N487 Leadership in Nursing: NCLEX Quiz Review ch 13-17

A client is experiencing a sickle cell crisis during labor and delivery. What is the best nursing action? 1. Maintain IV fluid infusion and assess adequacy of hydration. 2. Administer a high concentration of oxygen. 3. Insert a Foley catheter and monitor hourly urine output. 4. Provide continuous sedation for pain relief.

1 Adequate hydration is critical during stress periods for the client with sickle cell disease, and this is particularly true of a client in labor. Oxygen may or may not be ordered in low concentrations. A urinary retention catheter is not necessary at this time and would be a potential cause of infection. Although pain relief is important for both the sickling issues and the labor pains, continuous sedation would not be indicated because this would be detrimental to the fetus. (Lewis, 10 ed., pp. 617-619; Lowdermilk et al., 10 ed., pp. 721-722)

The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What information confirms that the tube has migrated too far into the trachea? 1. Decreased breath sounds are heard over the left side of the chest. 2. Increased rhonchi are present at the lung bases bilaterally. 3. Client is able to speak and coughs excessively. 4. Ventilator pressure alarm continues to sound.

1 An endotracheal tube that is inserted too far—beyond the carina—is most likely to enter the right main stem bronchus. The volume of air from the ventilator is only delivered to the right lung; breath sounds are decreased or absent over the left lung. The pressure alarm indicates that the current pressure is not adequate to deliver the tidal volume prescribed. This may occur but does not confirm the migration of the tube. (Ignatavicius & Workman, 8 ed., p. 615)

The nurse would question which medication order for a client with PACG (primary angle-closure glaucoma)? 1. Atropine 1 to 2 drops in each eye now 2. Hydrochlorothiazide 25 mg PO daily 3. Propranolol 20 mg PO two times a day 4. Carbamylcholine eye drops, 1 drop two times a day

1 Atropine causes mydriasis or pupillary dilation, which can precipitate an attack of acute glaucoma. It should be questioned if it is ordered for a client with glaucoma. The other drugs would be safe for a client with glaucoma. (Lewis et al., 10 ed., p. 379)

What symptoms would the nurse expect to observe in a 19-month-old client with a diagnosis of laryngotracheobronchitis (LTB)? 1. Stridor on inspiration 2. Expiratory wheezing 3. Paroxysmal coughing 4. Hemoptysis

1 Because croup causes upper airway obstruction, inspiratory stridor is a predominant symptom. Expiratory wheezing is heard in the asthmatic client. Paroxysmal coughing occurs more with spasmodic laryngitis. Hemoptysis is not common with croup syndromes. (Hockenberry & Wilson, 10 ed., p. 1186)

The nurse is caring for a postoperative client who had a thyroidectomy. The client develops difficulty breathing from laryngospasms, muscular spasms, and twitching, Which medication should the nurse have available for emergency treatment in the client who has had a thyroidectomy? 1. Calcium chloride. 2. Potassium chloride. 3. Magnesium sulfate. 4. Propylthiouracil.

1 Calcium chloride or calcium gluconate should be available to treat tetany caused by accidental removal of the parathyroid glands during surgery. The parathyroid glands regulate calcium metabolism. Potassium chloride replaces the electrolyte potassium. Magnesium sulfate is used in the treatment of preeclampsia (pregnancyinduced hypertension). Propylthiouracil is an antithyroid medication used to block production of thyroid hormone. (Lewis et al., 10 ed., p. 1173)

What finding on the nursing assessment would be associated with a diagnosis of pneumonia in the older adult? 1. Acute confusion 2. Hypertension 3. Hematemesis in the morning 4. Dry hacking cough at night

1 Confusion in the older adult is related to hypoxemia, which occurs with pneumonia. Vasodilation and dehydration cause hypotension and orthostatic changes. Crackles are typically heard when fluid is in the alveolar area. The cough is generally productive. The breathing is rapid and shallow without the use of accessory muscles. Hemoptysis may occur but not hematemesis (blood from the gastrointestinal tract). (Ignatavicius & Workman, 8 ed., pp. 591-592)

A client with Cushing's syndrome is admitted to the medical- surgical unit. During the admission assessment, the nurse notes that the client has a flat affect but is irritable when questioned, has a poor memory, reports a loss of appetite, wants to sleep all the time, and doesn't care if she gets well. What collaborative action should the nurse take in response to this information? 1. Discuss with the health care provider a concern for depression. 2. Request a neurology consult for a CT scan. 3. Discuss with the dietitian a need for a nutritional consult. 4. Request a social service consult for home evaluation.

1 Cushing's syndrome develops because of an excess of cortisol, in this case from prolonged exogenous steroid administration. Depression and a marked change in personality are common. It is important that the client be taught how to deal with the emotional changes of the disease. (Lewis et al., 10 ed., 1174)

The nurse is teaching self-care to an older adult client. What would the nurse encourage the client do for his dry, itchy skin? 1. Apply a moisturizer on all dry areas daily. 2. Shower twice a day with a mild soap. 3. Use a pumice stone and exfoliating sponge on areas to remove dry scaly patches. 4. Wear protective pads on areas that show the most dryness.

1 Dry skin should be moisturized daily and as needed, especially after the client takes a bath. The number of baths and showers should be limited. Exfoliation will remove the dry epidermal layer, but underlying areas also need moisturizing. Protective pads do nothing to provide moisture to dry areas. (Lewis et al., 10 ed., p. 409)

A parent and an 8-month-old child come into a public health clinic for a well-child checkup. The parent tells the nurse the child has been crying more than usual. What information obtained during the nursing assessment would cause the nurse the most concern? 1. Crying when sucking on his bottle 2. Crying when placed in crib at night 3. On-and-off crying throughout the day 4. Crying when left at the child care center

1 Pain during feeding may indicate increased inner ear pain during sucking. With effusion in the middle ear space, negative pressure draws mucus into the middle ear in response to a child crying, or sucking on a nipple, resulting in increased pressure and pain. Crying when placed in a crib and on and off during the day is normal in childhood development. Separation anxiety is not an uncommon problem. (Hockenberry & Wilson, 10 ed., pp. 1179-1181)

What physical characteristics of a client would place the client at highest risk for development of malignant melanoma? 1. Light to pale skin, blond hair, blue eyes 2. Olive complexion, oily skin, dark eyes 3. Dark skin with freckles, dry flaky skin, hazel eyes 4. Coarse skin, ruddy complexion, brown eyes

1 People with light to pale skin and who are excessively exposed to sunlight are most at risk for development of malignant melanoma. Dark-skinned and olive-skinned individuals have more melanin in their skin, which provides a measure of protection from UV exposure. Although those with a ruddy complexion are more prone to the development of skin cancers, the coarseness of the skin does provide some protection from the sun's harmful rays. (Lewis et al., 10 ed., p. 411)

A client has been diagnosed with pernicious anemia. What will the nurse teach this client regarding the medication he will need to take after he goes home? 1. Monthly vitamin B12 injections will be necessary. 2. Daily ferrous sulfate (in oral form) will be prescribed. 3. Coagulation studies are important to monitor the effect of medications. 4. He should reduce his intake of leafy, green vegetables to decrease vitamin K.

1 Pernicious anemia is caused by lack of intrinsic factor to effectively utilize vitamin B12 and is treated by monthly vitamin B12 injections. Ferrous sulfate is given for iron deficiency anemia. Coagulation studies are not necessary because the client is not receiving anticoagulants. Decrease in vitamin K is not necessary because the client is not receiving warfarin. (Lewis et al., 10 ed., pp. 612)

The nurse is monitoring a client who is experiencing an acute asthma attack. What observations would indicate an improvement in the client's condition? 1. Respiratory rate of 18 breaths/min 2. Pulse oximetry of 88% 3. Pulse rate of 110 beats/min 4. Productive cough with rapid breathing

1 The respiratory rate is within normal limits at 18 breaths per minute. The option for the pulse oximetry is too low. The pulse rate is too high to indicate improvement, and the productive cough with rapid breathing is not as significant as the decrease in respiratory rate. (Ignatavicius & Workman, 8 ed., pp. 550-556)

An unknown chemical was splashed into a client's eyes. What is most important for the nurse to tell the client to do immediately? 1. Rinse the eye with a large amount of water or saline solution. 2. Put a pad soaked in sterile saline solution over the eye. 3. Go to the closest emergency department. 4. Have a coworker visually check the eye for a foreign body.

