N487 Leadership in Nursing: NCLEX Quiz Ch 18-22

The nurse is caring for a client with chronic hepatitis B virus (HBV). What will the teaching plan for this client include? 1. Use a condom for sexual intercourse. 2. Report any clay-colored stools. 3. Eat a high-protein diet. 4. Perform daily urine bilirubin checks.

1 HBV is spread by sexual contact, so it is important to teach patients to use a condom for sexual intercourse, and the partner should be vaccinated. There will be no bilirubin in the urine or stools; claycolored stools are expected, so they would not be reported. Client would not be told specifically to eat a high-protein diet. (Lewis et al., 10 ed., p. 982)

The nurse is caring for a client who has had a right-sided stroke. What would be appropriate nursing care for this client? 1. Performing passive ROM exercises to affected side, active ROM on unaffected side 2. Placing food on the affected side of the client's mouth 3. Applying hot packs to the right leg to decrease muscle spasms 4. Turning client every 2 hours and maintaining position on the right side for 2 hours

1 The rehabilitation program for a client who has had a stroke includes actions that prevent deformity (passive range of motion on affected side and active ROM on the unaffected side) and prevent complications that may be associated with immobility. The client's affected side should be protected, and food should be placed on the unaffected side so that the client can control it. The client should be turned to his right (affected side) but for shorter periods of time. Hot packs would not be applied to decrease spasticity or spasms. (Lewis et al., 9 ed., p. 1393)

The client returns to his room after liver biopsy. The nurse positions the client on his right side and assesses for bleeding. What is a priority nursing assessment? 1. Assess the vital signs. 2. Observe for frank bleeding. 3. Check pretest prothrombin time and partial thromboplastin time values. 4. Determine adequacy of urinary output.

1 Vital signs must be assessed first if the nurse is monitoring the client for bleeding or shock. The nurse would do all of the assessments with vital signs as the priority. (Lewis et al., 10 ed., p. 845)

The nurse would identify which of the following clients to be at an increased risk for the development of a fecal impaction? Select all that apply: 1. Post barium enema 2. Obese client in traction 3. Poorly hydrated older adult 4. Client receiving opioid medications 5. Three days after colostomy 6. Acute appendicitis

1, 2, 3, 4 A barium enema procedure can lead to fecal impaction caused by barium left in the colon. An obese client in traction who is immobile and a poorly hydrated older adult (decreased motility and fluid intake) may also experience fecal impaction. These three conditions can contribute to the development of an impaction that may require manual removal. Opioid medications are central nervous system depressants, thus slowing peristalsis and contributing to constipation and fecal impaction. Acute appendicitis would be a condition in which no rectal enemas or manipulation would be indicated. (Lewis et al., 10 ed., pp. 934-935)

The nurse is preparing discharge teaching for a client with a diagnosis of gastroesophageal reflux disease (GERD). What would be important for the nurse to include in this teaching plan? Select all that apply. 1. Elevate the head of the bed. 2. Decrease intake of caffeine products. 3. Discuss strategies for weight loss if overweight. 4. Increase fluid intake with meals. 5. Take omeprazole at bedtime. 6. Eat a bedtime snack of milk and protein.

1, 2, 3, 5 Each of these actions will help either neutralize the acid in the stomach or decrease the physiologic reflux. Proton pump inhibitors will decrease the amount of acid produced in the stomach. Increased fluids with meals will exacerbate the problem, as will eating before going to bed. (Lewis et al., 10 ed., pp. 901-902)

The nurse is preparing a client for a cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure? Select all that apply. 1. Verify consent form has been signed. 2. Explain procedure to client. 3. Provide clear liquid, no caffeine diet. 4. Evaluate peripheral pulses. 5. Obtain a 12-lead ECG. 6. Obtain history for shellfish allergy.

1, 4, 6 In cardiac catheterization with angiography, contrast dye is injected into the coronary arteries, which allows visualization of the coronary arteries and provides information on patency. Informed consent is required before any invasive procedure. The physician is responsible for explaining the procedure to the client, and the nurse can reinforce the information. The client should be NPO for 6 to 18 hours before the procedure. A 12-lead ECG would be done, but this procedure is reflective of the conduction system, instead of the perfusion of the coronary arteries. Evaluating peripheral pulses is a nursing measure after the cardiac catheterization. It is important to check for iodine sensitivity or shellfish allergy because the procedure involves injecting contrast medium. (Lewis et al., 10 ed., pp. 677-678)

A client has been diagnosed with cholecystitis. What menu selection would be appropriate for this client? 1. Eggs, bacon, whole grain toast, and decaffeinated tea 2. Fresh fruit, oatmeal, and decaffeinated coffee 3. Roast beef sandwich with Swiss cheese and cranberry juice 4. Cottage cheese, avocado, bagel, and tea

2 A low-fat diet is appropriate for the client with cholecystitis. Eggs, bacon, cheese, and avocados are high in fat and should be avoided. Other foods to avoid include whole milk, cream, butter, ice cream, fried foods, rich pastries, gravies, and nuts. (Lewis et al., 10 ed., p. 1008)

The nurse is administering propranolol to a client who is being treated for hypertension. What is the desired response to this medication? 1. Vasodilation occurs, resulting in a decrease in the cardiac afterload. 2. The cardiac rate is decreased, with a resulting decrease in the cardiac output. 3. Cardiac output is decreased, and the arterial BP rises. 4. Pericardial fluid is decreased, thus decreasing the cardiac workload.

2 The primary action of the beta-blocker, propranolol, is to slow the cardiac rate. The medication is effective in the treatment of hypertension or dysrhythmias that result in tachycardia. With a decrease in cardiac rate, there is also a decrease in cardiac output. The betablockers do not cause vasodilation. A decrease in cardiac output would cause a decrease in arterial BP, not an increase. Beta-blockers do not have an effect on pericardial fluid. (Lewis et al., 10th ed., pp. 691-692)

After a tonic-clonic (formerly grand mal) seizure, what nursing action is the highest priority? 1. Loosen or remove constricting clothing and protect client from injuring himself or herself. 2. Maintain a patent airway by turning the client on his side and suctioning, if necessary. 3. Remain with the client and administer anticonvulsant medications as ordered by the physician. 4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.

2 The priority after a grand mal seizure is to maintain a patent airway. The question is asking for a nursing intervention after the seizure is over. The clothes should be loosened so that they do not constrict the client. The nurse may need to remain with the client, and the events of the seizure need to be recorded, but the priority of this question is the airway. (Lewis et al., 9 ed., p. 1426)

The nurse is teaching a client about home care and treatment of venous stasis ulcers on his leg. What should be included in the nurse's instructions? Select all that apply: 1. Dressings do not need to be changed frequently because there is minimal drainage. 2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in the sitting position, he should keep his legs elevated. 4. Avoid standing for prolonged periods of time. 5. Cool packs can be applied to the ulcers to decrease inflammation. 6. Soak the affected extremity in warm water every evening.

2, 3, 4 Healing of venous stasis ulcers is dependent on relieving the venous congestion in the extremity. Compression devices and elevation of the extremity are the most effective methods. The client should avoid standing for long periods because this increases venous stasis. Moist cool and/or warm packs are not used, but moist environment dressings are utilized. Dressings need to be changed as frequently as necessary because there may be excessive drainage. (Ignatavicius & Workman, 8th ed., pp. 734-735)

The nurse is caring for a client who begins to exhibit the cardiac rhythm shown in the illustration below. As the nurse observes, the rhythm remains the same. What is the best nursing actions? Select all that apply. 1. Call an emergency code and begin resuscitation. 2. Assess apical pulse, comparing to distal pulse. 3. Apply oxygen. 4. Assess for chest pain or shortness of breath. 5. Have the client cough. 6. Assess the blood pressure.

