Med. Surg Final

The nurse is advising a community group on hospital procedures established for a bioterrorism attack. The nurse specifically addresses which agent where victims need a room under negative air pressure?

Smallpox

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement.

You are caring for a client who has just had total parenteral nutrition (TPN) ordered. The LPN is correct when informing the client that TPN is used for what?

To meet the client's caloric and nutritional needs

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

Elevated hematocrit level

The major advantage for giving a client medication via intravenous (IV) route is which of the following

Rapid distribution of the drug to all target tissues

A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?

"I guess the doctor could not remove the entire tumor."

Which is the best option for raising the white blood cell count in a cancer client who is at risk for congestive failure?

24 hours

What is one process by which dissolved chemicals from one area of the body to another?

Active transport

A client is prescribed pain medications. Which of the following interventions will enable the client to consume an adequate meal during treatment?

Administer the medication 30 to 45 minutes before meals.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics on a regular basis, as per physician's order

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?

Adrenergic drugs

A physically fit 86-year-old is scheduled for right knee replacement. What factor in this client makes him at increased risk for surgery?

Age

The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?

"I hope they find a bone marrow donor who matches."

You are taking a class on chemical disasters with your local emergency response team. What toxins would you be learning about? Select all that apply.

Blistering agents Nerve agents Cyanide

The nurse is administering a narcotic analgesic for the control of a newly postoperative patient's pain. What medication will the nurse administer to this patient?

Fentanyl (Duragesic)

A client visits the clinic with the complaint of a circular rash on the upper right arm. The rash is diagnosed as tinea corporis. What type of infection does the nurse anticipate the client will be treated for?

Fungus

The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?

"My cancer has now spread to my liver."

The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?

"A pulmonary artery pressure provides information about pressure on the left side of the heart."

A client sustained second- and third-degree burns to the chest and neck 4 days ago and is now refusing analgesics stating, "I don't want to become addicted to pain medication." What is the best response by the nurse?

"Although misusing the medication may cause addiction, there is little evidence that those who require narcotics for legitimate pain become addicted."

The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse?

"I can continue taking my vitamins and herbs because they make me feel better."

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?

"In my experience, clients who know are more likely to be involved with their plan of care."

The client asks the nurse why it is necessary to prime the intravenous tubing. Which is the best response by the nurse?

"It eliminates air and potential of complications."

A client informs the nurse that he has been taking ibuprofen every 6 hours for 3 weeks to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is taking a proton pump inhibitor for the treatment of this disorder. What should the nurse instruct the client about the use of the ibuprofen?

"It would be best to contact the physician prior to take any over-the-counter medications."

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

"Make sure your family has all their childhood immunizations."

A client is diagnosed with a viral illness and requests an antibiotic to "cure" his illness. When the request is refused by the physician, the client states to the nurse, "I will never get better." What is the best response by the nurse?

"Prescribing antibiotics for a viral infection may result in drug-resistant bacteria."

A client with a 4-cm breast mass is scheduled for biopsy with frozen section followed by lumpectomy and possible mastectomy. The client asks the nurse, "Why can't the doctor tell me specifically whether I will need to have my entire breast removed"? Which is the best response from the nurse?

"The frozen section will determine presence of cancer and type of surgery required."

The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia?

"The hair loss is temporary."

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before I sign a consent."

You are working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks you why these medications are needed. What would be your best answer?

"These medications decrease gastric acidity and volume."

You are caring for a client who has an order to receive Hespan IV. The client asks you what this solution is for. What would be your response? Select all that apply.

"This solution pulls fluid into the vascular space." "This is a colloid solution used to replace blood." "Hespan is a solution used instead of a transfusion." "Hespan can be used to treat hypovolemic shock."

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?

"Tumor removal will promote comfort."

The nurse, on a mission trip, is caring for a client with internal radiologic contamination from the fallout. The client states, "I need to get this out of me, and then I will be done with it." The nurse is most correct to reply which of the following?

"Yes, but you must also consider further exposure from contaminated food and water sources."