1 When an unknown solution has been splashed in the eyes, it is most important to remove as much of the solution as possible by rinsing the eyes with large amounts of water or normal saline solution, if available. Placing a pad soaked in sterile saline solution over the eye, going to the closest emergency department, and having a coworker visually check the eye for a foreign body do not address removing the excess solution from the eye to prevent further damage. (Lewis et al., 10 ed., p. 371)

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 3 pm, the nurse finds the client apparently asleep. What priority action should the nurse perform to assess for a hypoglycemic reaction? 1. Feel the client and bed for dampness. 2. Observe the client for Kussmaul respirations. 3. Smell the client's breath for acetone odor. 4. Note if the client is incontinent of urine.

1 When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia, and polyuria may be associated with hyperglycemia. (Lewis et al., 10 ed., p. 1146)

A patient with a pituitary tumor is treated with a transsphenoidal hypophysectomy. What would be a priority postoperative action? 1. Ensure that any clear nasal drainage is tested for glucose. 2. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leak. 3. Assist the patient with tooth brushing to keep the surgical area clean. 4. Encourage deep breathing and coughing to prevent respiratory complications.

1 With a transsphenoidal hypophysectomy the pituitary gland is removed. CSF leaks and epistaxis are common postoperative complications, and it is important that any clear fluid draining from the nose is tested for glucose. Postoperative care includes elevating the head of the bed at all times to a 30-degree angle, and the client should avoid sneezing, coughing, and tooth brushing for at least 10 days to prevent a CSF leak. (Lewis et al., 10 ed., p. 1159)

A nurse is caring for a client with Addison's disease who has been in a car accident and presents to the emergency department with severe hypotension, fever, weakness, and confusion. Place the nurse's action in a priority order. 1. Vital sign assessment. 2. Delivery of 0.9% saline and 5% dextrose solution. 3. Placement of an IV. 4. Delivery of high-dose hydrocortisone replacement. 5. Health history information.

1, 3, 2, 4, 5 (listed in order of priority) Addison's disease is due to a hypofunctioning of the adrenal cortex. This client is demonstrating signs of addisonian crisis. Since the client is known to have Addison's disease and is demonstrating signs of crisis, assessment of vital signs should be followed by the placement of an IV, IV fluids, and IV hydrocortisone to allow the body the hormone needed for the stress response. Circulatory collapse can occur in these clients, so there is urgency in the delivery of cortisol. They are often unresponsive to vasopressors and fluid replacement. (Lewis et al., 10 ed., p. 1178)

Which of the following would be appropriate discharge instructions for the client that has just been diagnosed with polycythemia vera? Select all that apply. 1. "You can expect to have repeated phlebotomies." 2. "Take an iron supplement daily." 3. "Low-dose aspirin may be prescribed by your health care provider." 4. "A warm bath may be used to decrease generalized pruritus." 5. "Avoid crowds due to increased risk of infection secondary to your low white blood cell (WBC) count." 6. "Try to keep well hydrated by drinking at least 2 liters of fluid per day."

1, 3, 6 Phlebotomy is the main method of treatment to reduce the hematocrit. Generally, the client will have 300 to 500 mL of blood removed each time, aimed at keeping the hematocrit level between 45% and 48%. Iron supplementation is to be avoided because it raises the hematocrit, and low-dose aspirin is often prescribed to help prevent clot formation. Warm baths may precipitate pruritus, not relieve it. Cool baths may be beneficial, and alpha-interferon is sometimes prescribed for severe itching. There is no risk of infection with crowds, as the WBC count is increased instead of decreased, and the client should maintain normal hydration, which helps decrease clot formation. (Lewis et al., 10 ed., p. 621)

The nurse is evaluating a client recently diagnosed with primary open-angle glaucoma (POAG). What will be an important nursing action(s)? Select all that apply. 1. Review all medications the client is currently taking to determine whether any of them cause an increase in intraocular pressure as a side effect. 2. Determine whether the client has experienced any sudden loss of vision accompanied by pain. 3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision. 4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes.

1, 5, 6 Medications must be evaluated in terms of their potential for increasing intraocular pressure. Ophthalmic eye drops are often prescribed for the client with glaucoma, and clients should know how to administer them correctly. Diabetes is a risk factor for the development of glaucoma, and management of the diabetes is important in helping to prevent progression of the glaucoma. An increase in intraocular pressure could cause further damage to the eye in the client with glaucoma. The question states the client has already been diagnosed; primary open-angle glaucoma (POAG) is painless and is not correlated with the blood pressure. (Lewis et al., 10 ed., pp. 379-382)

A client with a diagnosis of type 2 diabetes has been prescribed a course of prednisone for severe arthritis pain. How should the nurse adjust the plan of care? Select all that apply. 1. Monitor blood glucose levels more frequently. 2. Monitor for signs of bleeding. 3. Monitor urine output every 4 hours. 4. Monitor for increased signs of infection. 5. Monitor for increased confusion.

1,4 An adverse reaction to corticosteroids is hyperglycemia. A client with type 2 diabetes must monitor blood glucose levels closely while taking steroids. Clients taking corticosteroids are also at increased risk for infection due to suppressed immune response and not a decrease in white blood cells. Bleeding, confusion, and changes in urine output are not typical a concern. (Lehne, 8 ed., p. 874)

The nurse is caring for a client with thyroid disease who is experiencing a "racing heart," weight loss, exophthalmos, and heat intolerance. What additional actions should the nurse take? Select all that apply. 1. Evaluate if the client is receiving a beta-blocker. 2. Assess for hypotension. 3. Request increased calories with three balanced meals a day. 4. Apply lubricating eye drops throughout the day. 5. Place a circulating fan in the room.

1,4,5 Beta-blockers are used effectively for symptomatic relief of thyrotoxicosis. When the client feels palpitations or "heart racing," the nurse should evaluate for tachycardia and cardiac changes. The client with hyperthyroidism will experience hypertension, not hypotension. Because of the weight loss, a high-calorie diet of 4000 to 5000 cal/day is recommended with six full meals each day. Exophthalmos is the protrusion of the eyeballs from the orbits from fat deposits and fluid in the orbital tissues and ocular muscles from hyperthyroidism. When the eyelids do not close, corneal ulcers and loss of vision can occur. Eyedrops are helpful to prevent dryness. A fan in the client's room will provide comfort. (Lewis et al., 10 ed., pp. 1164-1166)

The nurse is caring for a client who began showing signs of diabetes insipidus 4 hours ago and was treated with IV fluids and one dose of nasal desmopressin (DDAVP). How will the nurse know the treatment is effective? Select all that apply. 1. Urine output will decrease. 2. Blood pressure will lower. 3. Glucose level will normalize. 4. Sodium level change from 128 mEq/L to 134 mEq/L. 5. Urine specific gravity of 1.029.