2, 3, 4, 6 The rhythm is premature ventricular beats or contractions (PVCs). Treatment is related to the cause, which may be hypoxia or from electrolyte replacement. Assessment of the client's hemodynamic status is important to determine whether treatment with drug therapy is needed. Drug therapy includes beta-blockers, procainamide, or amiodarone. (Lewis et al., 10 ed., p. 769)

After administering diuretics to a client with ascites, which of the following nursing actions most ensures safe care? 1. Monitoring serum potassium for hyperkalemia 2. Assessing the client for hypervolemia 3. Weighing client weekly 4. Documenting accurate intake and output

4 Accurate intake and output measurements are essential for clients receiving diuretics. Hypokalemia, not hyperkalemia, is a frequent occurrence with diuretic therapy. Hypovolemia is a greater risk with an increased urine output. Clients should be weighed daily. (Lewis et al., 10 ed., p. 994)

The client who has undergone a traditional cholecystectomy has a T-tube in place after surgery. What is the purpose of the T-tube in the care of this client? 1. To remove bile leaking from the incision 2. To provide a means of wound irrigation 3. To drain bile from the common bile duct 4. To prevent rupture of the inflamed gallbladder

3 A T-tube is used after a common bile duct exploration to drain bile and maintain patency of the duct until healing can occur. A T-tube should never be irrigated by the nurse. (Lewis et al., 10 ed., p. 1007)

The nurse is assessing a client whose condition is being stabilized after experiencing a ST-segment-elevation myocardial infarction. Which assessment is most indicative of inadequate renal perfusion? 1. Increasing serum blood urea nitrogen (BUN) level 2. Urine specific gravity of less than 1.010 3. Urine output of less than 30 mL/hr 4. Low urine creatinine clearance

3 A sustained low cardiac output decreases renal perfusion and results in oliguria and impaired renal function. Oliguria is marked by output of less than 30 mL/hr. Increased BUN, changes in specific gravity (osmolarity), and creatinine clearance will be affected if the client develops renal failure. (Lewis et al., 10 ed., p. 1070)

The nurse is making a home visit to a client with hepatitis A virus (HAV). Before assessing the client, the nurse will gather the equipment and perform what action next? 1. Wipe the bedside table with alcohol preps. 2. Place the supplies on a clean, convenient work area. 3. Maintain standard precautions before and after client contact. 4. Put on a gown, mask, and gloves.

3 Hepatitis A is transmitted via fecal contamination and oral ingestion. It is important to maintain standard precautions before and after client contact. The use of standard precautions should prevent transmission of HAV to the health care worker. Paper towels are used to create a clean area surface. Alcohol preps are not effective. The mask is not appropriate because hepatitis is not spread by respiratory secretions. (Lewis et al., 10 ed., p. 982)

Which nursing observations support the identification of the early development of a chronic subdural hematoma in a 3-month-old infant? 1. Closed posterior fontanel; open anterior fontanel 2. Retinal hemorrhages and hemiparesis 3. Increased irritability and vomiting 4. Papilledema and regressive behavior

3 Irritability and vomiting are common signs of increased ICP in the infant; the symptoms are often delayed in the infant because of the open fontanels. Retinal hemorrhage, paresis, and papilledema are indications of more acute hematoma formation. (Hockenberry & Wilson, 10 ed., p. 989)

Which nursing action would be most effective in preventing venous stasis in the postoperative surgical client? 1. Raise the foot of the bed for 1 hour, then lower it to stimulate blood flow. 2. Massage the lower extremities every 6 hours. 3. Facilitate active range of motion of the upper body to stimulate cardiac output. 4. Help the client walk as soon as permitted and as often as possible.

4 The postoperative client has decreased mobility, which may create an environment in which clotting can be caused by venous stasis. Active exercise, such as having the client ambulate as soon as possible, will stimulate circulation and venous return. This reduces the possibility of clot formation. The lower extremities should not be massaged because this may disrupt a clot and cause a pulmonary embolism. (Ignatavicius & Workman, 8th ed., pp. 730-731)

The nurse practitioner orders an enteral formula at a rate of 50 mL/hr. A can holds 250 mL. How many cans would the nurse need for the next 24 hours? Answer: ______ cans

5 cans 50 3 mL/hr 3 24 hours/day 5 1200 total mL for 24 hours 1200 mL/24 hr ÷ 250 mL/can 5 4.8 cans or 5 cans. (Potter & Perry, 9 ed., p. 617)

Which position is best for the client who has undergone a traditional abdominal cholecystectomy? 1. Side-lying position, to prevent aspiration 2. Semi-Fowler's position, to facilitate breathing 3. Supine, to decrease strain on the incision line 4. Prone, to reduce nausea

2 A semi-Fowler's position improves lung expansion. The incision for a cholecystectomy is high and may interfere with respiratory exchange. The other positions would probably interfere with respirations. (Lewis et al., 10 ed., p. 1011)

The nurse is caring for a client being discharged after experiencing infective endocarditis. What is most important to include with the discharge teaching? 1. Begin an exercise regimen as soon as possible, progressively increasing intensity each day. 2. Monitor urinary output daily and report a change in color or quantity. 3. Continue antibiotic therapy until the prescription is completed. 4. Track and monitor heart rate and blood pressure daily upon arising.

3 Antibiotics (usually administered by IV piggyback [IVPB]) are indicated for infective endocarditis. This may continue at home with the assistance of a home care nurse to administer the IVPBs, or the client may be changed to oral antibiotics. The continued antibiotic is critical to the prevention of vegetation growth on the valves. The other options are not specific for managing a client with infective endocarditis. (Lewis et al., 10 ed., p. 780)

A client is admitted for evaluation of his permanent pacemaker. Which assessment is most concerning? 1. Pulse rate of 96 beats/min with regular rate and rhythm 2. Irregular pulse rate with premature ventricular beats 3. Atrial premature beats shown on the monitor 4. Pulse rate of 48 beats/min with premature ventricular beats

4 Most demand pacemakers are set somewhere between 60 and 72. A pulse rate of 48 is too slow for a properly functioning pacemaker. If the client's pulse rate falls below the preset pacemaker rate, the pacemaker should take over the pacing. With bradycardia, ventricular escape beats occur. A pulse rate of 96 beats/min is within normal limits. An irregular pulse rate with PVCs or atrial contractions are related to irritable foci in the heart and not indicative of pacemaker problems. (Lewis et al., 10 ed., p.775)

The nurse is teaching a client with hypertension about his antihypertensive medications, hydrochlorothiazide (HCTZ) and enalapril. What is important to include in this teaching? 1. "Stand up slowly to decrease problem with dizziness." 2. "Increase fluid intake because of increased loss of body fluids." 3. "When you begin to feel better, the doctor will decrease your medications." 4. "Stay out of the sunshine, and make sure you have adequate sodium intake."

1 A common side effect of a combination of antihypertensive and diuretic medications is postural hypotension. It is important to teach the client how to deal with it. The client should not increase intake of fluids, because the diuretics are being given to decrease excess fluid. The client should decrease his intake of sodium. When the client is feeling better, the medication is working and will probably not be decreased. (Lewis et al., 10th ed., p. 697)

The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? 1. CVP of 3 cm H2O and urine output of 20 mL/hr 2. Jugular vein distention with the head elevated 45 degrees 3. Chest tube drainage of 50 mL/hr in the first 2 hours 4. Increased BP and increased pulse pressure

1 A low-range CVP reading and the decrease in urine output would be associated with hypovolemia caused by hemorrhage. Normal CVP is 2 to 6 cm H2O. The decrease in urine output is reflective of poor renal perfusion. Jugular vein distention is indicative of increased CVP, which does not occur with hypovolemia. Chest tube drainage is within the normal expectations. The blood pressure decreases with hemorrhage. (Lewis et al., 10th ed., p. 1564)

Six hours after gastric resection, the client's NG aspirate is continuing to drain bright red fluid. What is the best nursing action? 1. Continue to monitor the amount of drainage and correlate it with any change in vital signs. 2. Reposition the NG tube and irrigate the tube with normal saline solution. 3. Call the physician immediately and notify of the continued bright red aspirate. 4. Irrigate the NG tube with iced saline solution and attach the tube to gravity drainage.

