

ERCP The ERCP is the most useful study in the diagnosis of chronic pancreatitis. The other answer choices may be used; however, these are not the most useful in the diagnosis of chronic pancreatitis.

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?

Employs the Z-track technique When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.

A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included?

Encourage the client to avoid exercise. Activity promotes healing and normal stool patterns. Proper cleansing prevents infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?

Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

Which is a key characteristic of pleurisy?

Pain The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

Which of the following is the most common symptom of a polyp?

Rectal bleeding The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.

A nurse is caring for a client who had an ileal conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation?

Red, sensitive skin around the stoma site Red, sensitive skin around the stoma site may indicate an ill-fitting appliance beefy redness at a stoma site that isn't sensitive to touch is a normal assessment finding. Urine mixed with mucus is also a normal finding.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome?

Steatorrhea Hyperacidity in the duodenum inactivates pancreatic enzymes causing steatorrhea and ulcer diathesis.

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a:

fissure. An anal fissure (fissure in ano) is a linear tear in the anal canal tissue. An anal fistula (fistula in ano) is a tract that forms in the anal canal. Hemorrhoids are dilated veins outside or inside the anal sphincter. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output?

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include

the importance of blood tests to monitor serum concentrations. The nurse should inform clients about the importance of blood tests to monitor serum concentration. The therapeutic range of theophylline is between 5 and 15 μg/mL. The client is at risk of developing hypokalemia.

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:

there are usually no symptoms. The early stage of oral cancer is characteristically asymptomatic.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for

vision changes. Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?

Graft-versus-host disease Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications.

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?

Ineffective Airway Clearance The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Risk for Infection is a real potential because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

Ineffective airway clearance related to obstruction by mucus All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.

A client is instructed to follow a low-fat diet after an inflammatory attack of the gallbladder. Which vitamins will the nurse recommend the client supplement due to the client's dietary restrictions? Select all that apply.

A D K Essential fatty acids A low-fat diet should be supplemented with vitamins A, D, K, and essential fatty acids. These vitamins are fat-soluble and will need to be administered if the client does not have adequate fat intake. Folic acid is not a fat-soluble vitamin.

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?

nasogastric intubation The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply.

semen breast milk blood vaginal secretions There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

An older adult client in a long term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"?

stool consistency and client comfort Normal bowel patterns range from three bowel movements per day to three bowel movements per week. In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination.

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

The nurse is caring for a client with heart failure who has been prescribed digoxin. What laboratory value for the client can precipitate digoxin toxicity?

Potassium 3.0 milliequivalents per liter The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. A potassium level of potassium 3.0 milliequivalents per liter is low or hypokalemic. A potassium level of 5.6 is high or hyperkalemic. The sodium levels do not precipitate digoxin toxicity.

A nurse cares for a client with anemia requiring nutritional supplementation. Which nursing intervention best promotes client adherence with the prescribed therapy?

Assist the client to incorporate the therapeutic regimen into daily activities The best way for the nurse to promote adherence to the therapeutic regimen is to assist the client to incorporate the therapeutic regimen into daily activities. This action is the only answer choice that is a collaborative effort with the client and is the reason it is correct.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:

Make a notation on the call light system that the client cannot speak. The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

Vomiting results in which of the following acid-base imbalances?

Metabolic alkalosis Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find?

Stool cultures negative for microorganisms or parasite Stool cultures fail to reveal an etiologic microorganism or parasite, but occult blood and white blood cells (WBCs) often are found in the stool. Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies. The WBC count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder. Serum protein and albumin levels may be low because of malnutrition.

The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?

There is excess fluid volume in the interstitial space in areas affected by gravity. Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide?

Wear a medical identification bracelet. Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed?

With meals Nearly 90% of clients with cystic fibrosis have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.

A client has had an echocardiogram to measure ejection fraction. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6 Step 1:2 × 8 oz = 16 oz Step 2:1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 40% for a patient with COPD. What stage should the nurse document the patient is in?

III All grades of COPD are associated with an FEV1/FVC ratio of less than 70%. Grade I (mild) is associated with an FEV1 of greater than or equal to 80%. Grade II (moderate) is associated with an FEV1 of 50%-80%. Grade III is associated with an FEV1 of <30%-50%. Grade IV is associated with an FEV1 of <30%.