1,5 Desmopressin (DDAVP) alleviates polyuria by acting as antidiuretic hormone (ADH). In the case of diabetes insipidus, urine output will decrease and urine specific gravity should return to a normal level of 1.010 to 1.030. The blood pressure should increase because more water is being retained in the bloodstream, which will lower sodium levels. Glucose is not affected by diabetes insipidus. (Lewis et al., 10 ed., p. 1161)

Which client is at highest risk for retinal detachment? 1. A 4-year-old with amblyopia 2. A 17-year-old who plays physical contact sports 3. A 33-year-old with severe ptosis and diplopia 4. A 72-year-old with nystagmus and Bell palsy

2 Participating in physical contact sports puts this person at the highest risk for retinal detachment because trauma is a leading cause. The other pathologies (amblyopia, ptosis, diplopia, nystagmus, and Bell palsy) will affect eye function but have minimal likelihood of causing retinal detachment. (Lewis et al., 10 ed., p. 376)

A client comes to the clinic with decreased hearing. Examination of the ear canal reveals a large amount of cerumen. What is the recommended method for removal of the cerumen? 1. Curettage with suction and irrigation 2. Warm sterile solution irrigation 3. Cool tap water irrigation 4. Cotton swab applicator

2 Although the structures of the outer ear are not sterile, sterile drops and solutions are used for irrigations in case the tympanic membrane is ruptured. The addition of nonsterile solutions may result in possible infections of the middle ear. Cool irrigants will be uncomfortable, and tap water is not considered sterile. Curettage with suction and irrigation and use of a cotton swab applicator can damage the tympanic membrane. (Lewis et al., 10 ed., p. 385)

What nursing observation indicates that an unplanned extubation of an endotracheal tube has occurred? 1. The high-pressure ventilator alarm activates 2. Client is able to speak 3. Increased swallowing efforts by client 4. Increased crackles (rales) over left lung field

2 An unplanned extubation, which would be accidental removal of the endotracheal tube from the trachea, would allow air to pass through the trachea and vocal cords, allowing the client to make a noise—or to speak. Activation of the low-pressure alarm on the ventilator will be noted, along with diminished or absent breath sounds, signs of significant respiratory distress, and gastric distention. Increased swallowing is indicative of irritation in the throat or bleeding. Increase in adventitious sounds indicates excessive mucus in the lungs. (Lewis et al., 10 ed., p. 1573)

A client who has glaucoma is concerned about her adult children "inheriting" the condition. What is the best nursing response? 1. "There is no need for concern; glaucoma is not a hereditary disorder." 2. "Your children should have an ophthalmologic examination with screening for glaucoma around age 40. After that, examinations should be done every 2 to 3 years." 3. "There may be a genetic factor with glaucoma, and your children over 30 years of age should be screened yearly." 4. "Are your grandchildren complaining of

2 Blindness from glaucoma is preventable. A comprehensive eye examination should be done around age 40, then every 2 to 4 years until 64 years, and then every 1 to 2 years after age 65. There is a familial tendency and a significantly higher incidence in African Americans. Therefore African Americans should have ophthalmic examinations more frequently. (Lewis et al., 10 ed., pp. 380, 382)

The nurse is caring for an infant who is experiencing respiratory distress and being treated with continuous positive airway pressure (CPAP). The nurse knows that for this treatment to be most effective, the infant must be: 1. Intubated with respiration maintained by controlled ventilation 2. Able to breathe spontaneously 3. Frequently stimulated to maintain respiratory rate 4. Suctioned frequently to maintain alveolar ventilation

2 CPAP only works when the infant is breathing on his own. When the airway is opened for a breath, the CPAP increases the pressure in the airway, which increases airflow to the lungs and oxygenation. CPAP is not used when a child requires controlled ventilation. Stimulating the infant may be appropriate, but the child must be able to breathe spontaneously for this to be effective. The child is not suctioned unless an excessive amount of mucus must be removed. (Hockenberry & Wilson, 10 ed., pp. 373-374)

A client has been diagnosed with disseminated intravascular coagulopathy (DIC). The nurse will anticipate administering which of the following fluids? 1. Packed red blood cells (PRBCs) 2. Fresh frozen plasma (FFP) 3. Volume expanders, such as D10W 4. Whole blood

2 Fresh frozen plasma contains all coagulation factors including V and VIII. DIC results when the body can no longer create clotting factors; thus, fresh frozen plasma is the best answer. Packed red blood cells will be used to increase oxygenation, but this is second-line treatment in this situation. Whole blood is used less frequently, but it does not provide adequate clotting factors. Volume expanders will not help increase clotting factors. (Lewis et al., 10 ed., pp. 630-631)

A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the teaching plan for the parents of this child? 1. Provide a diet low in protein and high in carbohydrates. 2. Avoid unwashed fruits and vegetables. 3. Notify the doctor if the child's temperature exceeds 102°F (39°C). 4. Increase the use of humidifiers throughout the house.

2 Fresh fruits and vegetables harbor microorganisms, which can cause infections in the immunosuppressed client. Fruits and vegetables should either be peeled or cooked. The doctor should be notified of a temperature greater than 100°F because of immunosuppression. A diet low in protein is not indicated, and humidifiers may harbor fungi in the water containers. (Lewis et al., 10 ed., pp. 639-640)

Herpes zoster has been diagnosed in an older adult client. What will the nursing management include? 1. Apply antifungal cream to the areas daily. 2. Maintain client on contact precautions. 3. Instruct on the need for sexual abstinence. 4. Closely inspect the perineal area for lesions.

2 Herpes zoster is considered infectious and contact precautions should be used with an older adult client. Antiviral medications would be given instead of antifungal agents. Lesions are usually along the sensory dermatomes (waist, neck, face) and not in the perineal area, which is HSV-2. There is no need for sexual abstinence, although a condom should be worn if contact may occur with the lesions. (Lewis et al., 10 ed., p. 415)

A young adult comes to the clinic complaining of dizziness, weakness, and palpitations. What will be important for the nurse to evaluate initially when obtaining the health history? 1. Activity and exercise patterns 2. Nutritional patterns 3. Family health status 4. Coping and stress tolerance

2 Iron deficiency anemia is characterized by fatigue, dizziness, weakness, increased pulse, palpitations, and increased sensitivity to cold. The adult female often becomes anemic for a variety of reasons, such as poor nutrition and heavy menses. (Lewis et al., 10 ed., pp. 609-610)

What is the type of skin cancer that is most difficult to treat? 1. Dysplastic nevi 2. Malignant melanoma 3. Basal cell epithelioma 4. Squamous cell epithelioma

2 Malignant melanoma is the most difficult to treat; it involves extensive full-thickness skin resections and has the poorest prognosis. Dysplastic nevi are thought to be a precursor of malignant melanoma, although they are not considered malignant in the initial stage. Basal cell epithelioma and squamous cell epithelioma are easier to treat and do not metastasize as does melanoma. (Lewis et al., 10 ed., pp. 411-413)

A teacher notifies the school nurse that many of the students in her third-grade class have been scratching their heads and complaining of intense itching of the scalp. The nurse notices tiny white material at the base of a student's hair shaft. What condition does this assessment reflect? 1. Tinea capitis 2. Pediculosis capitis 3. Dandruff 4. Scabies

2 Pediculosis capitis (head lice) is characterized by tiny white nits (eggs) that attach to the base of the hair shaft and are highly contagious. Tinea capitis is characterized by a red, scaly, rash with central clearing in the well-defined margins. Dandruff is often mistaken for head lice, but dandruff can be easily removed from the hair shaft. Nits adhere to the hair shaft and are not easy to remove. Scabies form burrows under the skin and cause intense nighttime itching. (Lewis et al., 10 ed., p. 416)

A client has a diagnosis of right-sided empyema. Thoracentesis is to be performed in the client's room. The nurse will place the client in what position for this procedure? 1. Prone position with feet elevated 2. Sitting with upper torso over bedside table 3. Lying on left side with right knee bent 4. Semi-Fowler's position with lower torso flat

2 Positioning over the bedside table allows the ribs to separate, which assists the physician in positioning the needle into the pleural cavity. If the client is unable to assume a sitting position, he or she is placed on the affected side with head of bed slightly elevated. The area containing the fluid should be dependent. (Ignatavicius & Workman, 8 ed., p. 511 )

A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. At what point in the day should the client be educated about peak incidence of hypoglycemia? 1. 12 p.m. to 1 p.m. (1200-1300 hours). 2. 9 a.m. and 5 p.m. (0900 and 1700 hours). 3. 10 a.m. and 10 p.m. (1000 and 2200 hours). 4. 8 a.m. and 11 a.m. (0800 and 1100 hours).