1 After gastric surgery, the aspirate is usually bright red at first, gradually darkening within the first 24 hours after surgery. Normally the color changes to yellow-green within 36 to 48 hours. This is a normal occurrence on the first postoperative day and should be correlated with the vital signs. The tube is in the correct position because it is draining gastric secretions. There is no indication to notify anyone or to irrigate the NG tube. (Lewis et al., 10 ed., p. 918)

The nurse is preparing to administer spironolactone to a client. After assessing the client, what data indicate the need to withhold the medication? 1. Potassium level of 5.8 mEq/L (mmol/L) 2. Apical pulse rate of 58 beats/min 3. BP of 130/90 mmHg 4. Urine output of 30 mL/hr

1 Aldactone is a potassium-sparing diuretic. The client's potassium level is high; therefore the medication should be held and the doctor should be notified. Urine output of 30 mL/hr is normal output. The BP is elevated, which is the reason the client is receiving the medication. The pulse rate is not affected by this medication. (Igntavicius & Workman, 8th ed., pp. 262, 712, 714)

The vital signs of a client with cardiac disease are as follows: blood pressure of 102/76 mmHg, pulse of 52 beats/min, and respiratory rate of 16 breaths/min. Atropine sulfate is administered IV push. What nursing assessment indicates a therapeutic response to the medication? 1. Pulse rate has increased to 70 beats/min. 2. Systolic blood pressure has increased by 20 mmHg. 3. Pupils are dilated. 4. Oral secretions have decreased.

1 Atropine is administered for symptomatic bradycardia. An increase in pulse rate is the therapeutic response for this client. All other options (increase in BP, dilated pupils, and dry mouth) are characteristic of atropine but are not desired actions for this client. (Lewis et al., 10 ed., p. 763)

The nurse is taking the history of a client with heart failure caused by chronic hypertension. Which statement by the client is most concerning? 1. "I get short of breath after walking about half a block." 2. "My weight has dropped 15 pounds over the past 3 months." 3. "My legs get swollen in the evenings." 4. "Sometimes I get dizziness when I get up too quickly."

1 Dyspnea on exertion is a classic sign of left ventricular problems, regardless of the precipitating cause. Lower extremity edema is also characteristic, but it is not as significant as dyspnea on exertion. Dizziness and fainting on standing are indicative of postural (orthostatic) hypotension. (Lewis et al., 10 ed., p. 664)

The nurse is caring for a client who is 6 hours postpartum. What nursing actions are directed toward the prevention of postpartum thrombophlebitis? 1. Encourage early ambulation and increased fluid intake. 2. Allow bathroom privileges only and elevate the lower extremities. 3. Administer anticoagulants and evaluate the clotting factors. 4. Encourage the client to breastfeed the infant as soon as possible.

1 Early ambulation is the most effective and safe way to prevent thrombophlebitis with any type of client. This promotes venous return and prevents venous stasis. Anticoagulants (heparin and warfarin) are administered as ordered postpartum with a diagnosis of thrombophlebitis; they are not used for prevention. The legs should be elevated when the client is in a sitting position. There is no evidence that breastfeeding affects blood coagulation in any way. (Ignatavicius & Workman, 8th ed., pp. 730-731)

The nurse is assessing a client with a tentative diagnosis of multiple sclerosis (MS). Which assessment finding would the nurse identify as characteristic of early signs of MS? 1. Diplopia 2. Resting tremor 3. Flaccid paralysis 4. Unilateral neglect

1 Early signs of MS include difficulty with fine motor movement, especially of the head and neck. Often, visual disturbance is the most ominous sign. Tremors, flaccid paralysis, and unilateral neglect are not seen in the client with MS. (Lewis et al., 9 ed., p. 1488)

What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection? 1. Evaluate the NG tube for patency. 2. Call the physician for an antiemetic order. 3. Place client in semi-Fowler's position so that he will not aspirate. 4. Medicate the client with a narcotic analgesic.

1 Evaluate the NG tube patency; it is important to prevent the nausea and vomiting. The next action would be to put the client in semi- Fowler's position. It is important to assess the client and take nursing measures to determine the source of the nausea and to decrease the nausea before calling the doctor. (Lewis et al., 10 ed., p. 918)

The nurse is providing preoperative care for a client who is scheduled for cardiac surgery. During the preoperative preparation, what is an important nursing action? 1. Perform a thorough nursing assessment to provide an accurate baseline for evaluation after surgery. 2. Discuss with the client the steps of myocardial cellular metabolism and the anticipated surgical response. 3. Provide preoperative education regarding the mechanics of the cardiopulmonary bypass machine. 4. Discuss with the client and family the anticipated amount of postoperative chest tube drainage.

1 It is important to perform a thorough nursing assessment before the surgery. This provides a baseline for comparison of physiologic assessment data after surgery. Physiologic needs come first. The client and family do need to know about the chest drainage; however, this is client education. Providing a discussion about cellular metabolism and the mechanics of the cardiopulmonary bypass machine are not part of preoperative preparation. (Lewis et al., 10 ed., p. 739)

The nurse is providing preoperative care for a client who will have a gastric resection. What will the preoperative teaching include? 1. An NG tube will be in place several days after surgery. 2. The client will be started on a low-residue, bland diet about 2 days after the surgery. 3. Explain the anticipated prognosis and implications that the client may have a malignancy. 4. A urinary retention catheter will be in place for 1 week after surgery.

1 NG tubes are left in place for several days after gastric resection. It is important to prevent the stomach from becoming distended and putting pressure on the suture line. A diet will be started after there is evidence of good bowel function. Diet will be clear liquids until client tolerance is determined. It is not a nursing responsibility to advise the client regarding prognosis and status of malignancy. A urinary retention catheter may or may not be in place; preferably, the client will be voiding. (Lewis et al., 10 ed., p. 918)

The nurse is planning care for a client scheduled for esophagogastroduodenoscopy (EGD) and a barium swallow. What will the nursing care plan include? 1. Anticipating the client will receive a clear liquid diet in the evening and then receive nothing by mouth (NPO status) 8 hours before the test. 2. Discussing with the client the NG tube and the importance of gastric drainage for 24 hours after the test. 3. Explaining to the client that he will receive nothing by mouth (NPO status) for 24 hours after the test to make sure his stomach can tolerate food. 4. Discussing the general anesthesia and explaining to the client that he will wake up in the recovery room.

1 NPO status before a barium swallow and an esophagogastroduodenoscopy (EGD) and a clear liquid diet the evening before the procedures are routine orders for these tests. There is no general anesthesia. The client can eat or drink as tolerated after procedure once the gag reflex returns, and there is no routine placement of NG tubes. (Lewis et al., 10 ed., p. 845)

The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. Which data identified on a nursing assessment would indicate a possible intestinal perforation and require immediate nursing action? 1. Increasing abdominal distention, with increased pain and vomiting 2. Decreasing hemoglobin and hematocrit with bloody stools 3. Diarrhea with increased bowel sounds and hypovolemia 4. Decreasing blood pressure with tachycardia and disorientation

1 Perforation is characterized by increasing distention and boardlike abdomen. There is frequently increasing pain with fever and guarding of the abdomen. Peritonitis occurs rapidly. The nurse should maintain the client NPO, keep the client on bed rest, and immediately notify the physician. Decreasing hemoglobin and hematocrit and decreasing blood pressure are associated with hemorrhage rather than perforation. Remember to select an answer that reflects what the question is specifically asking. (Lewis et al., 10 ed., p. 912)

The nurse is caring for a client with hepatitis A. Which type of infection precaution is appropriate for this client? 1. Standard precautions 2. Droplet precautions 3. Contact precautions 4. Bloodborne precautions

1 Standard precautions are the appropriate type of infection precautions for all clients with hepatitis. Droplet precautions are not necessary for clients with hepatitis. Because hepatitis A is transmitted through the oral-fecal route, contact precautions are not necessary, except for the methods provided by standard precautions. Bloodborne precautions (part of standard precautions) are necessary for clients with hepatitis B and C (which are bloodborne), as well as for clients with hepatitis D and G. (Lewis et al., 10 ed., p. 982)

What will be important for the nurse to do when collecting a stool specimen for an occult blood (Hemoccult) test? 1. Samples should be taken from two areas of the stool. 2. Three separate stool samples will be required for accuracy of test. 3. The nurse should collect about 20 mL of stool sample. 4. Any red color on or near the specimen is considered positive.