While doing a health history, a client tells you that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting cancer. What would be your best response?

"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."

Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic acidosis

The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students that the average daily fluid intake for an adult is?

2500 mL

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?

24

A client is in the acute care facility for the administration of intravenous (IV) antibiotics to treat bacterial pneumonia. The client begins to have severe diarrhea 3 days after the IV antibiotics with abdominal cramping and pain. What does the nurse suspect the client has developed due to the antibiotic use?

3 to 6 inches, used for up to 4 weeks

A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?

Gastrointestinal bleeding

Physician orders: 150 mL to run over 30 minutes via infusion pump. Calculate the flow rate.

300 mL/hr

The physician has order Lactated Ringers 125 mL/hour via gravity using tubing calibrated at 15 gtts/mL.

31 gtts/min

The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?

3:1

The physician orders one liter Normal Saline to infuse over 24 hours via gravity using microdrip tubing. Calculate the flow rate.

42 gtts/min

Physician order: Keflin 2 grams in 100 mL NS IVPB over 20 minutes. The IV tubing is 15 gtts/mL. Calculate the flow rate.

75 gtts/min

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

You are the nurse caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. You know that these clients would be classed as being victims of which of the following?

A biologic disaster

The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?

A client with gastrointestinal surgery and general anesthesia

The nurse is caring for a client with an abscess on his back. The nurse observes purulent drainage coming from the abscess. What type of specimen does the nurse anticipate the physician will order to determine the type of bacteria present in the exudate?

A culture

The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

A drop in systolic blood pressure (15 mm Hg) upon rising

The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?

A hot dog with catsup

The nursing supervisor has been notified of a large industrial fire with multiple injuries started with an electric short. When notifying the nursing peers, the nurse would classify this as which type of disaster?

A human disaster, unintentionally caused

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?

A wide excision of lump will be performed.

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply.

Acute agitation Overdose of pain medication Anxiety

A client with appendicitis has an appendectomy. After surgery, what type of pain does the nurse anticipate the patient will have?

Acute pain

The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a tutorial on the neurotransmitters and nervous system affected. Which couplet is most correct?

Acetylcholine, parasympathetic nervous system

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

Active transport

The nursing staff, working in an emergency room, begins to see an influx of clients with the following condition: acute nausea and vomiting; redness and itchiness of the skin, leading to open sores; bleeding from the nose, mouth, and gums; and blisters in the mouth and throat. Which condition is suspected?

Acute radiation syndrome

The nurse is obtaining data regarding the medication that the client is taking on a regular basis. The client states he is taking duloxetine (Cymbalta), an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?

Adjuvant drug therapy

Following surgery for adenocarcinoma, the client learns the tumor stage is T3, N1, M0. What treatment mode will the nurse anticipate?

Adjuvant therapy is likely.

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?

Administer an epinephrine injection.

A client is receiving morphine sulfate intravenously (IV) every 4 hours as needed for the relief of pain related to a surgical procedure the client had 3 days previously. The physician is discontinuing the IV and will be starting the patient on oral pain medication. What would provide the client with optimal pain relief when discontinuing the IV dose?

Administer an equianalgesic dose.

The nurse is caring for a client who does not accept blood or blood products. Which nursing actions conserve blood? Select all that apply.

Administer medication to stimulate bone marrow Reinfuse the client's own blood via closed circuit container. Administer factor VIII to stimulate coagulation process.

The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?

Alertness in level of consciousness

The nurse has received shift report on a postoperative surgical client. Which medication order would indicate that the medication was being administered prophylactically?

Amoxicillin 500 mg two tablets every 8 hours for 48 hours

A client comes to the clinic and informs the nurse that he has a "painful area under his armpit." The nurse observes a 2-cm raised area that is erythremic and has a white substance inside of it. What does the nurse suspect the patient may be experiencing?

An abscess

The nurse is caring for an older adult client who develops a fever, rash over the trunk, and back and complains of feeling achy and very tired. What should the nurse suspect is occurring with this client?