2 Regular insulin (a short-acting insulin) peaks in 2 to 3 hours, and NPH (an intermediate-acting insulin) peaks in 4 to 10 hours. Hypoglycemia would most likely occur between 9 a.m. and 5 p.m. (0900 and 1700 hours). (Lewis et al., 10 ed., p. 1126)

The nurse is providing discharge instructions to a client who has had a splenectomy. The teaching is based on the knowledge that splenectomy clients have: 1. Decreased leukocytes 2. Increased platelets 3. Decreased hemoglobin 4. Increased eosinophils

2 Removing the spleen will lead to an increase in peripheral RBC, WBC, and platelet counts. In addition, after splenectomy, immunologic deficiencies may develop (IgM); however, IgG and IgA remain normal. There is always a lifelong risk for infection after a splenectomy. (Lewis et al., 10 ed., p. 647)

A nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? 1. Slow the infusion and evaluate the vital signs and the client's history of transfusion reactions. 2. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution. 3. Stop the infusion of blood and begin infusion of normal saline solution from the Y connector. 4. Recheck the unit of blood for correct identification numbers and cross-match information.

2 Stop the blood infusion and disconnect the line to decrease the further infusion of red blood cells. Begin administration of normal saline solution with new tubing. The remainder of the blood should be returned to the blood bank for evaluation regarding the reaction. (Lewis et al., 10 ed., pp. 650-652)

The nurse understands clamping a chest tube may cause what problem? 1. Atelectasis 2. Tension pneumothorax 3. Bacterial infections in the pleural cavity 4. Decrease in the rate and depth of respirations

2 Tension pneumothorax occurs when air enters the pleural space with each inspiration, becomes trapped there, and is not expelled during expiration (i.e., one-way valve effect). Pressure builds in the chest as the accumulation of air in the pleural space increases. This can lead to a mediastinal shift. Atelectasis occurs when the atmospheric pressure enters the pleural cavity. This procedure has nothing to do with an infection or pulmonary consolidation. (Ignatavicius & Workman, 8 ed., pp. 623-624)

A client's eye has been anesthetized for an ophthalmology examination. What instructions will be important for the nurse to give the client? 1. Do not watch television for at least 24 hours. 2. Do not rub the eye for 15 to 20 minutes. 3. Irrigate the eye every hour to prevent dryness. 4. Wear sunglasses when in direct sunlight for the next 6 hours.

2 The eye has been anesthetized, therefore there is no feeling or sensation in it for 15 to 20 minutes. It would be very easy to rub the eye and cause damage. Not watching television for a day would have no effect on the safety. Irrigating the eye every hour is not necessary. Because there is no effect on the client's tolerance of direct sunlight, sunglasses would be optional. (Lilley, 8 ed., p. 916)

For a client with COPD, what is the main risk factor for pulmonary infection? 1. Fluid imbalance with pitting edema 2. Pooling of respiratory secretions 3. Decreased fluid intake and loss of body weight 4. Decreased anterior-posterior diameter of the chest

2 The ineffective clearing of secretions with resultant pooling can lead to an increased risk for infection. The client's appetite is usually decreased. The client has an increased anteroposterior diameter of the chest. (Ignatavicius & Workman, 8 ed., p. 566 )

The nurse is caring for a client with leukemia who is experiencing bleeding into the knee joints. What is the best nursing care for this client regarding joint mobility and activity? 1. Encourage short walks around the room every 2 hours. 2. Keep the joint immobilized and maintain bed rest for the client. 3. Gently put the legs through passive range of motion every 4 hours. 4. Keep the legs wrapped with elastic bandages and immobilized in splints.

2 The knee joint should remain immobilized during the active bleeding phase; walking and passive range of motion may increase the bleeding. The legs are not wrapped, but compression dressings may be placed on the knee. (Lewis et al., 10 ed., p. 628)

A client has extensive burns with eschar on the anterior trunk. What is the nurse's primary concern regarding eschar formation? 1. It prevents fluid remobilization in the first 48 hours after burn trauma. 2. Infection is difficult to assess before the eschar sloughs. 3. It restricts the ability of the client to move about. 4. Circulation to the extremities is diminished because of edema formation.

2 The primary concern would be watching for infection, because the eschar makes it difficult to visually examine the healing skin. Removal of the eschar enhances healing and prevents infection, which occurs because of the moist, enclosed area under the eschar. Eschar formation will not prevent fluid remobilization. It might restrict mobility if the eschar were involving the arm, legs, or joint areas. Circulation to the extremities would not be affected by eschar on the anterior trunk; that would be the case if the eschar were on the extremities. (Lewis et al., 10 ed., p. 443)

Which client is most likely to have iron deficiency anemia? 1. A client with cancer receiving radiation therapy twice a week 2. A toddler whose primary nutritional intake is milk 3. A client with a peptic ulcer who had surgery 6 weeks ago 4. A 15-year-old client in sickle cell crisis

2 The toddler will need to eat a balanced diet and may require an iron supplement. A diet based primarily on milk products will not cove the iron needs of a toddler. A client in sickle cell crisis may experience anemia, but it is due to the increased destruction of red blood cells, not poor iron intake. The client receiving radiation therapy may also develop anemia; however, it is not due to poor nutritional intake but to bone marrow suppression. The client who has had gastric surgery may develop anemia as a result of a lack of adequate utilization of vitamin B12. (Lewis et al., 10 ed., p. 610)

A client is found to be comatose with a blood glucose level of 50 mg/dL (2.8 mmol/L). What action should the nurse implement first? 1. Infuse 1000 mL of D5W over a 12-hour period. 2. Administer 50% glucose intravenously. 3. Check the client's urine for the presence of sugar and acetone. 4. Encourage the client to drink orange juice with added sugar.

2 The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). Administering 1000 mL of D5W over 12 hours does not provide enough glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available. (Lewis et al., 10 ed., p. 1180)

A client has an order for one unit of packed cells. What is a correct nursing action? 1. Initiate the IV with 5% dextrose in water (D5W) to maintain a patent access site. 2. Initiate the transfusion within 30 minutes of receiving the blood. 3. Monitor the client's vital signs for the first 5 minutes. 4. Monitor the client's vital signs every 2 hours during the transfusion.

2 The whole blood must be given within the first 30 minutes to prevent hemolysis and growth of bacteria in the blood. Vital signs are to be checked after administration of the first 50 mL and after the first 15 minutes. (Lewis et al., 10 ed., p. 649)

What is the priority assessment finding for a client who has sustained burns on the face and neck? 1. Spreading, large, clear vesicles 2. Increased hoarseness 3. Difficulty with vision 4. Increased thirst

2 When there is evidence of burns around the face, the airway should be carefully assessed. Increased respiratory rate and hoarseness may be the first sign of respiratory complications. Large, clear vesicles are expected on burns of second degree or worse and are not a sign of a complication. Difficulty with vision may be of concern, but it is not life threatening like respiratory distress. Increased thirst is common in the first few hours after a burn because of fluid shift into the extravascular space. Intubation is often needed within 1 to 2 hours of the injury in burns of the face and neck. (Lewis et al., 10 ed., p. 438)

The nurse is preparing a teaching plan for a family with a child who has been diagnosed with sickle cell anemia and crisis. What will the nurse include in the teaching regarding the pathophysiology of sickle cell crisis? 1. It results from altered metabolism and dehydration. 2. Tissue hypoxia and vascular occlusion cause the primary problems. 3. Increased bilirubin levels will cause hypertension. 4. There are decreased clotting factors with an increase in white blood cells.

2 When there is inadequate hydration, the sickled cells begin to clump together, which leads to vascular occlusion. Tissue hypoxia occurs as a result of the decreased oxygen-carrying capacity of the sickled red blood cells and from the vascular occlusion. Increased bilirubin from the hemolysis of the RBC does not cause hypertension, but jaundice and an increased incidence of cholelithiasis may occur. With sickle cell anemia, there is not a decrease in clotting factors. (Lewis et al., 10 ed., pp. 616-617)

The nurse is assigned to care for a newly admitted client with acute pancreatitis. Admitting assessment includes midepigastric pain of an 8 out of 10, low-grade fever, and elevated amylase and lipase levels with hypocalcemia and hyperglycemia. What should be the nurse's priority action? 1. Deliver proton pump inhibitor. 2. Place nasogastric (NG) tube. 3. Administer IV calcium gluconate. 4. Administer oral analgesic.