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?

6 weeks Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia).

60; 50 Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to less than 60 mm Hg on room air) and hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to greater than 50 mm Hg with an arterial pH of less than 7.35).

This example of cholesterol gallstones (left side of picture) is the result of decreased bile acid synthesis and increased cholesterol synthesis in the liver, which in turn, form stones. Cholesterol stones account for what percentage of cases of gallbladder disease in the United States?

75% Cholesterol stones account for approximately 75% of cases of gallbladder disease in the United States.

A nurse is caring for an older client who has been admitted to the unit with iron-deficiency anemia. What would the nurse suspect?

Blood loss from the gastrointestinal or genitourinary tract If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.

A client who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the past year. The nurse attributes which factor as the most likely cause of this weight loss?

Skipping meals out of fear of painful attacks Weight loss is a major problem in chronic pancreatitis. More than 80% of clients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?

Sputum and a productive cough Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years.

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? You Selected:

Stool specimen for ova and parasites A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this?

Women lose iron through menstrual cycles Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

The two types of inherited B-cell deficiencies result from lack of differentiation of B cells. These types result from which two of the following deficiencies? Choose the two that apply.

Mature B-cells Plasma cells Two types of inherited B-cell deficiencies exist. The first type results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are absent, and the germinal centers from all lymphatic tissues disappear, leading to a complete absence of antibody production against invading bacteria, viruses, and other pathogens.

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem?

Bowel perforation Megacolon is a dilated and atonic colon caused by a fecal mass that obstructs the passage of colon contents. Symptoms include constipation, liquid fecal incontinence, and abdominal distention. Megacolon can lead to perforation of the bowel.

Which clinical manifestation is not associated with hemorrhage?

Bradycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.

In women, which of the following types of cancer exceeds colorectal cancer?

Breast In women, only incidences of breast cancer exceed that of colorectal cancer. In men, only incidences of prostate cancer and lung cancer exceed that of colorectal cancer.

A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy?

Bring the viral load to a virtually undetectable level The goal of antiretroviral therapy is to bring the viral load to a virtually undetectable level. This level is no more than 500 or 50 copies, depending on the sensitivity of the selected viral load test. It is not possible to reverse the status to a negative, and it cannot eliminate the risk of AIDS but can help with prolonging the asymptomatic stage of HIV. Antiretroviral therapy does not treat mycobacterium avium complex.

Which is a symptom of Cooley anemia?

Bronzing of the skin Clients with Cooley anemia exhibit symptoms of severe anemia and a bronzing of the skin, which is caused by hemolysis of erythrocytes. Dyspnea, stomatitis (inflammation of the mouth), and glossitis (inflammation of the tongue) are symptoms of pernicious anemia.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Dyspnea Dyspnea, the main symptom of PH, occurs at first with exertion and eventually at rest. Substernal chest pain also is common. Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur). Anorexia and abdominal pain in the right upper quadrant may also occur.

A nurse should expect to administer which vaccine to the client after a splenectomy?

Pneumovax 23 Pneumovax 23, a polyvalent pneumococcal vaccine, is administered prophylactically to prevent the pneumococcal sepsis that sometimes occurs after splenectomy. Recombivax HB is a vaccine for hepatitis B. Attenuvax is a live, attenuated virus vaccine for immunization against measles (rubeola). Tetanus toxoid is administered to prevent tetanus resulting from impaired skin integrity caused by traumatic injury.

A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

Polyps Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Potassium levels A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

Preload Preload is the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

Proton pump inhibitors. Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client?

Provide the client with an irrigating solution of baking soda and warm water. If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Headache, blurry vision, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?

Low ferritin level concentration The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.

Which of the following are functions of saliva? Select all that apply.

Lubrication Protection against harmful bacteria Digestion The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.

Which of the following is the most common type of diverticulum?

Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

active transport Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.

Hemophilia A is the most common of the three types of hemophilia. What is diminished in the less serious form of hemophilia A, known as von Willebrand's disease?

amount and quality of factor VIII In a less serious form of hemophilia A, von Willebrand's disease, the amount and quality of factor VIII is diminished.