An autoimmune response

The registered nurse is receiving a client from the emergency room on a dopamine drip. The registered nurse asks the nurse to prepare the room for the client. The practical nurse obtains an IV pump, sets the bed, arranges the furniture, and places towels and a gown in the bathroom. Which other piece of equipment is essential?

An automatic blood pressure monitoring machine

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance

A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?

An induration of 12 mm

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings

The nurse is caring for a client diagnosed with botulism. Which medication classification does the nurse anticipate?

Antitoxins

When assessing the client postoperatively, which nursing consideration is essential before offering oral fluids?

Assess ability to swallow.

The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?

Assist to the bathroom.

Which teaching point would the nurse stress to decrease the risk of a phlebitis?

Avoid crossing the legs.

Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?

Avoid kissing and sexual contact.

You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?

Avoid spicy and fatty foods.

You are working on a gerontology unit. A family member calls and tells you he wants to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should you provide to someone with a respiratory infection?

Avoid visiting older adults.

The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a class of sixth graders. Which action by bases keeps the blood pH nearly neutral?

Bases bind with hydrogen.

A nurse on your unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?

Be tested for disease antibodies at appropriate intervals.

The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Beverages with alcohol or caffeine

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

You are caring for a client with breast cancer who has been receiving chemotherapy. The client was admitted with an infected lesion on her left leg. The physician has ordered Neupogen. What will Neupogen do for this client?

Boost the immune system Increase white blood cell production

A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started?

Call for portable chest x-ray.

The nurse is caring for a client with cyanide poisoning. The nurse is most correct to assess which systems where manifestation of the poisoning primarily occurs?

Cardiovascular and neurological system

A client comes to the outpatient clinic to receive cortisone injections in the neck for pain that has been occurring consistently for 8 months. What type of pain is this client experiencing?

Chronic pain

The nurse caring for a client with an intravenous infusion is looking up her institution's policy on changing IV equipment used in a venipuncture. When is most IV tubing changed?

Circulatory overload

A client is brought to the emergency department with a diagnosis of possible cerebral vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma (FFP). Which is the best nursing understanding for this action?

Client is experiencing a hemorrhagic stroke.

You are caring for a client who has just received orders for IV fluids. What information should you obtain from the client before performing a venipuncture?

Client's nondominant hand

Which of the following would be considered a mechanical defense mechanism?

Coughing

Which of the following nursing interventions contributes to achieving a client's pain relief?

Collaborate with the client about his or her goal for a level of pain relief.

The nursing instructor is discussing the different types of IV fluids with the nursing students. What type of fluid would the instructor tell the students is used to replace circulating blood?

Colloid solutions

A client comes to the clinic with complaints of fever, chills, and coughing and is found to be positive for influenza. The nurse is aware that the flu is transmitted from one infected person to another. What type of infection is this considered?

Community acquired

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?

Compensated respiratory alkalosis

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Complete a head-to-toe assessment.

The nurse educator is developing a teaching plan to prepare nurses for a disaster situation. Which teaching method is best?

Conduct a simulation for the nurses to have a role as participants.

The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?

Consult with the physician regarding the need for an increased dose of the drug and not to reduce its dosage or frequency of administration.

Which compensatory mechanism, during the first stage of shock, is the nurse most correct to identify as responsible for stabilization of fluid balance?

Corticosteroid hormones

You are the emergency department nurse caring for a client who has just been admitted by ambulance for a suspected myocardial infarction. The physician orders IV fluids of normal saline to be hung at 100 mL/hr. You know that this is what type of IV solution?

Crystalloid

You have admitted a new client to your unit. This client has an open draining sore on his leg. What diagnostic test would you anticipate being ordered?

Culture and sensitivity

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to?

Cyanide

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

Dark, concentrated urine

A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?

Debridement

A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation

The client will be using transcutaneous electrical nerve stimulation (TENS) for the treatment of lower back pain. What does the nurse explain to the client that this will do for his back pain?