1 Stool samples should be taken from different areas of the stool to more accurately reflect the presence of occult blood. The nurse only needs to collect a small sample of stool for the test. The test is done on the nursing unit and is not sent to the laboratory for further evaluation. Three separate samples will more accurately validate the presence of blood, but it is not required. Diets rich in red meat may cause a false-positive result. (Potter & Perry, 9 ed., p. 1156)

A client has had her blood pressure evaluated weekly for month. At the end of the month, the nurse averages out the weekly blood pressures at 150/96 mmHg. The client is 20 pounds (9.1 kg) overweight, and her cholesterol is 240 mg/dL (6.22 mmol/L). What is important information for the nurse to include in the teaching plan for this client? 1. Refer her to the doctor for further follow-up and medications. 2. Increase the fiber in her diet and begin a daily 30-minute workout. 3. Reduce her sodium intake and decrease the dietary calories that come from fat. 4. Reduce her cholesterol intake for 1 month and check her BP 3 times a week.

1 The client should be referred for further evaluation of blood pressure. The blood pressure is definitely elevated, the client is overweight, and she has an increased level of cholesterol. A multifocal approach is necessary to control the blood pressure. Because of the multiple risk factors, increasing fiber in the diet and exercise would not likely be sufficient to reduce the hypertension. Neither would dietary changes. This patient needs a multifocal approach. (Ignatavicius & Workman, 8th ed., pp. 710-712)

The nurse received handoff for a client returning from a cardiac angiogram and begins the initial assessment. The right femoral groin dressing has a dime-sized area of blood. What additional actions should the nurse perform? Select all that apply. 1. Assess peripheral pulses in both legs and feet. 2. Mark the dressing with a pen, circling the bloody drainage. 3. Hold pressure on the dressing site for 20 minutes. 4. Assess blood pressure. 5. Place the client in a high-Fowler position.

1, 2, 4 A cardiac catheterization includes the insertion of a large sheath into the femoral artery. There is a risk of hemorrhage after the procedure along with a loss of circulation distal to the insertion site. Priority care includes frequent assessment of circulation to the extremity. Peripheral pulses, color, and sensation should be evaluated in both feet as a comparison. Observation of the insertion site for hematoma and bleeding is also important. The nurse should mark the site, and if it enlarges, pressure should be applied. Monitor of the ECG and vital signs in important for evaluation of instability. The head of bed should remain flat until the groin site has developed hemostasis. (Lewis et al., 10 ed., pp. 677, 729)

The nurse is monitoring a client after thrombolytic therapy has been initiated. Shortly after the infusion is started, the client becomes confused, disoriented, cool, and clammy. The heart rate progressively increases to 120 and blood pressure drops to 60/40. What actions should the nurse take? Select all that apply. 1. Stop the thrombolytic 2. Apply oxygen 3. Raise the head of the bed 4. Call for assistance 5. Reorient the client

1, 2, 4 The symptoms the client is demonstrating support that he/she is hemorrhaging, the most common complication of thrombolytic therapy. The nurse needs to support oxygenation and perfusion by applying oxygen, lowering the head of the bed, and increasing fluids. The thrombolytics should be stopped and additional help given if needed since the client is very unstable. (Lewis et al., 10 ed., p. 724)

The nurse is assisting a client immediately before a colonoscopy. The nurse will direct the client and help him move into what position? 1. Prone 2. Sims' lateral 3. Slight Trendelenburg 4. Flat with lithotomy stirrups

2 Sims' lateral position is most commonly used for best access and visualization during the procedure and for the client's comfort. Lithotomy position with stirrups is used for gynecologic examinations and prostate surgery. (Ignatavicius & Workman, 8 ed., p. 1095)

The nurse is caring for a client with a history of heart failure. Which statements by the client require additional inquiry? Select all that apply. 1. "I've noticed that I've gained 3 lbs. This week." 2. "I sleep best in my recliner chair." 3. "I've noticed that the swelling in my feet seems less." 4. "I cannot make it through the grocery store without resting." 5. "I often have to use the restroom at night."

1, 2, 4, 5 Symptoms of heart failure include weight gain, orthopnea, fatigue, edema, and nocturia. Additionally the client can experience tachycardia, skin changes, behavioral changes, and chest pain. (Lewis et al., 10 ed., pp. 742-743)

The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to assess during the initial visit? Select all that apply. 1. Presence of cardiac discomfort 2. Medications taken before hospitalization 3. Presence of jugular vein distention 4. Heart sounds and apical rate 5. Presence of diaphoresis 6. History of difficulty breathing

1, 3, 4, 5 A focused cardiac assessment is directed toward assessing physiologic symptoms (cardiac pain, JVD distention, heart sounds and rate, presence of diaphoresis) that provide immediate information regarding the client's condition, which is appropriate for the nurse to do at the beginning of each shift. After the physiologic parameters have been evaluated, the nurse can determine any history of difficulty breathing and a list of medications the client was taking before admission. (Lewis et al., 10 ed., p. 663)

The nurse is caring for a client with venous blood pooling in the lower extremities caused by chronic venous insufficiency. The nurse would identify what assessment data that would correlate with this diagnosis? Select all that apply. 1. Stasis dermatitis 2. Diminished peripheral pulses 3. Peripheral edema 4. Gangrenous wounds 5. Venous stasis ulcers 6. Skin hyperpigmentation

1, 3, 5, 6 Long-term impairment of venous return leads to chronic venous insufficiency that is characterized by leathery, brawny appearance from erythrocyte extravasation to the extremity, persistent edema, stasis dermatitis, and pruritus. Venous leg (stasis) ulcers characteristically form near the ankle on the medial aspect, with wound margins that are irregularly shaped with tissue that is a ruddy color. Gangrenous wounds and diminished peripheral pulses are associated with arterial occlusive disease. (Lewis et al., 10th ed., pp. 826-828)

What are the best nursing actions in caring for a young client with appendicitis before surgery? Select all that apply: 1. Maintain bed rest. 2. Offer full liquids to maintain hydration. 3. Keep patient still and position with right leg flexed 4. Position on left side, apply a warm K-Pad to the abdomen. 5. Administer morphine intravenously to relieve pain. 6. Keep the client NPO and maintain a peripheral IV for fluid replacement.

1, 3, 6 Before surgery, keep the patient still, minimize movement, and offer to flex the right leg, which may increase comfort. Keep the client NPO because of the impending surgery; initiate IV fluid replacement. Maintain the client on bed rest; do not apply any type of heat to the abdomen. Narcotics are given cautiously if at all because the analgesic may mask the symptoms of rupture. (Lewis et al., 10 ed., p. 942)

The nurse is assessing a child with a tentative diagnosis of appendicitis. The nursing assessment is most likely to reveal what characteristics concerning the pain? Select all that apply. 1. Colicky, cramping abdominal pain located around the umbilicus 2. Tenderness in the left lower quadrant, associated with decreased bowel sounds 3. Nausea, vomiting, and anorexia after onset of pain 4. Gnawing pain radiating through to the lower back, with severe abdominal distention 5. Sharp pain with severe gastric distention, frequently associated with hemoptysis 6. Tenderness at McBurney's point

1, 3, 6 Colicky, cramping abdominal pain located around the umbilicus often noted as "referred pain" for its vague periumbilical localization is characteristic of appendicitis. The most common point of tenderness is over the area known as McBurney's point. Typically, nausea, vomiting, and anorexia follow onset of pain. Diarrhea, poor feeding, lethargy, and irritability may accompany peritonitis. Tenderness in the right lower quadrant (not the left) that occurs during palpation or percussion is called Rovsing's sign. Gastric distention and gnawing radiating pain are not common signs of appendicitis; gnawing pain is more characteristic of ulcers. Hemoptysis is not seen in appendicitis but in pulmonary edema. Remember, all the items in an option have to be correct if it is the correct answer. (Hockenberry & Wilson, 10 ed., p. 1079)

The nurse is caring for a client who is doing well after a craniotomy. What will the bowel care for this client include? 1. An enema every other day to avoid the Valsalva maneuver 2. High-fiber diet and stool softeners to prevent constipation 3. Low-residue diet to decrease stool formation and prevent constipation 4. Daily checking for impaction caused by loss of bowel innervations

2 Straining at defecation or the use of the Valsalva maneuver may exacerbate increased ICP. The nurse promotes normal bowel movements that prevent straining by encouraging a high-fiber diet and stool softeners when needed. Enemas are discouraged, and it is important to prevent constipation so that an impaction does not occur. (Lewis et al., 9 ed., p. 1368)

In planning discharge teaching for the client who has undergone a gastrectomy, the nurse includes what information regarding dumping syndrome? Select all that apply. 1. Symptoms may include nausea, vomiting, weakness, and abdominal cramping. 2. The client should eat three to four small meals per day. 3. Consumption of fluids should be very limited with the meal. 4. The client should increase the amount of complex carbohydrates and fiber in the diet. 5. Activity will decrease the problem; it should be scheduled about 1 hour after meals. 6. You may need to take a multivitamin with calcium and iron supplements.