A client being treated for HIV/AIDS has a decreased appetite, almost to the point of anorexia. What is the best action by the nurse?

Administer megestrol acetate. Appetite stimulants are successfully used in clients with AIDS-related anorexia. The anorexia is compounded by medications that cause nausea and vomiting. The anorexia has a physiologic cause, and this must be addressed. Bringing in favorite foods or making favorite foods may have little or no effect on the client's appetite; it is physiological rather than psychological.

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?

Creatinine level of 6 mg/100 mL The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.

A client is having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of?

Crohn's disease The most conclusive diagnostic aid for Crohn's disease has classically been a barium study of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.

Which is one of the primary symptoms of irritable bowel syndrome (IBS)?

Diarrhea The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.

The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. Which study will the nurse prepare the client for?

Flexible sigmoidoscopy The treatment of fecal incontinence depends on the cause. A rectal examination and other endoscopic examinations, such as a flexible sigmoidoscopy, are performed to rule out tumors, inflammation, or fissures. X-ray studies such as barium enema, computed tomography (CT), anorectal manometry, and transit studies may be helpful in identifying alterations in intestinal mucosa and muscle tone or in detecting other structural or functional problems.

A nurse helps a patient recently diagnosed with a pituitary adenoma understand that:

Most tumors produce too much of one or more hormones. Explanation: The majority of these tumors are benign. In rare cases, they may be malignant. Functioning tumors produce hormones, frequently in excessive amounts, resulting in conditions such as hyperthyroidism, Cushing's syndrome, and gigantism or acromegaly.

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?

Multiple myeloma The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.

What assessment finding best indicates that the client has recovered from induction therapy?

Neutrophil and platelet counts within normal limits Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction therapy.

A client is prescribed methylprednisolone (Solu-Medrol) 125 mg intravenously. The medication is available in a 125 mg single-dose vial containing 2 mL. The nurse will administer methylprednisolone over 2 minutes. How many mL will the nurse administer each 15 seconds? Write your answer to 2 decimal places. Starting with 0., enter the correct number ONLY.

0.25 The volume to be infused is 2 mL over 2 minutes. There are 60 seconds in each minute. For every 15 seconds, the nurse will administer 0.25 mL. 2 mL/120 sec = x/15 sec. 0.25 mL = x

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest." Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum The clinical manifestations of pulmonary contusions are based on the severity of bruising and parenchymal involvement. The most common signs and symptoms are crackles, decreased or absent bronchial breath sounds, dyspnea, tachypnea, tachycardia, chest pain, blood-tinged secretions, hypoxemia, and respiratory acidosis. Patients with moderate pulmonary contusions often have a constant, but ineffective cough and cannot clear their secretions.

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?

Borborygmus Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent client assessments. An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.

A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about?

EPS

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Extracellular fluid volume deficit Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.

Which is a characteristic of right-sided heart failure?

Jugular vein distention Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

The nurse is caring for a client receiving chemotherapy. For which mouth conditions associated with HIV infection should the nurse assess? Select all that apply.

Kaposi sarcoma Stomatitis Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion that is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy, as well as HIV infection. Erythroplakia is caused by a nonspecific inflammation, and candidiasis is caused by fungus.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

Lamb and peaches Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

Pancytopenia Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Performing guided imagery Putting on soothing music Changing the client's position Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis?

Providing intensive insulin therapy Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores?

There is a strong correlation between iron stores and hemoglobin levels A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.

Which statement best describes the function of stem cells in the bone marrow?

They produce all blood cells. All blood cells are produced from undifferentiated precursors called pluripotent stem cells in the bone marrow. Other cells produced from the pluripotent stem cells help defend against bacterial infection, produce antibodies against foreign antigens, and are active against hypersensitivity reactions.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:

canned peas. There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

A client admitted to the hospital with abdominal pain, anemia, and bloody stools reports feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help them:

onto the bedpan. A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which electrocardiogram changes will the client display?

peaked T waves The earliest changes occur when the serum potassium level is 7 mEq/L (mmol/L). Cardiac tracings include peaked and narrow T waves, ST segment depression, and a shortened QT interval.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). What diagnosis will the nurse suspect for this client?