Deliver a burst of electricity to the skin and underlying nerves, decreasing pain

The nurse is instructing community members on understanding the indications of bioterrorism. Which of the following would be highlighted? Select all that apply.

Development of similar symptoms in a community Unexplained deaths of domestic or wild animals in an area Atypical presentation of an illness for the time of year Presence of unexplained mortality

A client arrives at the clinic with the complaint that she is having a vaginal discharge after having sexual intercourse with her boyfriend 1 week ago. The patient is diagnosed with gonorrhea and given a prescription for treatment. What type of infection transmission does the nurse understand occurred?

Direct contact

You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock?

Distributive

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?

Distributive

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)?

Dosage of gamma radiation

The nurse is aware that when corticosteroids are administered, it is important that which of the following occurs?

Doses are tapered when discontinuing.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated blood pressure

A client was admitted to your 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 his 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.

The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?

During the postoperative phase

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

During the preoperative period

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?

Egg white omelet with spinach and mushrooms Steamed broccoli and carrots Turkey breast on whole wheat bread

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?

Encourage the client to move legs frequently and do leg exercises.

The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline. Which is the most likely nursing diagnosis for this client?

Excess Fluid Volume

The nurse is working at a natural disaster scene. A patient requires triage and treatment. Which category would the patient be assigned to?

Expectant

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.

Explanation of procedure Potential risks Benefits of surgery Description of alternatives

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?

Extravasation

A male client has been in pain for 12 hours related to the presence of kidney stones and states, "I can't take this pain any longer. It is getting worse by the minute." What does the nurse understand about the client's ability to tolerate pain?

Fatigue diminishes the ability to cope with pain and heightens the perception of pain.

Your client is going out on pass for the afternoon with his family. The physician has ordered that his venipuncture device needs to be temporarily capped. How will you ensure that the vein remains patent?

Flush the lock with saline or heparinized saline.

The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?

Flush the toilet twice after every use.

An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client?

Follow a bowel regimen.

The nurse is caring for a client needing emergency surgery. Which preoperative teaching should be omitted to prepare the client for surgery?

Frequency of postoperative vital signs

The infection control nurse collects data that indicates an increase in the number of clients in the hospital with multidrug-resistant infections. What priority education should healthcare providers receive?

Hand hygiene

Thirty minutes after hanging a glass intravenous bottle of total parenteral nutrition (TPN), the nurse notices the solution has stopped dripping. Which is the best troubleshooting action of the nurse?

Hang vented tubing.

The nurse is caring for a client who has progressed to the decompensation stage of shock. Which intravenous medication does the nurse anticipate as a prophylactic means to prevent complications?

Heparin

A client diagnosed with cancer has his tumor staged and graded based on what factors?

How they tend to grow and the cell type

The nurse caring for victims of a volcano eruption knows that this disaster is categorized as a natural disaster. What is the other category of disaster?

Human

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

Hypocalcemia

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

Hypomagnesemia

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply.

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection

When caring for a client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?

Inspect the skin frequently.

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Ice bag

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?

Increase in arterial oxygenation

The nurse is providing community instruction on the impact of aging and surgical incisional considerations. Which instructional areas would be included in the presentation? Select all that apply.

Increase protein in the diet. Instruct on symptoms of wound/incision infection. Cleanse wound/incision with products such as soap and water.

The nurse receives an order for a client to be given a colloid solution. Which is the likely reason for the use of this type of solution?

Increased blood loss

You are precepting a senior nursing student for the day. One of your clients needs a blood transfusion. What would you explain to the student about interventions a nurse should perform to minimize the risk for a septic reaction due to bacterial contamination of blood used for transfusion?

Infuse the blood in 4 hours or less after refrigerating it.

While completing an admission assessment, the client reports a family history of ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?

Inherited gene mutation

Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?

Initiate an IV of albumin.

The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?

Instruct the client to stay in bed until sensation and movement returns. Monitor respiratory rate and sensation every 2 hours or as per ordered.

The nurse is caring for a client who has been exposed to radiation. The client is being treated with diethylenetriamine pentaacetate (DTPA) to reduce the organ damage from radiation. The nurse knows that DTPA is administered how?