1, 3, 6 Dumping syndrome is not uncommon after a combination bariatric surgery. Common symptoms include nausea, vomiting, abdominal cramping, weakness, palpitations, diaphoresis, and dizziness. Precautions such as limiting the amount of fluids taken with a meal should be implemented. The intake of foods high in iron, calcium, and B12 may not prevent the vitamin or mineral deficiencies, because the problem is with the absorption of these elements; supplements may be necessary. The client should plan to eat six small meals a day to decrease distention of the remaining stomach and limit the ingestion of carbohydrates, which may cause hyperglycemia. Rest after a meal, rather than activity, is helpful because it may prevent gastric contents from emptying too rapidly into the small intestine, thus generating the symptoms. (Lewis et al., 10 ed., pp. 917-918)

The nurse is assessing a client who has just had a lumbar puncture. What nursing observation would cause the nurse the most concern? 1. Client tells the nurse he has a headache. 2. Nurse observes clear fluid oozing from the puncture site. 3. Client states he has less strength in his arms. 4. Client has difficulty voiding from supine position.

2 The spinal needle is inserted at L3-L4. If there is any oozing after the procedure, it could be spinal fluid. This would increase the risk of headache and infection. Headache is not uncommon. Remaining in the supine position should help prevent the headache. Weakness of the upper muscles is not relevant to the lumbar puncture, and many clients have difficulty voiding while confined to bed. (Lewis et al., 9 ed., pp. 1350-1351)

The nurse is assessing the pulse of a client in atrial fibrillation. Based on the graphic below, where should the stethoscope be placed to correctly auscultate this client's pulse? (image with negative T waves that interrupt QRS)

4 The nurse needs to auscultate the apical pulse when a client is in atrial fibrillation. The point of maximal impulse is the correct location for auscultation of the apical pulse. It is located at the fifth intercostal space, at the midclavicular line. This is the apex of the heart. It is noted with a black dot on the correct area in the illustration. (Lewis et al., 10 ed., p. 667)

When obtaining a health history, the nurse expects a client with a recent diagnosis of Parkinson disease to report which sign or symptom? 1. Weight loss 2. Slowness of movement 3. Continual motor tremors 4. Depression

2 An early symptom of Parkinson disease is slowness of movements in all normal ADLs. Tremors and weight loss may occur but are not commonly the first symptoms. Depression is a complication, along with other issues such as hallucinations, psychosis, and dementia, which can occur later in the disease process. (Lewis et al., 9 ed., p. 1434)

What will the nurse anticipate the neurologic nursing assessment of an 88-year-old client with a left cranial hemisphere hemorrhage to reveal? 1. Spasticity, bilateral Babinski sign 2. Right-sided flaccidity and hemiparesis 3. Spasticity and left foot clonus 4. Flaccidity and bilateral foot clonus

2 Because the motor fibers from one side of the brain cross to the opposite side before passing down the spinal cord, hemorrhage on the brain's left side causes right-sided hemiplegia and vice versa. Spasticity is not a common occurrence, and both sides of the body are not affected. (Lewis et al., 9 ed., pp. 1392-1394)

The nurse is conducting discharge dietary teaching for a client with diverticulosis who is recovering from an acute episode of diverticulitis. Which statement by the client would indicate to the nurse that the client understood his dietary teaching? 1. "I will need to increase my intake of protein and complex carbohydrates to increase healing." 2. "I need to progress my diet from liquids to soft, low-fiber foods until the diverticulitis is completely resolved." 3. "I will not put any added salt on my food, and I will decrease intake of foods that are high in saturated fat." 4. "Milk and milk products can cause a lactose intolerance. If this occurs, I need to decrease my intake of these products."

2 Constipation increases problems with diverticula. Upon discharge, the client should continue fluids, progressing to soft foods that are low in fiber. A diet high in fiber is recommended once the acute diverticulitis is resolved completely. The other options do not have any specific relevance to diverticula disease. (Lewis et al., 10 ed., p. 964)

The nurse is monitoring an IV infusion of sodium nitroprusside. Fifteen minutes after the infusion is started, the client's blood pressure goes from 190/120 mmHg to 120/90 mmHg. What is a priority nursing action? 1. Recheck the BP and call the doctor. 2. Decrease the infusion rate and recheck the blood pressure in 5 minutes. 3. Stop the medication and keep the IV open with D5W. 4. Assess the client's tolerance of the current level of BP.

2 Nipride is a powerful, rapid vasodilator. The nurse should decrease the infusion first before the pressure drops further, then assess the client's response to the decreased rate. If the client's urinary output remains adequate and there is no dizziness or neurologic change, then the client is probably tolerating the blood pressure level. (Lewis et al., 10th ed., p. 692).

The nurse applies a nitroglycerin patch on a client who has undergone cardiac surgery. What nursing observation indicates that a nitroglycerin patch is achieving the desired effect? 1. Chest pain is completely relieved. 2. Client performs activities of daily living without chest pain. 3. Pain is controlled with frequent changes of patch. 4. Client tolerates increased activity without pain.

2 Nitroglycerin is used to prevent angina so that the client can perform the normal activities of daily living without chest pain. Sublingual nitroglycerin or translingual spray is used to treat immediate-onset chest pain. (Lehne, 9 ed., p. 591)

While caring for a client who has recently been diagnosed with Parkinson disease, the nurse should understand that: 1. Intellectual capabilities will decrease. 2. Diversional interests may decrease. 3. Mood fluctuations may occur. 4. Communication skills may fluctuate.

3 Because of the emotional stress of Parkinson disease, mood disturbances often occur. Problems with communication, intellectual skills, and diversional interest are usually not as common as mood disturbance in the early stages. (Lewis et al., 9 ed., pp. 1436-1437)

A client who underwent cholecystectomy 3 days ago has a T-tube that has stopped draining. What is the best nursing action? 1. Flush the tube with 5 mL of normal saline solution. 2. Reposition the client. 3. Continue to monitor. 4. Assess for tube placement.

3 Continue monitoring, as T-tube drainage decreases after day 2 and may stop between days 3 and 5. T-tubes are not irrigated. Placement is not checked. Repositioning will not change the drainage. (Lewis et al., 10 ed., p. 1009)

What statement would indicate to the nurse that the client understands the discharge teaching regarding his cirrhosis? 1. "I will decrease vitamin B intake." 2. "I need to continue Tylenol daily." 3. "I will weigh myself every day in the morning." 4. "I can eat my regular diet."

3 Daily weight measurement is essential to monitor for volume overload. Clients with cirrhosis need increased vitamin B, especially B6 (pyridoxine). Acetaminophen is hepatotoxic. The diet should be high in carbohydrates, include adequate amounts of protein to build tissue, and be moderate to low in fat intake. (Lewis et al., 10 ed., p. 994)

Pneumonia is a common problem in children with spastic cerebral palsy. The nurse understands that this occurs because: 1. There is an associated dysfunction of the respiratory center in the central nervous system. 2. The immunologic system is immature and does not produce adequate antibodies to fight infection. 3. Decreased mobility leads to stasis of secretions in the respiratory passages. 4. There is a weakness of the voluntary muscles that control respiration.