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort. A client with diverticulitis commonly states he has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

nausea and vomiting Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly so it won't fall off while I nap." The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a water-soluble lubricant, such as K-Y jelly, to prevent drying. Smoking is contraindicated wherever oxygen is in use; posting of a "no smoking" sign warns people against smoking in the client's house. Cleaning the mask with water two or three times per day removes secretions and decreases the risk of infection.

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply.

"I will watch my urine output to be sure that the medication is not affecting my kidneys." "If I take my digoxin I should have limited episodes of shortness of breath." Digoxin is excreted by the kidneys and causes renal failure, so the client should monitor urine output. Digoxin therapy will increase ventricular output, so it can be effective in decreasing heart failure symptoms like shortness of breath. Digoxin toxicity may can anorexia, not increased appetite. Digoxin therapy will slow AV conduction, not increase heart rate or blood pressure. A client taking digoxin therapy will have levels drawn if symptoms of toxicity or renal function changes are present.

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?

"The child must inherit two defective genes, one from each parent." Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, he or she carries sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors

A nurse cares for an older adult client and teaches the client about age-related changes of the biliary tract. What statements will the nurse include when discussing age-related changes that occur in the pancreas of the older adult? Select all that apply.

"The pancreas develops fibrous material with age." "The pancreas develops fatty deposits with age." "The pancreas decreases secretion of enzymes with age." "The pancreas decreases bicarbonate secretion with age." Age-related changes to the pancreas include: the development of fibrous material and fatty deposits, as well as decreased secretion of both pancreatic enzymes and bicarbonate. The pancreas remains the same size as the client ages and atrophy is not a normal age-related finding

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"The people I have contact with at work should be checked regularly." The client requires additional teaching if he states that coworkers need to be checked regularly. Such casual contacts needn't be tested for tuberculosis. However, a person in close contact with a person who's infectious is at risk and should be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months, that coworkers don't need medication, and that he requires laboratory tests while on medication. Coworkers not needing medications, taking the medication for 9 to 12 months, and having scheduled laboratory tests are all appropriate statements.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?

"The tube will drain air from the space around the lung." Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

Which medication reverses digitalis toxicity?

Digoxin immune FAB Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

Which statement describes emphysema?

A disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?

Achalasia Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?

Actinic cheilitis Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of the horny layer of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed clients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Erythroplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.

A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?

Acute chest syndrome One of the unique manifestations of sickle cell disease is "acute chest syndrome," a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs. Acute chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing, tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion and predisposes the client to pneumonia but is not the present problem with this client. Pneumocystis pneumonia is present in the client with HIV/AIDS or other immunocompromised clients. The client's symptoms do not correlate with a diagnosis of acute muscular strain.

A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?

Administer epinephrine. PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers). PEA is treated with epinephrine according to advanced life support protocol. Applying oxygen or analyzing an arterial blood gas will not change the client's heart rhythm. PEA is treated until there is no change in the client's rhythm after treatments.

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply.

Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Assess respiratory status every 4 hours and prn. The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take?

Administer the prescribed enoxaparin (Lovenox). Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?

Administer the third sublingual nitroglycerin tablet. The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.

A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first?

Administering I.V. fluids The nurse should first administer I.V. infusions containing normal saline solution and potassium to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to help diagnose bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication commonly is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

An older adult client at the free clinic has a history of seizures and presents with severe fatigue, frequent headaches, and a sore and beefy red tongue. Which of the following does the nurse suspect as causes of the client's current condition? Select all that apply.

Alcoholism Intestinal disorders Not eating vegetables Poor nutrition The client is showing signs of folic acid deficiency anemia caused by a deficiency of folate or folic acid in the client. Alcoholism, Intestinal disorders that affect absorption, lack of vegetables or other folate-containing foods in the diet where folic acid is not being supplemented or consumed by other sources, and poor nutrition are all causes of folic acid deficiencies.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases In left-sided heart failure, arterial blood gases may be obtained to assess ventilation and oxygenation.

A client experienced surgical resection of a tumor of the esophagus. After recovery from the anesthesia, what will the nurse include in the postoperative care plans? Select all that apply.