Injection

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss

In providing nursing care to a client, which actions should the nurse take to reduce the risk of administering a contaminated intravenous (IV) solution? Select all that apply.

Inspect IV solutions for transparency prior to administration. Do not use any solution that is expired. Do not use any solution that is leaking

The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?

Inspect the conjunctiva.

The nurse is preparing an intravenous partial bottle (IVPB) of anti-infective as ordered. Which is the best method of delivery for a client with a history of congestive failure?

Intermittent infusion via medication lock

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water?

Intracellular fluid

A client informs the nurse that she has been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?

It causes destruction of the normal flora of the vagina and allows the development of vaginal infections.

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

Kidney stones and blood clots

The nurse is caring for a client who is critically ill and has high radiation levels in the system. When discussing the needs of patient care and the need to protect nursing staff, which is discussed as the optimal barrier against gamma radiation?

Lead barriers and protective aprons

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?

Malignant tumor

To avoid complications of blood transfusion reaction, which nursing action is most important?

Matching numbers on blood bag to client bracelet

The nurse is completing an assessment of the patient prior to surgery. What areas of the patient assessment should the nurse question further? Select all that apply.

Medication Elimination Activity Support system

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

Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?

Metastasis

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with normal saline and place on any organ.

The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?

Monitor the client closely to prevent infection.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

Multiple organ failure

A client is brought to the emergency department by a family member that states that he found the client crying on the bed with an empty bottle of Tylenol with approximately 30 pills missing. What should the nurse anticipate administering to this client?

N-acetylcysteine (Mucomyst)

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?

Neurogenic

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurological system

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?

Neuropathic pain

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

No intravenous solution

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

Your client required reversal drugs after surgery. What nursing intervention is required when caring for a client who is treated with reversal drugs?

Observe the client for an extended period.

The nurse is caring for a client being transitioned from the postanesthesia care unit (PACU) to the surgical nursing floor. Which nursing action is first when a client states, "I am nauseated"?

Obtain an emesis basin and cool washcloth.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

The nurse is caring for a client who has acquired immunodeficiency disease (AIDS) and has developed oral thrush. What type of infection is the nurse aware that has developed due to the immunocompromised state of the client?

Opportunistic

The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

Organ damage

The LPN has been assigned to obtain vital signs on several patients. While obtaining vital signs such as temperature, blood pressure, heart rate, and respiratory rate, what other vital sign should the nurse be sure to include in her documentation?

Pain

The nursing instructor is talking with the students about botulism. The instructor tells the students that when caring for a client with botulism, what condition is most likely to cause death?

Paralysis of respiratory muscles

Which phase of pain transmission occurs when the one is made aware of pain?

Perception

The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?

Phlebitis can develop.

A client, contaminated following exposure to radiation, is brought to the hospital for assessment. Which nursing action is essential?

Place the client in strict isolation.

The nurse is admitting and preparing the client for surgery. Following administration of Ativan 2 mg orally, one time dose, which safety measure is most appropriate?

Place the side rails in the up position.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEq/L

The nurses are preparing the healthcare facility for clients injured in an explosion. While understanding the characteristics of explosives, what would be the focus of the facility?

Preparing the operating room

You are an intensive care unit nurse caring for a client with a transmissible spongiform encephalopathy. You know that this type of encephalopathy is caused by what type of infectious agent?

Prion

A client informs the nurse that he "thinks he is getting sick." Chief complaint of the client is low-grade fever, headache, and "has no energy." What stage of the infection does the nurse recognize the client is experiencing?

Prodromal stage

You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?

Production of antidiuretic hormone and corticosteroid hormones

A client is being taught to self-administer a narcotic analgesic by means of an intravenous pump system. Which of the following functions is designed to help prevent the patient from unintentionally overdosing?

Programming the dosage and time interval into the device

A client sustained severe burns over both lower extremities 1 week ago. The client informs the nurse that he had to wait for 30 minutes last night to receive pain medication, which caused the pain not to be relieved after administration. What suggestions could the nurse make to the physician to provide adequate relief of pain?

Provide the patient with a patient-controlled analgesia (PCA) pump.

The nurse is caring for a client prescribed Prussian blue. Which teaching instruction is most helpful?

Prussian blue can turn the mouth, teeth, and stools blue.

The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?

Pulse rate decrease

You are a nurse caring for clients in the emergency department who have been admitted from the area surrounding a nuclear power plant. There had been a small explosion at the plant and a small amount of radiation had escaped. You know that this is what type of a disaster?

Radiologic

A client arrives in the emergency department with complaints of nausea and pain in the left shoulder and arm. The physician determines that the client is having a myocardial infarction (heart attack). What type of pain does the nurse understand the client is experiencing since the location of the pain is not the chest?

Referred pain

The nurse is providing a gentle massage on a painful area of a client's hip. What is the goal of the nurse in providing this intervention?

Release of endorphins and enkephalins

The nurse is working the triage, phone answering questions about the radiologic disaster. When in the fallout period of the disaster, which suggestion is most appropriate?

Remove all outer garments before entering a house or shelter.

The nurse gave a client an injection and, when attempting to recap the needle, sustained a needlestick injury to the finger. What is the priority action by the nurse?

Report the injury or exposure to the supervisor.

The client complains that the intravenous (IV) site is stinging. No signs of infiltration or inflammation are assessed, but the nurse notices the rate is running faster than ordered. Which action should the nurse take first?

Reset the drip rate.

The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?

Respiratory compromise

The nurse is monitoring a client who is in the hospital and has a fentanyl (Duragesic) patch in place for the control of breakthrough pain for breast cancer. What would be a concern for the nurse when she obtains vital signs for this client?

Respiratory rate of 10 breaths/minute

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?

Restores blood pressure

The nurse identifies four nursing diagnosis for a client exposed to toxin. Which nursing diagnosis would be prioritized last?

Risk for Contamination

Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?

Risk for Impaired Gas Exchange

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub nurse

You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should you do?

Seek a physician's order to dilute the infusion.

You are the nurse caring for a client with shock accompanied by lung congestion. How would you position this client?

Semi-Fowler's with lower extremities raised to approximately 15º

You are assessing a 6-year-old little girl in the emergency department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?

She is having an allergic reaction and going into anaphylactic shock.

The nurse is on a community awareness safety committee. When prioritizing biological agents according to potential morbidity and mortality, which cluster of biological agents hold the highest mortality?

Skin preparation

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent?

Smallpox

The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person?

Smallpox

You are an emergency department nurse working triage during a disaster. Why should you tag a victim after assessment in a disaster situation?

Someone else does not duplicate the assessment.

You are a public health nurse giving a talk on the warning signals of cancer to a local community group. Which of the following are the warning signals of cancer? Select all that apply.

Sores that don't heal Unusual bleeding or discharge Persistent indigestion

Which isolation category should the nurse use to guide care when caring for a client with anthrax?

Standard precautions

The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?

Sun safety and use of sunscreen

The nurse asks the client about a reddened area on the left arm. The client states that he was bitten by an insect, and it burned briefly. What type of pain does the nurse document this as?

Superficial somatic pain

The nursing instructor is teaching beginning nursing students about infection. Toward the end of class, the instructor gives the students a scenario of a client with an infection who has developed fever and diarrhea. What should the student nurse instruct the client to avoid?

Tea and coffee

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5° F

A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.

Temperature of 102° F Heart rate of 120 beats/minute Respiratory rate of 24 breaths/minute

A preschool-age child is admitted for complaints of abdominal pain and vomiting. What is the best method for the nurse to collect data about the pain level of the child?

The Wong-Baker FACES scale

Chemotherapy has been used for the past 3 months to treat a client with pancreatic cancer. The CA 19-9 levels are rising. Which explanation would the nurse attribute as the most likely cause?

The cancer is growing despite the chemotherapy treatment.