3 Decreased mobility over an extended period leads to stasis of secretions. There is no associated dysfunction in the CNS regarding the respiratory system. The immune response is mature but may become impaired as a result of the chronic illness. (Hockenberry & Wilson, 10 ed., p. 1149)

A client is admitted with duodenal ulcers. What will the nurse anticipate the client's history to include? 1. Recent weight loss 2. Frequent acetaminophen use 3. Burning pain 2 to 5 hours after a meal 4. Episodes of vomiting

3 Duodenal ulcers are characterized by high gastric acid secretion and rapid gastric emptying. Food buffers the effect of the acid; consequently, pain increases when the stomach is empty. Pain does not characteristically occur immediately after eating but 2 to 5 hours after a meal because the presence of food helps buffer the acid. The client does not usually have bouts of nausea unless bleeding or obstruction is a problem. Duodenal ulcers are associated with aspirin and NSAID use but not acetaminophen. (Lewis et al., 10 ed., p. 911)

In preparing a pediatric client for an appendectomy, the nurse would question which doctor's orders? 1. Penicillin 600,000 units IV piggyback, now. 2. Obtain signed consent form from parents. 3. Administer enemas until clear. 4. 500 mL Ringer's lactate solution at 50 mL/hr.

3 Enemas or laxatives are not administered before surgery in clients with an acute abdomen. If gastric motility is stimulated, there is an increased danger of appendiceal rupture. All other orders are appropriate before an appendectomy. (Lewis et al., 10 ed., pp. 942-943)

The nurse questions the use of which drug for the client with cerebral hemorrhage? 1. Gemfibrozil 2. Mannitol 3. Enoxaparin 4. Nitroprusside

3 Enoxaparin is a low-molecular-weight heparin. Thinning the blood of a client with cerebral hemorrhage could significantly worsen the bleed. Gemfibrozil is used to decrease cholesterol. Mannitol is an osmotic diuretic. Nitroprusside is used for a hypertensive crisis. (Lewis et al., 9 ed., pp. 1370-1373)

During the shift handoff report, the nurse learns that one of the assigned clients is in first-degree heart block. What action should the nurse take? 1. Count the radial pulse for 1 full minute. 2. Determine the cardiac rate at the point of maximum impulse. 3. Evaluate an ECG or monitor strip. 4. Take hourly pulse checks and correlate with blood pressure.

3 First-degree heart block can only be evaluated with an ECG or monitor tracing because the distinguishing factor is a prolonged P-R interval; all beats are being conducted. Other options are appropriate (determine cardiac rate, counting radial pulse for a full minute, and hourly pulse checks with blood pressure assessment) for this client; however, they do not assess first-degree block. (Lewis et al., 10 ed., p. 767)

A client in the acute phase of Guillain-Barré syndrome is admitted with weakness and numbness of the lower extremities, along with continual pain that worsens at night. What would be a priority nursing diagnosis? 1. Fear related to uncertain outcome and seriousness of the problem 2. Acute pain related to paresthesias, muscle aches, and cramps 3. Risk for ineffective breathing pattern related to progression of the disease 4. Risk for aspiration related to dysphagia

3 Guillain-Barré is an acute and rapidly progressing condition affecting the peripheral nervous system characterized by an ascending level of paralysis leading to a serious complication of respiratory failure. This necessitates constant monitoring of the respiratory system. Although other autonomic dysfunctions can occur (requiring the other assessments), such as orthostatic hypotension, hypertension, heart block, bowel and bladder dysfunction, facial flushing, diaphoresis, and lower brainstem involvement (cranial nerves), respiratory problems are the priority. (Lewis et al., 9 ed., p. 1467)

A client with portal hypertension and ascites has had a paracentesis to relieve respiratory compromise. What medication will the nurse anticipate the client will receive? 1. D10W 2. Morphine 3. IV salt-poor albumin 4. Furosemide

3 IV salt-poor albumin is given to replace protein lost in the ascites fluid and to restore oncotic pressure in the vascular bed. D10W is an IV fluid, not a medication. Furosemide will diminish the ascitic fluid. The client has respiratory compromise and would not be given a narcotic pain medication (morphine). (Lewis et al., 10 ed., p. 991)

What is the primary purpose of giving lactulose to a client with advanced liver disease? 1. To ensure regular bowel movements 2. To prevent bowel obstruction 3. To decrease ammonia levels in the blood 4. To promote clotting

3 In a client with end-stage liver disease, lactulose is used to decrease ammonia levels in the blood, thus improving cognition and alertness. The ammonia is eliminated through the regular bowel movements that the medication promotes, preventing obstructions. Lactulose is not involved in blood clotting. (Lewis et al., 10 ed., p. 992)

While talking with a client with a diagnosis of end-stage liver disease, the nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition? 1. Hyperglycemia 2. Increased bile production 3. Increased blood ammonia levels 4. Hypocalcemia

3 In end-stage liver disease, the liver cannot break down ammonia byproducts of protein metabolism. The increased ammonia levels in the serum cross the blood-brain barrier, causing uncontrolled drowsiness and confusion. Hyperglycemia is characterized by polyphagia, polydipsia, and polyuria, along with fatigue, weight loss, excessive thirst, and abdominal pain. Hypocalcemia is characterized by tetany symptoms. Increased bile production does not cause neurologic symptoms; it is related more to digestion. (Lewis et al., 10 ed., p. 990)

Clients with liver disease frequently develop a problem with jaundice. What would the nurse identify as the physiologic cause of jaundice? 1. Increased levels of ammonia 2. Increased alanine aminotransferase (ALT) level 3. Bilirubin levels above 4 mg/dL (68.4 umol/L) 4. Increased red blood cell production

3 Increased levels of bilirubin (greater than 2.0 mg/dL [34 umol/L]) cause a discoloration of the skin called jaundice. The bilirubin value needs to be two to three times the normal level for jaundice to be manifested. Normal value of total bilirubin is 0.2 to 1.3 mg/dL (5-21 umol/L). Jaundice occurs because of an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary system. Increased ammonia and ALT levels do not cause jaundice; they are problems associated with the malfunctioning liver. Hemolytic jaundice is due to an increased RBC production. (Lewis et al., 10 ed., pp. 977, 986)

An 8-year-old child is admitted after an accident where he sustained a closed head injury. The child is alert and oriented but very lethargic. There is clear fluid draining from the child's nose. What is the best nursing action? 1. Gently suction the fluid from the nasal area. 2. Turn from side to side only. 3. Keep head of bed elevated. 4. Encourage participation in games to play in bed.

3 Most CSF leaks resolve spontaneously. The child should be maintained on bed rest until drainage ends. Nonsteroidal antiinflammatory drugs are not contraindicated. The child may turn and assume a position of comfort, and there are usually no dietary restrictions. (Hockenberry & Wilson, 10 ed., pp. 991-992)

Which instruction should be included in discharge teaching for the client with a new prescription for simvastatin? 1. Flushing occurs in almost all individuals. 2. Sedation is common but will decrease with time. 3. Liver enzyme levels should be monitored every few months. 4. Watch closely for occurrence of postural hypotension.

3 Most of the "statin" drugs used for hyperlipidemia are hepatotoxic. Liver enzyme levels should be determined as a baseline before administration of the drug is started and then checked periodically throughout therapy. (Lewis et al., 10th ed., pp. 709-711)

A client with cirrhosis is receiving neomycin sulfate. The nurse understands that the purpose of this medication is to: 1. Decrease gastric acidity. 2. Acidify feces and trap ammonia in the bowel. 3. Decrease bacterial flora. 4. Reduce portal hypertension.