Assess lung sounds every 4 hours and prn. Monitor drainage in the closed chest drainage system. Verify rhythm on the cardiac monitoring system. Following recovery from anesthesia for a surgical resection of an esophageal tumor, the client is placed in the Fowler's position. A common postoperative complication is aspiration pneumonia. The nurse assesses for this complication by assessing lung sounds. The nurse monitors the drainage in the closed chest drainage system. Because of irritation of the vagus nerve, the nurse assesses for the complication of atrial fibrillation. The nurse does not replace the nasogastric tube if it becomes dislodged.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?

Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows. Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?

B12 The medication metformin (Glucophage) increases the client's risk for developing B12 deficiency because the medication inhibits the absorption of B12.

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

A client who had developed jaundice 2 months earlier is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this client to have?

Bile-stained vomiting Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.

A nurse cares for a client with early Hodgkin lymphoma. While assessing the client, the nurse will most likely find painless enlargement of which lymph node?

Cervical Non painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.

Which is an accurate statement regarding cancer of the esophagus?

Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Class I (Mild) Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply.

Clay-colored stools Dark urine Jaundice Pruritis The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

A nurse working with clients diagnosed with sickle cell disease notices that sickle cell crisis cases increase in the winter months. What is the primary pathophysiological reason for this?

Colder temperatures slows the blood flow. Colder temperatures lead to vasoconstriction, which slows the blood flow. Colder temperatures do not worsen sickling or impair oxygen uptake. Vasoconstriction does increase vessel pressures but the vessel pressures are not the reason that sickle cell crisis increases with colder temperatures.

A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive treatment is indicated. What is the first action by the nurse?

Collects sputum for culture and sensitivity Aggressive therapy for cystic fibrosis involves airway clearance and antibiotics, such as vancomycin and tobramycin, which will be prescribed based on sputum cultures. Sputum must be obtained prior to antibiotic therapy so results will not be skewed. Administering oral pancreatic enzymes with meals will be a lesser priority.

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.

Which of the following is the diagnostic of choice if the suspected diagnosis is diverticulitis?

Computed tomography scan A computed tomography scan is the diagnostic of choice if the suspected diagnosis is diverticulitis; it can also reveal one or more abscesses. A barium enema or colonoscopy may be used to diagnosis diverticulosis. Magnetic resonance imaging would not be used to diagnose diverticulitis.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Consult with the physician about discontinuing heparin. Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.

A patient is prescribed a mast cell stabilizer for the treatment of asthma. Which commonly used medication will the nurse educate the patient about?

Cromolyn sodium Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to moderate anti-inflammatory agents and are considered alternative medications for treatment. These medications stabilize mast cells. The other medications listed are not mast cell stabilizers.

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?

Delayed hypersensitivity response A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.

Which is the primary symptom of achalasia?

Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness?

Endoscopy with mucosal biopsy Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.

Which blood test confirms the presence of antibodies to HIV?

Enzyme immunoassay (EIA) EIA and Western blotting identify and confirm the presence of antibodies to HIV. ESR is an indicator of the presence of inflammation in the body. p24 antigen test is a blood test that measures viral core protein. Reverse transcriptase is not a blood test. Rather, it is an enzyme that transforms single-stranded RNA into double-stranded DNA.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive?

Enzyme-linked immunosorbent assay (ELISA) The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.

A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir?

Every 4 to 6 hours The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. This prevents the accumulating effluent from spilling or causing infection.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

A patient with chronic anemia has had many blood transfusions over the last 3 years. What type of transfusion reaction should the nurse monitor for that is commonly found in patients who frequently receive blood transfusions?

Febrile nonhemolytic reactions A febrile nonhemolytic reaction is caused by antibodies to donor leukocytes that remain in the unit of blood or blood component; it is the most common type of transfusion reaction. It occurs more frequently in patients who have had previous transfusions (exposure to multiple antigens from previous blood products) and in Rh-negative women who have borne Rh-positive children (exposure to an Rh-positive fetus raises antibody levels in the untreated mother).

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?

Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

Which medication is categorized as a loop diuretic?