2 With the management of acute pancreatitis, the pain is better controlled when the client is NPO and an NG tube with gastric suction is initiated. Pain medicine should be IV because patient is NPO. Although a PPT and IV calcium may be used, they are not the priority. (Lewis et al., 10 ed., p. 1001)

The parents of a client with hemophilia are taking their child home. Which statement indicates a need for further education regarding hemophilia? 1. "We should ensure that our child has regular dental appointments." 2. "We need to wrap our child's limbs daily to prevent bleeding." 3. "We should help our child select activities that minimize the risk of injury." 4. "We should not give our child aspirin."

2 Wrapping limbs does not prevent bleeding and does not stop bleeding during acute episodes. Regular dental appointments are necessary to prevent dental problems in a child with hemophilia. Children with hemophilia should be encouraged to participate in activities that are not contact sports and have minimal risk of injury. Aspirin, NSAIDs, and other blood thinners should be avoided. (Lewis et al., 10 ed., p. 628)

The nurse is caring for a client who is experiencing an acute asthma attack. He is dyspneic and experiencing orthopnea; his pulse rate is 120 beats/min. In what order will the nurse provide care to this client? Number the following options in the order in which they will be performed, with 1 being the first action and 4 being the last action. 1. ________ Administer humidified oxygen. 2. ________ Place in semi-Fowler's position. 3. ________ Provide nebulizer treatment with bronchodilator. 4. ________ Discuss factors that precipitate attack.

2, 1, 3, 4 1___2___ Because oxygen is a priority, begin administration of oxygen. 2___1___ The first action is to place the client in semi-Fowler's position. Oxygen or inhalation therapy cannot be effective with severe orthopnea if the client is not in a sitting or upright position. 3___3___ Then administer the nebulizer treatment, which would include bronchodilators. 4___4___ Physiologic needs must be addressed before teaching or psychosocial needs are considered. (Ignatavicius & Workman, 8 ed., pp. 548-557)

The nurse is preparing discharge teaching for a client with aplastic anemia. What will be important to include in the teaching plan? Select all that apply. 1. Take your iron with meals every day and decrease the amount of green, leafy vegetables in your diet. 2. Establish a balance between rest and activity; avoid excessive fatigue. 3. Rest and supplemental oxygen may be required during periods of dyspnea. 4. Drink a glass of wine in the evening to help increase your appetite. 5. Notify your health care provider if you begin to experience frequent bruising. 6. Increase your intake of dairy products (milk and cheese) and protein.

2, 3, 5 Because clients who are anemic experience chronic fatigue, it is important to balance rest and activities to avoid problems with tachycardia and dyspnea. If a client has a problem with dyspnea during activities, supplemental oxygen may be necessary. The health care provider should be notified if bruising occurs, because this could indicate further problems in the hematologic system. Iron should be taken on an empty stomach, but if significant GI upset occurs, it can be taken with food. All alcoholic beverages should be avoided. There is no indication to increase the intake of dairy products and protein. A balanced diet should be followed. (Lewis et al., 10 ed., pp. 608)

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Select all that apply: 1. Position the client directly on the trochanter when side-lying. 2. Avoid the use of donut-type devices. 3. Massage bony prominences. 4. Elevate the head of the bed no more than 30 degrees when possible. 5. When the client is side-lying, use the 30-degree lateral inclined position. 6. Avoid uninterrupted sitting in any chair or wheelchair.

2, 4, 5, 6 Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. When placing the client in a side-lying position, use the 30 degrees lateral inclined position. Do not place the client directly on the trochanter, which can create pressure over the bony prominence. Avoid the use of donut-shaped cushions because they reduce blood supply to the area, which can lead to the extension of the area of ischemia. Bony prominences should not be massaged, because this increases the risk for capillary breakage and injury to underlying tissue leading to pressure ulcer formation. (Ignatavicius & Workman, 8 ed., pp. 436-444)

Which of the following are appropriate nursing actions when measuring visual acuity using a Snellen chart? Select all that apply. 1. Position the client 30 feet (9 meters) away from the chart. 2. Have the client first read the chart with both eyes open. 3. Record visual acuity as the largest line that the client can read correctly. 4. Test each eye individually with the opposite eye covered. 5. Repeat the test with the client wearing corrective lenses. 6. Use a picture chart if the client is unable to read.

2, 4, 5, 6 The nurse should position the client 20 feet (6 meters) away from the chart, not 30 feet (9 meters). Record the smallest line that can be correctly read, not the largest. Each eye is tested separately with the opposite eye covered. The eye test is repeated with the client wearing corrective lenses. You may use an "E" chart or a picture chart if the client is unable to read. (Lewis et al., 10 ed., p. 355)

The nurse is caring for a client postoperative thyroidectomy. What action should the nurse prioritize? Select all that apply. 1. Have the client speak every 5 to 10 minutes if hoarseness is present. 2. Support the head with pillows and avoid flexion of the neck. 3. Check the breath sounds for stridor. 4. Assess for tingling in the toes, fingers, and around the mouth or muscular twitching. 5. Assess every 4 hours for the first 24 hours for signs of hemorrhage. 6. Place with head of bed flat, in a side-lying position in case of vomiting.

2,3,4 It is anticipated that the client will be hoarse for 3 to 4 days after surgery. Increased hoarseness can be a sign of edema, but other signs of edema are more frequently seen, such as laryngeal stridor. Serum levels of calcium are important to monitor because of possible damage to the parathyroids during surgery and can be assessed by signs of tetany like tingling and twitching. Increased hoarseness can also be a sign of hypocalcemia, but assessment every 5 to 10 minutes is excessive. Hemorrhage after surgery is a great concern, and assessments should take place every 2 hours for the first 24 hours. Positioning should be semi-Fowler's, supporting the head with pillows to avoid flexion and tension on the suture lines. (Lewis et al., 10 ed., p. 1168)

The nurse is creating a plan of care about exercise for a client newly diagnosed with diabetes. What should be included in the plan? Select all that apply. 1. Exercise needs to be vigorous and daily. 2. Properly fitting footwear is important. 3. Exercise is best done after meals when glucose levels are rising. 4. It is important to monitor glucose levels before, during, and after exercise. 5. Exercise-induced hypoglycemia may occur several hours after exercise.

2,3,4,5 Exercise for clients with diabetes mellitus should include regular and moderate activity with properly fitting footwear to prevent injury. Exercise sessions should include a warm-up and a cooldown period. The best time for exercise is after meals and should be individualized by the health care provider. Monitoring glucose is important before, during, and after exercise. The client needs to know that hypoglycemia can occur several hours after the exercise is completed. (Lewis et al., 10 ed., p. 1134)

The nurse prepares to irrigate the external auditory canal for a client with impacted cerumen. What would be included in the correct technique for irrigation? 1. Use cool tap water. 2. Pour solution into ear canal. 3. Assess for signs of pain and tenderness in the ear. 4. Use a cotton-tipped applicator to clean near the tympanic membrane.

3 Before performing the irrigation, the nurse should assess the client for pain and tenderness, which could be caused by a perforated eardrum or impaction of a foreign body, and for dizziness caused by disequilibrium. The temperature of the water or saline solution should be comfortable to the wrist of the client or nurse, and it should be sterile. The nurse uses an ear syringe to inject water onto the superior side of the ear canal. The client should be sitting or lying down to facilitate drainage and to maintain safety in case the client gets dizzy from the irrigation. Cotton-tipped applicators should only be used on the outer (pinna or auricle) ear. (Lewis et al., 10 ed., p. 384)

A client has a history of atherosclerotic heart disease with a sustained increase in his blood pressure. What is important to discuss with this client before he uses an over-the-counter decongestant? 1. Urinary frequency and diuresis 2. Bradycardia and diarrhea 3. Vasoconstriction and increased arterial pressure 4. Headache and dysrhythmias

3 Decongestants should be avoided by clients with hypertension because these medications often contain pseudoephedrine and phenylephrine, which cause central nervous system stimulation with vasoconstriction and increased blood pressure. They also precipitate anxiety and insomnia. Decongestants do not cause urinary frequency, diuresis, or dysrhythmias. (Lehne, 8 ed., p. 981)

The nurse is providing teaching to a family whose child has been recently diagnosed with hemophilia. Which of the following would the nurse include in this discussion? 1. Hemophilia is a genetic disease that is more common in females. 2. Hemophilia is correctable through transfusions and bone marrow transplantation. 3. Hemophilia is most often a sex-linked congenital disorder. 4. Hemophilia is preventable through genetic counseling.