3 Neomycin sulfate decreases bacterial flora in the bowel, thus decreasing ammonia. Proton pump inhibitors and H2 blockers decrease gastric acidity in the treatment of cirrhosis. Lactulose acidifies feces in the bowel and traps ammonia, causing its elimination in the feces. Propranolol reduces portal venous pressure. (Lewis et al., 10 ed., p. 992)

The nurse is administering nitroglycerin intravenously to a client experiencing chest pain of an 8 on a 1 to 10 scale. What assessment changes would cause the nurse to decrease the infusion rate? 1. Pain drops from an 8 to a 4. 2. Heart rate increases from 110 to 115 beats per minute. 3. Blood pressure drops from 110/65 (80) to 89/44 (59) mmHg. 4. Client verbalizes his head is pounding.

3 Nitroglycerin is a vasodilator. It dilates the coronary arteries, thereby increasing myocardial blood supply; vasodilation of the peripheral circulation decreases the pressure against which the heart must pump (decreases afterload) and, by dilating the venous system, allows blood to pool in the venous system (decreases preload). It is important to continue the delivery of nitroglycerin until the client is pain free, since pain means coronary ischemia in the cardiac client. A headache is anticipated, as is tachycardia. Hypotension is expected with a vasodilator, but a drop this significant since the mean arterial pressure is below 60 mmHg. (Lehene, 9 ed., p. 593)

While discussing her diagnosis of hypertension, a client asks the nurse how long she is going to have to take all of the medications that have been prescribed. On what principle is the nurse's response based? 1. The client will be scheduled for an appointment in 2 months; the doctor will decrease her medications at that time. 2. As soon as her blood pressure (BP) returns to normal levels, the client will be able to stop taking her medications. 3. To maintain stable control of her BP, the client will have to take the medications indefinitely. 4. The nurse cannot discuss the medications with the client; the client will need to talk with the doctor.

3 Noncompliance with blood pressure medications is a common problem in the treatment of hypertension. The client must understand that the only way to keep her blood pressure under control is to continue to take her medications, potentially for the rest of her life. She will not be able to discontinue the medications unless there is a significant change in her condition as a result of weight loss, an exercise program, and/or decreased stress. Patients usually require follow-up and adjustments at monthly intervals until the goal BP is reached. Antihypertensives control BP but do not cure hypertension, therefore the medication cannot be stopped once the target reading is reached. (Ignatavicius & Workman, 8th ed., pp. 712-713, 717-718)

Four hours after aortic-femoral bypass graft surgery, the nurse assesses the client and is unable to palpate pulses in the operative leg. The client complains of pain in the leg. What is the first nursing action? 1. Massage the leg and apply warm towels. 2. Elevate the leg and recheck the pulse. 3. Call the physician immediately. 4. Help the client ambulate.

3 Occlusion to the aortic/femoral bypass graft is considered a medical emergency, and physician notification is imperative. No other nursing options would alleviate the problem. Massaging the leg and having the client ambulate would be contraindicated. If the pulses cannot be palpated and the client is experiencing pain, the nurse should not wait to call the physician. (Ignatavicius & Workman, 8th ed., pp. 723-724)

The nurse is obtaining a health history from a client who reports having pain in the left arm. Which question by the nurse will elicit the most useful response from the client? 1. "Does the pain feel like pins and needles in your arm?" 2. "Does the pain radiate from your neck to your arms?" 3. "Can you describe the pain you are experiencing in your arm?" 4. "Is the numbness in your arm intermittent or constant?"

3 Open-ended questions are most helpful in obtaining accurate health history information because they elicit more detailed descriptions of the symptoms. Although the other options are applicable to the presenting symptom, they result in "yes" or "no" responses, and this does not encourage the client to provide detailed information about the problem. (Potter & Perry, 8 ed., p. 322)

The nurse is assessing a client with a tentative diagnosis of a brain tumor. What primary client complaint would the nurse anticipate? 1. Decreased appetite 2. Frequent insomnia 3. Recurrent headaches 4. Peripheral edema

3 Recurrent headaches that increase in frequency and severity are often the first complaint of a client with a brain tumor; the headaches usually correlate with the area of the brain involved. The headaches tend to be worse at night and may awaken the client. Headaches are described as dull and constant but occasionally throbbing. Nausea and vomiting can occur due to ICP. Mood and personality changes occur, especially with brain metastases. Muscle weakness, sensory losses, aphasia, and perceptual/spatial dysfunction are symptoms. Insomnia, decreased appetite, and peripheral edema are not relevant to a brain tumor. (Lewis et al., 9 ed., p. 1376)

During the night, a client with a diagnosis of acute coronary syndrome is found to be restless and diaphoretic. What is the best nursing action? 1. Check his temperature and determine his serum blood glucose level. 2. Turn the alarms low and promote sleep by decreasing the number of interruptions. 3. Check the monitor to determine his cardiac rhythm and evaluate vital signs. 4. Call the physician to obtain an order for sedation.

3 Restlessness and diaphoresis may be indicative of decreased cardiac output, frequently originating from a dysrhythmia. Checking temperature and blood glucose levels is not a priority. Turning the alarm sound to low and reducing interruptions to facilitate sleep will be done when all physical problems are resolved. Physiologic needs must be addressed first. It is important to obtain critical assessment data before calling the doctor. (Lewis et al., 10 ed., pp. 742)

What is the most important nursing intervention for the safety of a client with altered clotting mechanisms caused by hepatic cirrhosis? 1. Promote independence in the client's activities of daily living. 2. Administer antibiotics to decrease ammonia. 3. Implement bleeding precautions. 4. Increase vitamin supplements and nutritional intake.

3 The altered clotting mechanisms in a client with hepatic cirrhosis mean that the client has fewer clotting factors available to assist in the clotting process. Bleeding precautions should be in place. Although the client may be able to be independent in ADLs, for reasons of safety, supervision should be provided. Antibiotics and increased nutritional intake will not speed clotting times. (Lewis et al., 10 ed., pp. 994, 1008)

A client with chest pain is on a cardiac monitor. The monitor is showing ventricular tachycardia at a rate of 150 beats/min with multiple PVCs. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the nurse's next action? 1. Immediately defibrillate. 2. Administer adenosine IV push. 3. Assess the blood pressure. 4. Auscultation lung sounds.

3 The client is having chest pain; it is a priority to evaluate their blood pressure to determine whether they are tolerating the rhythm. Adenosine is given for supraventricular tachycardia. Defibrillation will be necessary if the client loses consciousness. Lung sounds are not a priority at this time. (Lewis et al., 10 ed., p. 769)

A new employee at a facility needs to receive the hepatitis vaccine. Which statement reflects accurate understanding of the immunization? 1. "I need to receive six shots—once a month until I show positive antibodies to hepatitis." 2. "Once I receive the hepatitis vaccine, I will be immune to all types of hepatitis." 3. "I will receive three injections over a period of months, which should protect me from hepatitis B." 4. "The hepatitis vaccine is an oral vaccine with live attenuated virus."

3 The hepatitis vaccine is used to protect health care workers and other individuals from hepatitis B. The series consists of three intramuscular injections, the first two given at least 1 month apart and the third given 4 to 6 months later to provide long-lasting protection from hepatitis B only. (Lewis et al., 10 ed., p. 982)

A client who has had a stroke 1 week ago remains aphasic. The client is beginning to show functional improvement and demonstrates an ability to follow verbal directions. What will rehabilitation now include? 1. A right-leg brace 2. Ambulation training 3. Speech training 4. Vocational retraining

3 When a stroke occurs in the dominant hemisphere, the client experiences communication difficulties or aphasia. Speech retraining cannot begin until the client understands and can follow directions. The question is focusing on the client's ability to speak and his current problem with aphasia. Although wearing a leg brace and ambulation training will begin when the client has stabilized, the question is focusing on the client's aphasia. Vocational retraining will be part of the client's rehabilitation at a later date. (Lewis et al., 9 ed., p. 1394)

A client with hypertension asks the nurse what type of exercise she should do each day. What is the nurse's best response? 1. "Exercise for an hour, but only three times a week." 2. "Walk on the treadmill for 45 minutes every morning." 3. "Begin walking and increase your distance as you can tolerate it." 4. "Exercise only in the morning and stop when you get tired."