Furosemide Furosemide is commonly used to treat cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide and chlorthalidone are categorized as thiazide diuretics. Spironolactone is categorized as a potassium-sparing diuretic.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client

Has wheezes in the right lung lobes Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living.

When assessing a client with anemia, which assessment is essential?

Health history, including menstrual history in women When assessing a client with anemia, it is essential to assess the client's health history. Women should be questioned about their menstrual periods (e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy.

A patient has a probable diagnosis of polycythemia vera. The nurse reviews the patient's lab work for which diagnostic indicator?

Hematocrit of 60% Although all results are elevated, the diagnostic indicator is the elevated hematocrit (normal = 42% to 52% for a male). These results are used in combination with other indicators (e.g., splenomegaly) for a definitive diagnosis.

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond?

High-carbohydrate, low-protein, low-fat diet The nurse should provide a high-carbohydrate, low-protein, low-fat diet when tolerated. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited.

Asthma is cause by which type of response?

IgE-mediated Atopy, the genetic predisposition for the development of an IgE-mediated response to allergens, is the most common identifiable predisposing factor for asthma. Chronic exposure to airway allergens may sensitize IgE antibodies and the cells of the airway.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?

Increase respiratory effectiveness. The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of:

Increased PaCO2. The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.

Which is a gerontological consideration associated with the pancreas?

Increased amount of fibrous material An increase in fibrous material and some fatty deposition occurs in the normal pancreas of people older than 70 years of age. There is a decreased rate of pancreatic secretion and decreased bicarbonate output in older adults. Decreased calcium absorption may also occur.

The pathophysiology of pericardial effusion is associated with all of the following except:

Increased venous return. Venous return is increased because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart.

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

Ineffective coping related to anxiety Any factor that interferes with normal breathing quite naturally induces anxiety, depression, and changes in behavior. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Although the other choices are correct, the most important psychosocial nursing diagnosis for a patient with COPD is ineffective coping related to a high level of anxiety.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Select all that apply.

Inflamed airways obstruct airflow. Mucus secretions block airways. Overinflated alveoli impair gas exchange. Because of the chronic inflammation and the body's attempts to repair it, changes and narrowing occur in the airways. In the peripheral airways, inflammation causes thickening of the airway wall, peribronchial fibrosis, exudate in the airway, and overall airway narrowing (obstructive bronchiolitis). The airways are actually moist, not dry. In the proximal airways, changes include increased goblet cells and enlarged submucosal glands, both of which lead to hypersecretion of mucus.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention?

Instruct the client to swish prescribed nystatin solution for 1 minute. A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate?

Neurologic involvement In clients with pernicious anemia, numbness and tingling in the arms and legs, and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.

The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action?

Notify the physician Thrombocytopenia is evidenced by purpura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues. Bleeding from other parts of the body, such as the nose, oral mucous membrane, and the gastrointestinal tract, also occurs. Internal hemorrhage, which can be severe and even fatal, is possible. This nurse should notify the physician of the suspected disorder.

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about?

Nystatin Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak. When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?

Persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms?

Place the client in semi-Fowler's position. A client with severe biliary colic is in extreme pain and has a very difficult time taking a deep breath due to severe pain on inspiration. Placing the client in upright or semi-Fowler's position best promotes adequate breathing and best supports the client's function. Ambulation, deep breathing and coughing, and incentive spirometry may be too difficult or impossible for the client with severe biliary colic symptoms.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

Right lower quadrant The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum lipase In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:

Sharp, stabbing chest pain The initial symptom is usually chest pain of sudden onset that leads to feelings of chest pressure, dyspnea, and tachycardia. A cough may be present.

Which term describes an inflammation of the salivary glands?

Sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200-900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client?

Supplement the diet with vitamin B12. Data support that the client is experiencing megaloblastic anemia. Findings include the laboratory test results, the client's older age, and the client's status as a vegetarian. Many vegetarians need to supplement their diet with vitamin B12. Eating more foods with vitamin B12 will not provide enough of this vitamin for the client's body. Increasing iron sources will not resolve the client's anemia. Telling the client to discontinue the vegetarian practice and eat red meat is nontherapeutic.