Which of the following is the only reliable source for quantifying pain?

The client

A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?

The client has a multidrug-resistant strain of bacteria.

The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification?

The client has an absence of bowel sounds.

A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing his hands or wearing gloves. Why should the client and family member be concerned with the nurse's actions?

The client will develop a nosocomial infection.

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?

The client's heart rate is greater than 90 beats/minute.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?

The difference between the systolic and diastolic pressure

A client has received a diagnosis of Lyme disease. What does the nurse understand about the transmission of infection resulting in this disease?

The disease is spread by arthropods.

A family member wants to donate blood for a client who needs a blood transfusion. What information from the family member would make them ineligible for donation?

The invasive nature of the catheter provides a portal for infection.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH?

The lungs are not able to blow off carbon dioxide.

You are teaching a health class in the local public health center. What instructions should you provide as the single most important measure to prevent the spread of infection?

Thorough handwashing

The nurse researcher has been brought to an area following a radiologic disaster 2 years before. The nurse will be interviewing individuals regarding their health status. Which would the nurse document as a long-term effect of exposure? Select all that apply.

Thyroid cancer Leukemia Cleft lip and palate Stillbirths

Which nursing interventions are most important when implementing care for a client receiving temporary internal sealed radiation therapy? Select all that apply.

Time, distance, and shielding Count wires, threads, or needles every shift Avoid standing in direct path of implants.

A client is experiencing intractable pain related to terminal pancreatic cancer. What does the nurse understand is the goal of palliative sedation for this patient?

To administer sedative medication at the minimum dosage necessary to decrease consciousness and relieve pain

A client comes to the clinic and informs the nurse that he needs more analgesics for chronic pain. The client states that the medication is not as strong, and he requires more than the prescribed dose. What does the nurse suspect is occurring with the client?

Tolerance

An ICU nurse is caring for a radiation victim who is being treated with Prussian blue. You know that Prussian blue works by doing what?

Traps cesium in the intestine to prevent its absorption

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

Weight

You are caring for a client 6 hours postsurgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what?

Urine retention

A severely cognitively impaired adult has had a surgical procedure, and the nurse is having a difficult time assessing the level of pain the client is having postoperatively. What method can the nurse use to obtain data about the client's pain?

Use behavioral comparison of the client's current and previous behavior patterns.

An enterostomal therapy nurse is caring for a postoperative client with a gaping wound. Which nursing measure is most helpful when a wound dressing adheres to the wound bed?

Use normal saline to soak the dressing for removal.

The nurse is caring for a group of five clients at the hospital. In order to control infections when caring for the group of clients, what intervention can the nurse perform?

Use standard precautions with all clients.

The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures?

Valium intravenous injection

A client arrives at the emergency department complaining of severe diarrhea and vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?

Vehicle

You have been called to assist a new nurse on the floor to perform a venipuncture on her client who is 82-years-old. The new nurse is upset because she is having difficulty performing the venipuncture. What would be best for you to explain to the new nurse about why they may find it difficult to conduct venipuncture on an older adult?

Veins of older adults tend to be rigid.

The nurse is caring for a client with kidney stones who is complaining of severe pain. What type of pain does the nurse understand this client is experiencing?

Visceral Pain

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

Vital signs Skin color Urine output Peripheral pulses

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?

WBC: 42,000/mm3

You are caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?

White blood cell (WBC) count of 22,000 cells/mm3

The nurse is reviewing a postoperative client's chart prior to a physician's office visit. Lab reports reveal a prior WBC of 40,000/mm3, a current WBC count of 8000/mm3, and a current wound culture negative, following a Staphylococcus aureus infection. Tertiary intention of wound healing is documented at the last visit. Which current assessment of wound healing is anticipated?

Wound edges sutured. Scant amount of drainage noted. No foul odor.

When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?

Wound healing

Your client has just had a transfusion ordered for severe anemia. You are gathering the supplies that you need in order to transfuse the client. What kind of tubing do you know that you need to infuse blood or blood products?

Y-administration tubing