3 Hemophilia is a sex-linked genetic disorder carried by females but manifested in males. The female is a carrier and the male exhibits the condition in a sex-linked disorder. Genetic counseling is important for a couple to identify the risks involved, but if a woman who is a carrier decides to have children, the risk of her children having the condition cannot be prevented. (Lewis et al., 10 ed., p. 626)

A nurse is urgently called to a homebound neighbor's house. The neighbor is found unconscious and has a history of insulindependent diabetes. After determining there is no functioning glucometer available, what should the nurse's next action be? 1. Administer 10 units of regular insulin subcutaneously. 2. Arouse the client to drink 4 to 6 ounces of orange juice. 3. Administer glucagon 1 mg subcutaneously. 4. Find a phone to call EMS.

3 Hypoglycemia can be quickly reversed with effective treatment. Treatment should not be delayed, because permanent brain death can occur. If monitoring equipment is not available or the client has a history of fluctuating blood glucose levels, hypoglycemia should be assumed and treatment initiated. (Lewis et al., 10 ed., p. 1146)

A client and her husband are positive for the sickle cell trait. The client asks the nurse about the chances of her children having sickle cell disease. The nurse understands that this genetic problem will reflect what pattern in the client's children? 1. One of her children will have sickle cell disease. 2. Only the male children will be affected. 3. Each pregnancy carries a 25% chance of the child being affected. 4. If she has four children, one of them will have the disease.

3 In autosomal recessive traits, when both parents have the trait, there is a 25% chance with each pregnancy that the child will have the disease. When only males are affected, it is an X-linked recessive disease, such as hemophilia. Because there is a 1 in 4 chance of transmitting the trait, it is possible that none of the children would be affected. Frequently, there is a negative family history of the disease. (Lewis et al., 10 ed., p. 616)

Clients with COPD usually receive low-dose oxygen via nasal cannula. The nurse understands that which problem may occur if the client receives too much oxygen? 1. Hyperventilation 2. Tachypnea 3. Hypoventilation or apnea 4. Increased snoring

3 In clients with chronic high Pco2 levels (COPD), the administration of oxygen at a flow rate that increases the Pao2 may cause apnea and require the use of a bag valve mask resuscitator to ventilate the client. When the Pao2 increases significantly, it can decrease the client's stimulus to breathe and may cause carbon dioxide narcosis. (Ignatavicius & Workman, 8 ed., pp. 515, 563)

The nurse is evaluating a teenager for hearing loss. In reviewing the client's history, the nurse knows that which finding is not associated with a hearing loss? 1. Listening to loud music on an iPod 2. Repeated chronic ear infections 3. Taking penicillin and cephalosporin medication 4. History of increased ear cerumen

3 Penicillin and cephalosporin medications are not ototoxic. Aminoglycosides are ototoxic. The other three options—listening to loud music on an iPod, repeated chronic ear infections, and a history of increased ear cerumen—are risk factors for hearing loss. (Lewis et al., 9 ed., p. 391; Lehne, 9 ed., p. 1056.)

A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. Which assessment is most concerning? 1. Glucose of 70 mg/dL. 2. Potassium of 3.4 mEq/L. 3. Blood pressure of 169/98 mm Hg. 4. Sodium of 146 mEq/L.

3 Pheochromocytoma is a tumor in the adrenal medulla that produces excess catecholamines (epinephrine and norepinephrine). An excess of these catecholamines can cause severe hypertension. Surgery (adrenalectomy) alleviates the elevated blood pressure most of the time. In 10% to 30% of clients, hypertension remains and must be monitored and treated. Electrolyte imbalances and blood sugar are not typically affected. (Lewis et al., 10 ed., pp. 1107, 1181)

On the first postoperative day after a right lower lobe (RLL) lobectomy, the client deep breathes and coughs but has difficulty raising mucus. What nursing observation would indicate the client is not adequately clearing secretions? 1. Chest x-ray film showing right-sided pleural fluid 2. A few scattered crackles on RLL on auscultation 3. Increase in Paco2 from 35 to 45 mmHg 4. Decrease in forced vital capacity

3 Retained secretions may cause hypoventilation; this results in an increase in the Paco2. The other options do not as effectively reflect a problem with clearing mucus. Pleural fluid is not removed via coughing; the fluid is in the pleural space, not in the lung. Although the Paco2 is within the normal limits, there is still an increase noted, which is due to the hypoventilation. The nurse cannot easily measure the forcedvital capacity at the bedside. (Ignatavicius & Workman, 8 ed., pp. 579, 581)

The nurse understands that scaling around the toes, blistering, and pruritus is characteristic of what condition? 1. Eczema 2. Psoriasis 3. Tinea pedis 4. Pediculosis corporis

3 Scaling, itching, and redness are common signs of tinea pedis or athlete's foot. Eczema or atopic dermatitis in adults is characterized by reddened lesions in antecubital and popliteal space with pruritus or in children on cheeks, arms, and legs. Psoriasis is a benign condition of the skin where there are silvery scaling plaques on the skin, commonly the elbows, knees, palms, and soles of the feet. Pediculosis corporis is body lice and is a parasitic infection. (Lewis et al., 10 ed., p. 418)

A client comes to the outpatient clinic with impetigo on his left arm. What information would the nurse give this client? 1. Apply antibiotic ointment to the crusted lesions. 2. Wash the lesions with soap and water and then apply a steroid ointment. 3. Soak the scabs off the lesions and apply an antibiotic ointment. 4. Wash the lesions with hydrogen peroxide and apply an antifungal cream.

3 Teaching should include the use of warm saline or aluminum acetate soaks followed by soap and water removal of crusts and application of a suitable antibiotic ointment, such as mupirocin (Bactroban). Hydrogen peroxide has little ability to reduce bacteria in wounds and can actually inflame healthy skin cells that surround a lesion, increasing the amount of time the wounds take to heal. Impetigo is caused by group A beta-hemolytic streptococcus or Staphylococcus species, which are bacterial and would not be treated by an antifungal cream. If lesions are on the face, a systemic antibiotic also may be given. (Hockenberry & Wilson, 10 ed., p. 226)

A client is walking down the hall, and he begins to experience vertigo. What is the most important nursing action when this occurs? 1. Have the client sit in a chair in a brightly lit room. 2. Administer meclizine PO. 3. Help the client sit or lie down. 4. Assess whether the problem is vertigo or dizziness.

3 The client experiencing vertigo is severely imbalanced and at high risk of falling, thus client safety is the priority. He should be assisted to sit or lie down immediately or he may fall. The client should be safely sitting or lying down before any treatment or further assessment can continue. Although sitting in a chair is not a bad option, the fact that the rest of the statement includes sitting in a well-lit room would not be prudent. The preferred action during an acute attack would be to have the client lie down in a quiet, darkened room. (Lewis et al., 10 ed., p. 386)

When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid? 1. It provides mechanical transmission for the damaged part of the ear. 2. It stimulates the neural network of the inner ear to amplify sound. 3. It amplifies sound and directs it into the ear canal. 4. It will assist the client to interpret the incoming sounds more effectively.

3 The hearing aid amplifies sound but does not change the overall ability to interpret incoming sound. Sensorineural hearing loss is the inability of the client to interpret the sounds. A hearing aid is used for clients with conductive hearing loss or a mix of conductive and sensorineural loss. The hearing aid does not stimulate the neural network to amplify sound, such as a cochlear implant. (Lewis et al., 10 ed., p. 391)

A client in sickle cell crisis is admitted to the emergency department. What are the priorities of care in order of importance? 1. Nutrition, hydration, electrolyte balance 2. Hydration, pain management, electrolyte balance 3. Hydration, oxygenation, pain management 4. Hydration, oxygenation, electrolyte balance

3 The priorities for care of a client in sickle cell crisis are focused on providing fluid, oxygen, and pain control during the crisis to reduce sickling and prevent complications. Electrolyte management is not a priority, nor is nutrition. (Lewis et al., 10 ed., pp. 617-619)

The nurse is admitting a postoperative client after removal of an acoustic neuroma. What would be most important to include in the postoperative nursing care for this client? 1. Determining when the client will begin chemotherapy 2. Evaluating hearing status 3. Assessing for clear, colorless nasal discharge 4. Encouraging the client to discuss problems with hearing loss

3 The removal of an acoustic neuroma may result in a cerebrospinal fluid (CSF) leak that would be a significant risk of infection, which would be noted by clear, colorless nasal discharge. This symptom requires immediate assessment and intervention. The tumor is benign; therefore the client will not begin chemotherapy. The nurse will need to evaluate the hearing loss in the affected ear as well as the effect of hearing loss on the client's body image and ability to perform ADLs; however, these are secondary to the assessment of a possible CSF leak. Hearing loss may also occur after this procedure, but this would not be as much a priority as the possible CSF leak. (Lewis et al., 10 ed., p. 387)

On auscultation, the nurse hears wheezing in a client with asthma. Considering the pathophysiology of asthma, what would the nurse identify as the primary cause of this type of lung sound? 1. Increased inspiratory pressure in the upper airways 2. Dilation of the respiratory bronchioles and increased mucus 3. Movement of air through narrowed airways 4. Increased pulmonary compliance

3 The wheezing is due to narrowing of the airway caused by bronchospasm. Increased mucus production hinders the airway as well; this also results in trapping of air in the alveoli. Increased pulmonary compliance indicates the lungs have good recoil and expansion. (Ignatavicius & Workman, 8 ed., pp. 550-551)

A 3-year-old child had a myringotomy about a week ago. The mother calls the nurse to report that one of the tubes fell out. She found the tube on the child's pillow. After the nurse makes an appointment for the child to be seen in the clinic, what would be important to tell the mother? 1. Observe for any purulent or bloody drainage from the ear. 2. Rinse the tube in soapy water and keep it. 3. Do not allow any water to get into the child's ears. 4. Do not allow the child to play outside.

3 There may still be an opening in the eardrum where the tube was placed. It is important to continue to keep all water out of the child's ear to prevent infection. Observing for drainage is important for the mother to do, but not allowing water to get into the ears is more important. The tube is usually thrown away. There is no need to wash it, and the child can play outside if he is comfortable. (Hockenberry & Wilson, 10 ed., pp. 1181-1182)

The nurse is discharging a client with bilateral cataracts following cataract surgery on one eye. What statement by the client would indicate to the nurse the need for additional teaching? 1. "I'll call if I have a significant amount of pain." 2. "I'll remember to wash my hands before changing the eye dressing." 3. "I'll be okay by myself at home today." 4. "I will have someone help me with my eye medications."

3 This client may experience visual impairment and difficulty with selfcare the day of surgery because the operative eye will be patched and the other eye still has a cataract. This client may need some special assistance at home until the vision improves, especially the first 24 hours while the operative eye is patched. Discomfort after cataract surgery is minimal, thus there should be no significant amount of pain. Proper hygiene is important to prevent wound/eye contamination during dressing changes. Eye drops may be difficult for the client to administer, so assistance is a good idea. (Lewis et al., 10 ed., p. 373)

An older adult client has an open wound over the coccyx that extends through the dermis and subcutaneous tissue, exposing the deep fascia. The wound edges are distinct, and the wound bed is a pink-red color. There is no bruising or sloughing. The nurse would correctly document this ulcer as what stage? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

3 This is classified as a stage III pressure ulcer because of the fullthickness tissue loss extending to the deep fascia. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. A stage I pressure ulcer is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. A stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough, which also may present as an intact or open/ruptured serum-filled blister. A stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling. (Lewis et al 10 ed., p. 173)

While a client's wife is visiting, she observes the client's chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse? 1. "Your husband has been really sick; this must be a very difficult time. Let's sit down and talk about it." 2. "I have checked all of the equipment, and it is working fine; you do not need to worry about it." 3. "The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding." 4. "The chest tube is draining the secretions from his chest; it is important for him to deep breathe frequently."

3 This is important information to explain to the client's wife regarding the bloody drainage in the chest tube collection system. After the nurse has explained the reason for the drainage, it would then be appropriate to sit down and talk with the wife. Checking the equipment may be appropriate, but telling the wife not to worry is a communication block (false reassurance). Having the client breathe deeply does not answer the question or address the wife's concern. (Ignatavicius & Workman, 8 ed., pp. 578-579)

A client is prescribed levothyroxine daily. What should the nurse include in the discharge teaching? Select all that apply. 1. Taper the dose, never stop abruptly. 2. Take it at bedtime to avoid the side effects. 3. Call the health care provider if you experience palpitations or nervousness. 4. Decrease the intake of juices and fruits with high potassium and calcium contents. 5. Regular follow-up care will be required.

3, 5 Levothyroxine increases the metabolic rate of body tissues. Some serious side effects include cardiovascular collapse, dysrhythmias, and tachycardia. Because of these side effects, clients should be instructed not to take the medication if their pulse is greater than 100 beats/min and to notify their provider of headaches, nervousness, chest pain, palpitations, or any unusual symptoms. Therapy will be lifelong, and regular follow-up care is needed to monitor serum blood levels. The medication should be taken in the morning before food, and there are no dietary limitations. (Lewis et al., 10 ed., p. 1170)

A client has sustained a third-degree burn. What would the nurse expect to find during an assessment of the burn? 1. Area reddened, blanches with pressure, no edema 2. Blackened skin and underlying structures 3. Thick, clear blisters, underlying skin edematous and erythematous 4. Dry white, charred appearance, damage to subcutaneous tissues

4 All of the skin is destroyed in a full-thickness or third-degree burn. Often it has a dry appearance and may be white or charred and usually requires skin grafting to repair. An area reddened that blanches with pressure is indicative of a superficial first-degree burn (partial thickness). Characteristics of a full-thickness fourth degree burn include blackened skin into underlying muscle and bone structures. Thick, clear blisters, underlying skin edematous and erythematous are characteristics of a deep second-degree burn (partial thickness). (Lewis et al., 10 ed., p. 432)

A 6-year-old client is admitted to the postoperative recovery area after a tonsillectomy. In what position will the nurse place the client? 1. Semi-Fowler's position, with the head turned to the side 2. Prone position, with the head of the bed slightly elevated 3. On the back, with the head turned to the right side 4. On the abdomen, with the head turned to the side

4 Before the child is fully awake, he or she should be placed on the abdomen with the head turned to one side to facilitate the drainage of secretions and to prevent aspiration. When alert, the child may sit up or assume a position of comfort. The other options are not appropriate because they do not allow for drainage of secretions from the mouth and throat after a tonsillectomy while the child is in early recovery. (Hockenberry & Wilson, 10 ed., p. 1174)

A teenager is diagnosed with conjunctivitis. Which statement indicates that the teenager understood the nurse's teaching? 1. "I can let my friends use my sunglasses while we are together." 2. "It's okay for me to softly rub my eye, as long as I use the back of my hand." 3. "I can pick the crusty stuff out of my eyelashes with my fingers when I wake up in the morning." 4. "I will use my own wash cloth and towel for my face while my eyes are sick."

4 Conjunctivitis is contagious through physical contact. The teenager should be directed not to touch the eye, if possible. Handwashing should be stressed after any contact with the eye, and the teen should not share any items that might be contaminated, such as facial towels. Conjunctivitis may be bacterial or viral, and sharing of possibly contaminated objects may result in the spread of infection. Rubbing or picking at the eyelashes may result in further irritation or contamination of the hands, which would further the risks of infection transmission. (Lewis et al., 10 ed., pp. 371-373)

The nurse receives the new orders below for a client admitted in thyroid crisis. Which order should the nurse question? Jane Johnson MR: 96837 DOB: 6/5/1962 Allergies: NKDA Admission Orders - 5/20/19 A. Admit to hospital for thyroid crisis B. Cardiac monitor continuous C. Hyperthermia blanket PRN D. IV fluids 0.9% 50 mL/hr 3 1 liter E. Propranolol F. Propylthiouracil G. Stat T3, T4, and TSH serum level 1. IV fluids. 2. Serum blood tests. 3. Propylthiouracil. 4. A hyperthermia blanket.

4 Fever (hyperthermia) is a symptom of thyroid storm. The correct treatment would be a hypothermia blanket to cool the client. All other choices (IV fluids, laboratory tests, and propylthiouracil) are appropriate prescriptions for this diagnosis. (Lewis et al., 10 ed., p. 1165)

A client is scheduled for a routine glycosylated hemoglobin A1c. What needs to be included in the teaching about the test? 1. Drink only water after midnight and come to the clinic early in the morning. 2. Eat a normal breakfast and be at the clinic 2 hours later. 3. Expect to be at the clinic for several hours because of the multiple blood draws. 4. Come to the clinic at the earliest convenience to have blood drawn.

4 Glucose attaches to the hemoglobin molecule of the red blood cell. A glycosylated hemoglobin test gives an average of blood glucose over the past 3 to 4 months, and a blood sample can be obtained at any time during the day. It is not used in the diagnosis of diabetes and does not need to be a fasting specimen. (Lewis et al., 10 ed., p. 1118)

The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information? 1. "You should avoid emotional situations that increase his shortness of breath." 2. "Help your husband arrange activities so that he does as little walking as possible." 3. "Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening." 4. "Your husband will be more short of breath when he walks, but that will not hurt him."

4 Physical conditioning is important for clients with COPD. Activity needs to be paced so that undue fatigue does not occur. Some increase in shortness of breath with exercise is to be expected but will not damage the lungs. If the client stops exercising before an increase in shortness of breath, he will not experience a training effect. (Ignatavicius & Workman, 8 ed., p. 565)

A client with hemophilia comes to the emergency department after bumping his knee. The knee is rapidly swelling. What is the first nursing action? 1. Initiate an IV site to begin administration of cryoprecipitate. 2. Perform a type and cross-match for possible transfusion. 3. Draw blood for determination of hemoglobin and hematocrit values. 4. Apply an ice pack and compression dressings to the knee.

4 Rest, ice, compression, and elevation (RICE) are the immediate treatments to reduce the swelling and bleeding into the joint. These are the priority actions for bleeding into the joint, regardless of the cause. The other options (administer cryoprecipitate, crossmatch for blood, draw blood to check hemoglobin and hematocrit) may be done, but they are not the initial priority action. It will be important to rest the joint to prevent hemarthrosis. No weight bearing on joint until all swelling is resolved. (Lewis et al., 10 ed., p. 628)

A nurse is planning care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). What is a priority problem that the nurse should consider for the patient, based on an understanding of this condition? 1. Disturbed sleep pattern related to nocturia. 2. Risk for fall related to hypovolemia. 3. Electrolyte imbalance related to metabolic acidosis. 4. Risk for seizures related to hyponatremia.

4 SIADH occurs when excessive antidiuretic hormone (ADH) is released, even when the plasma (serum) osmolality is normal. The excess ADH increases the permeability of the renal tubules, causing reabsorption of water into the circulation. As a result of extracellular fluid expansion, serum osmolality decreases, and sodium levels decline (as a result of being diluted), leading to hyponatremia and a risk for seizures. (Lewis et al., 10 ed., p. 1106)

Which statement correctly describes suctioning through an endotracheal tube? 1. The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn. 2. The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway. 3. With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn. 4. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

4 The catheter must be advanced to an adequate depth (to prevent secretion buildup at the end of the tube and to clear the airway as much as possible). To minimize trauma, suction is applied only during catheter withdrawal. If the upper airway is suctioned, another sterile catheter must be obtained to suction the endotracheal tube. (Ignatavicius & Workman, 8 ed., pp. 525-526)

A child is scheduled for a myringotomy with placement of tympanostomy tubes. What is the long-term goal of this procedure that the nurse will discuss with the parents? 1. To decrease pressure on the tympanic membrane 2. To irrigate the eustachian tube 3. To correct a malformation in the inner ear 4. To prevent recurrent ear infections

4 The goal of a myringotomy is to allow draining of the fluid within the ear that will help prevent recurrent ear infections. It will decrease the pressure immediately, but this is not the long-term goal. It neither corrects a malformation in the inner ear nor provides a way to irrigate the eustachian tube, and you do not want excessive fluid in the middle ear. (Lewis et al., 10 ed., p. 385)

A client is being admitted for problems with Ménière disease. What is most important for the nurse to assess to promote the client's safety? 1. Diet history 2. Screening hearing tests 3. Effect on client's activities of daily living (ADLs) 4. Frequency and severity of attacks

4 The nurse must assess the frequency and severity of attacks to plan best for the client's safety. Although hearing tests and diet may be of some significance, they will not protect the client immediately. After the client's immediate safety needs are met, the nurse will want to determine the effect that Ménière's disease has on the client's ADLs. (Lewis et al., 10 ed., p. 386)

The nurse is caring for a client who has hypersplenism. What laboratory test finding would indicate that the client has splenomegaly? 1. Presence of Reed-Sternberg cells 2. Elevated red blood cell count 3. Increased Bence-Jones protein in urine 4. Presence of Howell-Jolly bodies in a blood smear

4 The presence of pitted or packed RBCs or Howell-Jolly bodies in a peripheral blood smear is diagnostic of splenomegaly. The presence of Reed-Sternberg cells in a lymph node biopsy specimen is diagnostic for Hodgkin disease. Elevated Bence-Jones protein in the urine is found in multiple myeloma. With hypersplenism, you would find cytopenia characterized by anemia, leukopenia, and thrombocytopenia. An elevated RBC, WBC, or platelet count would occur after a splenectomy. (Lewis et al., 10 ed., p. 647)

The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home? 1. Because of his need for oxygen, the client will have to limit activity at home. 2. The use of oxygen will eliminate the client's shortness of breath. 3. Precautions are necessary because oxygen can spontaneously ignite and explode. 4. Use oxygen during activity to relieve the strain on the client's heart.

4 The primary purpose of oxygen therapy is to decrease the workload of the heart in clients with chronic pulmonary diseases and to assist in preventing right-sided heart failure. Use of oxygen may help relieve shortness of breath but will not eliminate it. Oxygen supports combustion but is not explosive; supplemental oxygen will allow more activity for the client, not less. (Ignatavicius & Workman, 8 ed., pp. 515)

When caring for a client with diabetes insipidus, which assessment changes require a priority action? Select all that apply. 1. Urine output change from 270 mL/hr to 100 mL/hr. 2. Finger stick glucose of 182 mg/dL. 3. Weight decrease of 1 kg overnight. 4. Urine becoming paler in color. 5. Serum osmolality of 300 mOsm/kg

4, 5 Diabetes insipidus (DI) is associated with a decrease (or deficiency) in the secretion of antidiuretic hormone (ADH). Lack of ADH leads to increased urinary output (as much as 5-20 L/day). A concern would be demonstrated if the urine becomes more dilute, increases in quantity, blood pressure drops, or the blood becomes more viscous. (Lewis et al., 10 ed. p. 1160-1161)

The nurse identifies which problems as risk factors for the development of a sickle cell crisis? Select all that apply. 1. Recurrence of acute otitis media 2. A fall with swelling at the kneecap and joint 3. Fractured radius requiring internal fixation 4. Recurrence of respiratory tract infection 5. Traveling to a location of higher altitude 6. Dehydration

4, 5, 6 Recurrence of respiratory tract infections is associated with an increase in sickling crisis, not an acute case of otitis media. Respiratory infections generally involve fever, coughing, malaise, and anorexia. These factors contribute to dehydration. Dehydration may also precipitate an attack as the blood is thicker and more prone to clotting. Problems with oxygen saturation are also associated with sickling crisis, thus traveling to a higher altitude where there is less oxygen may precipitate a crisis. Injuries to joints or fractures needing surgical repair do not lead to a sickle cell crisis. (Lewis et al., 10 ed., p. 617)