A client with hemophilia was admitted after sustaining an injury while playing outdoors with friends. Initially, the client presented with severe bleeding but has since stabilized. Which interventions will the nurse include in the care plan for this client? Select all that apply.

Support painful joints on pillows. Encourage the client to use a soft toothbrush and rinse the mouth with warm water between and after meals. Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Interventions are implemented to reduce pain and discomfort and to prevent further bleeding episodes. NSAIDs and aspirin are eliminated because these drugs can increase bleeding tendencies. The nurse takes the temperature over the temporal artery or tympanically to avoid oral or rectal injuries and checks the urine and stools for signs of bleeding.

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education?

Surgical removal of the diverticulum Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. A low-residue diet will not stop the progression of the disease. Chemotherapy and radiation therapy will not target the specific site of the Zenker's diverticulum.

Which of the following is a factor affecting an increase in urine osmolality

Syndrome of inappropriate antidiuretic hormone release (SIADH) Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.

What disease processes contribute to chronic heart failure? Select all that apply.

Tachydysrhythmias Valvular disease Renal failure Hypertension, tachydysrhythmias, valvular disease, cardiomyopathy, and renal failure can contribute to chronic heart failure. Pancreatic disease and pulmonary insufficiency do not contribute to chronic heart failure.

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching?

Take 1 hour before breakfast Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

Take ordered medications as scheduled. Although avoiding contact with fur-bearing animals, changing filters on heating and air conditioning units frequently, and avoiding goose down pillows are all appropriate measures for clients with asthma, taking ordered medications on time is the most important measure in preventing asthma attacks.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test all stools for occult blood. Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse?

To detect the abnormal sounds suggestive of acute chest syndrome and heart failure The nurse auscultates the lungs and heart to detect abnormal sounds that indicate pneumonia, acute chest syndrome, and heart failure. The nurse assesses vital signs to detect evidence of infection, such as fever and tachycardia. During the physical examination, the nurse observes the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. The nurse assesses mental status, verbal ability, and motor strength to detect stroke-related signs and symptoms.

A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?

The client has an absence of bowel sounds. A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?

The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives?

The female condom The female condom, the first barrier method controlled by women, is the only proven, effective method to prevent the transmission of HIV and sexually transmitted infections (STI).

When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature?

Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements The term leukemia means "white blood," which is used to describe the neoplastic proliferation of one hematopoietic cell type (granulocytes, monocytes, lymphocytes, and sometimes, erythrocytes and megakaryocytes).

Which of the following interventions are appropriate for clients with gastritis? Select all that apply.

Use a calm approach to reduce anxiety. Discourage cigarette smoking. Notify the physician of indicators of hemorrhagic gastritis. The nurse should use a calm approach when answering questions and providing teaching. He or she should discuss smoking cessation and monitor for any indicators of hemorrhagic gastritis. The client will take nothing by mouth for up to a few days until symptoms subside. The nurse needs to develop an individualized teaching plan for the client that includes information about stress management, diet, and medications.

The nurse is admitting a client to the unit with a diagnosis of ataxia-telangiectasia. The nurse would recognize that the client is exhibiting telangiectasia when assessing the presence of what?

Vascular lesions caused by dilated blood vessels Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia refers to uncoordinated muscle movement and is a clinical manifestation of combined B-cell and T-cell deficiencies. Telangiectasia is not peripheral edema, vascular lesions, or urticaria.

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelithiasis can interfere with the absorption of

Vitamin A Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Clients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. Vitamins B6, B12, and C are not fat soluble.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?

chlorpromazine Chlorpromazine (Thorazine) is used to treat intractable hiccups.

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?

decrease in renal perfusion A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

A client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults?

dementia Pernicious anemia may be accompanied by a dementia with symptoms similar to Alzheimer's disease. Therefore, clients experiencing cognitive changes should be screened because early detection of pernicious anemia is critical to prevent neurologic damage.

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?

dopamine Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client includes

implementing measures to clear pulmonary secretions. Nursing management focuses on alleviating symptoms and helping clients clear pulmonary secretions. Although teaching the family how to perform postural drainage and instructing the client on the signs of respiratory infection are important, they are not the nurse's primary focus. The presence of a large amount of mucus may decrease the client's appetite and result in inadequate dietary intake; therefore, the client's nutritional status is assessed and strategies are implemented to ensure an adequate diet.