3 When any client begins exercising, it should be gradually, with increasing activity as the client tolerates it. A complication of hypertension is heart failure, which may first be seen as dyspnea on exertion. The client should exercise as tolerated and stop when she gets tired or begins to have shortness of breath, regardless of the amount of time she has already exercised. (Lewis et al., 10th ed., p. 689).

An older adult client is taking digoxin 0.25 mg once a day and furosemide 40 mg daily. She states having increasing lethargy and nausea over the past 2 days, but she is still able to take her medication. Her blood pressure is 150/98 mmHg; pulse is 110 beats/min and irregular; respiratory rate is 18 breaths/min. What laboratory information is most important for the nurse to evaluate? 1. Hemoglobin, hematocrit, and white blood cell count 2. Arterial blood gases and acid-base balance 3. Blood urea nitrogen (BUN) and serum creatinine levels 4. Serum electrolyte level.

4 A low potassium level can precipitate digitalis toxicity. The client has been taking her medications and not eating regularly. She also has an irregular heartbeat and increased lethargy along with nausea, all of which can be signs of digitalis toxicity. She is taking a diuretic, which increases the excretion of potassium, and a low potassium level can cause digitalis toxicity. (Lehne, 9 ed., p. 524)

A client is scheduled for an electroencephalogram. What will the nurse explain to the client regarding the purpose of this test? 1. Evaluates electrical currents of skeletal muscles 2. Measures ultrasonic waves in the brain 3. Determines size and location of brain activity 4. Records brain electrical activity

4 An electroencephalogram measures the brain's electrical activity. There are no ultrasonic waves in the brain. An electroencephalogram determines the electrical activity but not the brain activity, such as thought or cognition. The electroencephalogram has no relevance to skeletal muscle activity because this type of test would be an electromyogram (EMG), which measures skeletal muscle contraction and electrical potential of the muscle. (Lewis et al., 9 ed., p. 1352)

The nurse is preparing discharge teaching for a client with hypertension who is being treated with furosemide and clonidine. The nurse would caution the client about which overthe-counter medications? 1. Antihistamines 2. Acetaminophen 3. Topical corticosteroid cream 4. Decongestant cough preparations

4 Decongestants and over-the-counter cough medicines frequently contain pseudoephedrine. These medications will cause an increase in blood pressure and interfere with the effectiveness of the antihypertensive medications. (Lewis et al., 10th ed., p. 697)

What is the desired action of dopamine when administered in the treatment of shock? 1. It increases myocardial contractility. 2. It is associated with fewer severe allergic reactions. 3. It causes rapid vasodilation of the vascular bed. 4. It supports renal perfusion by dilation of the renal arteries.

4 Dopamine will support renal perfusion when administered in low doses in the initial stages of shock. At higher doses and as the client becomes more decompensated, the effect of the dopamine on the renal perfusion decreases. Vasodilation would further complicate the shock situation, and allergies are not a common problem. Vasoconstriction is not a primary property of dopamine in low doses. Dopamine increases cardiac rate, but that is not the desired therapeutic action for a client in shock. (Ignatavicius & Workman, 8th ed., pp. 748; Lewis et al., 10th ed., p. 1599)

The nurse is caring for a client who has a temporal craniotomy, and this is the first postoperative day. What is an important nursing intervention? 1. Take temperature orally only. 2. Restrain the client as necessary. 3. Suction the client every 2 hours. 4. Maintain the client with his head elevated.

4 Lowering the client's head increases ICP. Restraints should not be used because pulling against restraints will increase ICP. The client should be suctioned only as necessary. The temperature monitoring depends on the equipment; if the client is prone to seizures, an oral thermometer should not be placed in the client's mouth. (Lewis et al., 9 ed, p. 1368)

What is an important nursing action in the safe administration of heparin? 1. Check the prothrombin time (PT) and administer the medication if it is less than 20 seconds. 2. Use a 20-gauge, 1-inch (2.5 cm) needle and inject into the deltoid muscle and gently massage the area. 3. Dilute in 50 mL 5% dextrose in water (D5W) and infuse by intravenous piggyback (IVPB) over 15 minutes. 4. Use a 25-gauge, 1⁄2-inch (1.25 cm) needle and inject the medication into the subcutaneous tissue of the abdomen.

4 Medication should be administered with a small-gauge (25 gauge) needle into the subcutaneous tissue without aspirating or massaging the area. Partial thromboplastin time (PTT) is used to monitor the effects of heparin. Although heparin may be administered IV, it must be diluted in more than 50 mL D5W and would be administered over a longer period of time than 15 minutes. (Lewis et al., 10th ed., p. 820)

What important teaching instructions should the nurse relay to the client before discharge following a laparoscopic cholecystectomy? 1. Avoid dietary fat for at least 1 year. 2. Avoid heavy lifting for at least 2 weeks. 3. Expect bile-colored drainage from the incision. 4. Resume all activities gradually.

4 Resuming all activities gradually is correct. A diet low in fat is usually ordered, and the client needs to avoid heavy lifting for 4 to 6 weeks. Bile-colored drainage is not to be expected postoperatively. (Lewis et al., 10 ed., p. 1009)

A school-age child with a diagnosis of celiac disease asks the nurse, "Which foods will make me sick?" Which food items would the nurse teach the child to avoid? 1. Rice cereals, milk, and tapioca 2. Corn cereals, milk, and fruit 3. Corn or potato bread and peanut butter 4. Malted milk, white bread, and spaghetti

4 The child with celiac disease will need a gluten-free diet, eliminating foods such as pastas and breads that are made from wheat or dessert foods made from malt whey. Remember BROW—barley, rye, oats, and wheat. Foods that would be appropriate include rice and corn cereals, milk, corn and potato breads, tapioca, peanut butter, and honey. (Lewis et al., 10 ed., p. 967)

A client with Parkinson disease is experiencing anorexia and vomiting. The client is taking levodopa. What will be the initial nursing activity? 1. Assess client's food preferences. 2. Monitor client's blood pressure. 3. Hold client's medication and notify the physician. 4. Administer client's medication with food.

4 The first side effect to be noticed may be gastrointestinal problems. Taking medication with meals may alleviate these symptoms, but high-protein meals should be avoided. The client may continue to take the medication, and attempts should be made to minimize the side effects. The client's food preferences and his blood pressure are not relevant to the situation. (Lewis et al., 9 ed., p. 1435)

In discharge planning for the client with heart failure, the nurse discusses the importance of adequate rest. What information is most important? 1. A warm, quiet room is necessary. 2. Bed rest promotes venous return. 3. A hospital bed is necessary. 4. Adequate rest decreases cardiac workload.

4 To help decrease pulmonary congestion and dyspnea, the nurse should encourage adequate rest to decrease cardiac workload; the client should not exert himself to the point of fatigue. Bed rest does promote venous return, but that is not the purpose of bed rest in the client with heart failure. A hospital bed is not necessary, and a quiet room is important if that is what promotes rest for the client. (Lewis et al., 10 ed., p. 752)

The nurse is caring for a client who is scheduled for a gastric endoscopy. Which of the following actions must the nurse perform before the client is able to eat or drink after the endoscopy? 1. Check oxygen saturation. 2. Give small sips of water. 3. Check all vital signs. 4. Assess the client's gag reflex.

4 Topical sedation during endoscopy helps block the gag reflex and numbs the esophagus, eliminating the discomfort of the tube. The nurse would know the dangers of allowing the client to eat or drink before the sedation has lost its effect. The nurse will test for the return of the client's gag reflex before allowing sips of water to be taken, to avoid aspiration. (Lewis et al., 10 ed., p. 849)

An obese 44-year-old woman with a history of chronic cholecystitis is to receive vitamin K before surgery. What is the purpose of this medication? 1. To increase the digestion and utilization of fats 2. To support the immune system and promote healing 3. To aid in the emptying of bile from the gallbladder 4. To facilitate coagulation activities of the blood

4 Vitamin K is necessary for normal clotting. Cholecystitis can decrease the absorption of fat-soluble vitamins (A, D, E, and K) by interfering with fat metabolism, which can lead to potential difficulties with clotting. (Lewis et al., 10 ed., pp. 992, 1008)