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb in 1 day." The nurse should instruct the client to weigh himself daily and report a gain of 2 lb in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy. The client shouldn't smoke at all.

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain." After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level?

115 mEq/L Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?

158.0 lbs (71.7 kg) A loss of 0.5 kg, or 1.1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2.2 lbs (1 kg), bringing the client's weight to 158.0 lbs (71.7 kg).

Which action should the nurse take first in caring for a client during an acute asthma attack?

Administer bronchodilator as ordered. Administering bronchodilator will dilate the airway and allow oxygen to reach the lungs. Although ABGs and chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

60 mm Hg; 90% The goal is a PaO2 of at least 60 mm Hg and an SaO2 of 90%.

A client comes to the health clinic after a positive skin test for tuberculosis. What additional diagnostic tests should the nurse begin teaching the client? Select all that apply.

A chest radiograph Complete history and physical examination Drug susceptibility testing Once a client had a positive skin test or a positive sputum culture for acid-fast bacilli, additional tests such as complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing are done. The nurse does not need to teach about a complete blood count or a repeat multiple puncture skin test, as the initial positive skin test will serve as the indicator of tuberculosis.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

A client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate?

Chemical irritation Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage. Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?

Decreased cardiac output Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.

Heart failure Pulmonary edema Renal impairment Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

Vitamin B6 Vitamin B6 (pyridoxine) is usually administered with INH to prevent INH-associated peripheral neuropathy. Vitamins C, D, and E are not appropriate.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:

Ineffective airway clearance. Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C Vitamin C is important for capillary formation, tissue synthesis, and wound healing through collagen formation. Vitamin A decreases the inflammatory response in wounds. Magnesium is essential for wound repair, and protein allows collagen deposition.

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?

Deficient knowledge (disease process and treatment regimen) This client is exhibiting Deficient knowledge about the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, his question reflects sadness at the prospect of being separated from his family rather than anxiety about the disease. Because he has just been diagnosed and hasn't had a chance to demonstrate compliance, a nursing diagnosis of Social isolation isn't appropriate. A diagnosis of Impaired social interaction usually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis.

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication. The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?

Magnesium Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur?

Metabolic alkalosis Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?

Notify the primary care provider immediately. If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?

Presence of Trousseau sign After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated. Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered dirty.

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse?

The employee enters the room wearing a gown, gloves, and a mask. The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?

Turn onto the affected side. Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side. In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting?

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?

"You must consume a diet rich in protein, such as chicken, fish, and beans." The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days HSV-1 is transmitted primarily by direct contact with infected secretions. The incubation period is about 2 to 12 days. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?

20% The patient would receive a cardiovascular/circulation score of 2 if the blood pressure is 20% of the preanesthetic level.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure. The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with nasal obstruction.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first?

Assess for bleeding. The client is tachycardic with low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the client, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance?

Hypocalcemia The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus concentration tends to cause a low serum calcium concentration.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. Besides checking the health care provider's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

Intubate the client and control breathing with mechanical ventilation A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal:

On the second or third day. The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result

Serum sodium level of 124 mEq/L In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis?

Sodium bicarbonate IV administration of sodium bicarbonate may be necessary in severe metabolic acidosis to alkalinize the plasma, shift potassium into the cells, and furnish sodium to antagonize the cardiac effects of potassium.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

The most diagnostic clinical symptom of pleurisy is:

Stabbing pain during respiratory movements. The key characteristic of pleuritic pain is its relationship to respiratory movement: taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held; leading to rapid shallow breathing. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid accumulates, the pain decreases.

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

The nursing instructor is talking with the junior class of nursing students about lung cancer. What would be the best rationale the instructor could give for the difficulty of early diagnosis of lung cancer?

Symptoms often do not appear until the disease is well established Early diagnosis of cancer of the lung is difficult because symptoms often do not appear until the disease is well established. Option A is correct, but it is not the best answer. Option B is incorrect because it is not a true statement. Option C is incorrect because lung cancer is not an infectious disease.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema. Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage