NCLEX Physiological Adaptation

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."

1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." (1. Correct: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat. 2. Incorrect: Weight gain is not associated with gallstones. 3. Incorrect: Black stools indicate blood in the stool and should be further investigated. Black stools are not associated with gallstones. 4. Incorrect: When the symptom of drinking milk or having a small snack relieves the abdominal pain, a duodenal ulcer may be a possible diagnosis.)

The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? 1. Abrupt onset of dyspnea, fever. 2. Small papule on skin resembling an insect bite. 3. Pustular vesicles on skin. 4. Fatigue.

1. Abrupt onset of dyspnea, fever. (1. Correct: Inhalation of anthrax spores is very serious, and clients will experience abrupt dyspnea and fever. Treatment must begin immediately. 2. Incorrect: Cutaneous anthrax manifests itself as papules resembling an insect bite that progresses to depressed black ulcers. 3. Incorrect: Pustular vesicles are consistent with smallpox. 4. Incorrect: Fatigue is a vague symptom that is usually not associated with inhaled anthrax.)

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? Select all that apply. 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1. Difficulty waking up 3. Blurry vision 5. Vomiting (1., 3. & 5. Correct: Increased intracranial pressure (ICP) is a result of increased pressure around the brain or blood in the brain. These are signs of increasing intracranial pressure (post-concussion syndrome). This is a medical emergency, and the PHP should be notified immediately. 2. Incorrect: A headache of 3/10 on the pain scale does not warrant notifying the primary healthcare provider. The primary healthcare provider should be notified if the pain intensity increases. 4. Incorrect: This is not related. This is not a symptom of increased ICP.)

A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? Select all that apply. 1. Firm, nodular liver 2. Ascites 3. Increased serum albumin levels 4. Increased ALT and AST levels 5. Lowered ammonia levels 6. Bleeding from the GI tract

1. Firm, nodular liver 2. Ascites 4. Increased ALT and AST levels 6. Bleeding from the GI tract (1., 2., 4., & 6. Correct: With cirrhosis, the liver can become very large in size and feels very firm and nodular upon palpation. Third spacing of fluids out of the vascular space (ascites) occurs due to lowered albumin levels. The client is often in a nutritional deficit which contributes to the lowered albumin level. Also, the liver is sick and unable to synthesize albumin. The liver enzymes ALT and AST will be elevated with liver problems such as cirrhosis. Increased pressure in the liver (portal hypertension) causes a backward pressure throughout the GI tract. Esophageal varices may form as a result of this pressure. If variceal rupture occurs, GI bleeding will be noted. In addition, liver diseases, such as cirrhosis, are the common causes of blood clotting problems because the liver is unable to produce the needed clotting factors. 3. Incorrect: Serum albumin levels are low in clients with cirrhosis. When the liver becomes damaged, it stops making certain proteins, including the blood protein albumin. 5. Incorrect: Ammonia levels rise in clients with cirrhosis because the liver is unable to convert the ammonia to urea to be excreted by the kidneys.)

A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? Select all that apply. 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs.

1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 5. When I sleep, I should keep a pillow between my legs. (1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place.)

The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? Select all that apply. 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver

1. Lowers the blood glucose 2. Provides more energy (1. & 2. Correct: In the presence of adequate insulin, exercise lowers the blood glucose. Exercise releases endorphins, providing the client with increased energy and feelings of well-being. 3. Incorrect: Exercise does not require the need; for the increased production of insulin. 4. Incorrect: Exercise does not reverse complications. Exercise helps prevent microvascular and macrovascular changes/complications. 5. Incorrect: Exercise does not increase the workload of the liver.)

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? Select all that apply. 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1. Monitor intake and output. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully. (1., 3., 4., 5., & 6. Correct: Removal of the pituitary gland can lead to diabetes insipidus (DI) as a result of the reduced production of antidiuretic hormone (ADH). The nurse should monitor I&O closely and watch for an increase in output which would indicate diuresis as part of DI. Daily weights are an important part of monitoring the client's fluid status. Monitoring the urine specific gravity is another good way of assessing the fluid status because, as the urinary output increases, the client's urine is becoming more dilute, which would result in a lower urine specific gravity. If the client's serum volume is decreasing from the excessive diuresis, the client can go into shock. The nurse should monitor for early signs of changes in the level of consciousness. To avoid disrupting the surgical site, the client should not blow the nose forcefully for at least one week post-op. 2. Incorrect: If the client is lacking ADH, the client may begin losing large amounts of fluid volume. Therefore, the fluid intake would need to be increased (not decreased) to avoid dehydration and shock.)

When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? Select all that apply. 1. Nervousness 2. Weight gain 3. Exophthalmos 4. Loss of appetite 5. Constipation 6. Hot and sweating

1. Nervousness 3. Exophthalmos 6. Hot and sweating (1., 3., & 6. Correct: With hyperthyroidism, the client has too much energy. They report being nervous and feeling hot. Exophthalmos is an irreversible eye condition where the eyes bulge. This condition is associated with hyperthyroidism that has not been treated early enough to prevent this from occurring. Due to the hypermetabolic state, the client will often report feeling hot and will be sweating. 2. Incorrect: The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 4. Incorrect: Loss of appetite is seen in the client with hypothyroidism. The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 5. Incorrect: Constipation is a sign of hypothyroidism due to slowed GI motility. In hyperthyroidism, the nurse would expect increased GI motility.)

An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? Select all that apply. 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.

1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip. (1., 2., 4., & 5. Correct: Pain in the affected hip, often severe, is one of the main signs of a hip fracture. This pain may radiate to the groin area. The pain and bone injury generally prevent the client from being able to bear weight on the affected leg. The client will often assume a position in which the leg on the injured side is held in a still and externally rotated position (the foot and knee turns outward). Discoloration and swelling can be an indication of a hip fracture in some clients. 3. Incorrect: A client who has a hip fracture often appears to have shortening of the extremity on the affected side. This is a result of the location of the break and the positioning of the body in response to the injury and pain.)

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? Select all that apply. 1. White blood cell count of 3,800 (3.8 × 10⁹/L) 2. White blood cell count of 15,000 (15.0 × 10⁹/L) 3. Platelet count of 90,000/µL (90 × 10⁹/L) 4. Platelet count of 450,000/µL (450 × 10⁹/L) 5. Red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L) 6. Red blood cell count of 7.3 million/mcL (7.3 × 10¹²/L)

1. White blood cell count of 3,800 (3.8 × 10⁹/L) 2. White blood cell count of 15,000 (15.0 × 10⁹/L) 3. Platelet count of 90,000/µL (90 × 10⁹/L) 4. Platelet count of 450,000/µL (450 × 10⁹/L) 5. Red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L) (1., 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000-10,000 (5.0-10.0 × 10⁹/L), so a level of 3,800 (3.8 × 10⁹/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150-450 × 10⁹/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL (4.2-5.4 × 10¹²/L), and the normal red blood count for a Male is 4.7-6.1 million/mcL (4.7-6.1 × 10¹²/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L) is indicative of anemia, regardless of the sex of the client. 2. Incorrect. The normal white blood cell count is 5,000-10,000 (5.0-10.0 × 10⁹/L). A WBC count of 15,000 (15.0 × 10⁹/L) is considered leukocytosis (elevated WBC level). 4. Incorrect: The normal platelet count is 150,000-400,000/µL (150-450 × 10⁹/L). Therefore, a platelet count of 450,000/µL (450 × 10⁹/L) would be an elevated platelet level (thrombocytosis). 6. Incorrect: The normal red blood cell count for a Female is 4.2-5.4 million/mcL (4.2-5.4 × 10¹²/L), and the normal red blood count for a Male is 4.7-6.1 million/mcL (4.7 - 6.1 × 10¹²/L). Therefore, a level of 7.3 million/mcL (7.3 × 10¹²/L) is elevated (polycythemia).)

A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? 1. Prolonged bleeding time 2. Elevated reticulocyte count 3. Decreased platelet count 4. Elevated bands

2. Elevated reticulocyte count (2. Correct: Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase. 1. Incorrect: Prolonged bleeding times occur with liver problems. 3. Incorrect: A decreased platelet count will cause bleeding but will not tell the nurse if there is chronic bleeding. 4. Incorrect: Elevated bands are a part of the WBC differential and are increased with acute infection.)

The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed? 1. "Prior to suctioning, I will hyper-oxygenate the client." 2. "I will instill normal saline bullets to liquefy secretions." 3. "I will allow at least 20 seconds between suctioning passes." 4. "Suctioning will be limited to a maximum of three catheter passes."

2. "I will instill normal saline bullets to liquefy secretions." (2. Correct. The best ways to liquefy secretions are to humidify secretions and hydrate the patient. Do not use normal saline solution or normal saline bullets routinely to loosen tracheal secretions because this practice may reach only limited areas, may flush particles into the lower respiratory tract, may lead to decreased post-suctioning oxygen saturation, increases bacterial colonization, and damages bronchial surfactant. 1. Incorrect. This is a true statement. Prior to suctioning, the client should be hyper-oxygenated. Suctioning a client will cause a decrease in the clients oxygen level. 3. Incorrect. This is a true statement. This allows the client to get oxygen between passes. The nurse should wait at least 20 seconds before suctioning the client again. This allows the oxygenation of the client to increase. 4. Incorrect. This is a true statement. Each session of suctioning should be limited to no more than 3 passes this will allow the client proper oxygenation and to prevent tissue damage during repeated suctioning.)

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent? 1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier.

2. History of pharyngitis approximately 4 weeks ago. (2. Correct: Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the assessment should include a remote history of pharyngitis. 1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation of rheumatic fever. 3. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and is not considered a major manifestation of rheumatic fever. Although the child may have a history of vomiting, this finding would not be specific to rheumatic fever. 4. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame for the development of rheumatic fever is not appropriate if the cough started 1 week earlier, even if it had been associated with an upper respiratory streptococcal infection.)

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include? 1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water.

2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water. (2., 3., 4. & 5. Correct: All of these measures will promote comfort and decrease risk of transmitting infection. Clients should also avoid touching the eyes and shaking hands/touching other. Cool compresses provide symptomatic relief. 1. Incorrect: Use a new tissue every time you wipe the discharge from the eye. You can dampen the tissue with clean water to clean the outside of the eye. If a personal handkerchief is used, reinfection can occur.)

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2. Notify the primary healthcare provider immediately. (2. Correct: These symptoms are consistent with neuroleptic malignant syndrome (NMS), which is an adverse reaction to antipsychotic drugs. The symptoms of NMS are fever, altered mental state, muscle rigidity, and autonomic dysfunction. This is a medical emergency, and immediate action should be taken. 1. Incorrect: The symptoms indicate a medical emergency and the need for an immediate response. The nurse should notify the primary healthcare provider first. 3. Incorrect: The high temperature should be assessed, but the extreme muscle rigidity and fluctuating vitals are a medical emergency. The client needs further immediate attention. 4. Incorrect: The nurse should not administer another dose of the antipsychotic medication due to the client's presenting symptoms. Usually, the primary healthcare provider would discontinue the medication immediately.)

A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider? 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity.

2. Pain not relieved by elevation, cold packs, and pain medication. (2. Correct: Pain that is disproportionate to the injury, becomes severe, and/or is not relieved by elevation, cold packs, and pain medication could indicate a complication such as compartment syndrome. Failure to detect this could lead to neurovascular damage and possible amputation. 1. Incorrect: Due to the drying process of the cast material, it is normal for the cast to feel warm. The primary healthcare provider would not need to be notified. The warm feeling should subside. 3. Incorrect: A common complaint is itching under the cast. The cast material may cause irritation to the skin. Cool air under the cast may help to relieve this. The primary healthcare provider would not need to be notified at this time. 4. Incorrect: Some swelling is expected initially due to the damage of the tissue around the fracture which may result in dependent swelling of the toes. This compromised circulation should be relieved by elevation. The primary healthcare provider would not need to be notified at this time.)

The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment? 1. Assess for dependent edema. 2. Monitor for cardiac arrhythmias. 3. Auscultate breath sounds. 4. Monitor sodium and potassium levels

3. Auscultate breath sounds. (3. Correct: The nurse is "worried" about fluid volume excess. In fluid volume excess (FVE), the number one concern is heart failure with resultant pulmonary edema. In FVE, you can stress the heart so much that the heart begins to fail. With heart failure, the cardiac output decreases. With decreased cardiac output, there is decreased forward flow out of the heart. With decreased forward flow there is back flow. Back flow from the left ventricle results in fluid accumulation in the lungs. The best assessment for heart failure is to auscultate lung sounds. 1. Incorrect: Inspecting for dependent edema does not address the biggest problem/concern in FVE. The nurse is "worried" about pulmonary edema. This client will probably have edema, but it is not more important than breath sounds. 2. Incorrect: After evaluating the output versus the input amounts, the lungs should be assessed to evaluate the pressure of FVE. Cardiac arrhythmias are a possibility, due to the stress on the heart due to FVE. 4. Incorrect: Electrolytes may be abnormal due to FVE. The number one concern is FVE and pulmonary edema.)

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first? 1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea.

3. Draw blood cultures. (3. Correct: Blood cultures MUST be drawn immediately to identify the causative bacteria. Once the organism is identified, the primary healthcare provider will order organism specific antibiotics. Always draw blood cultures before administering the antibiotic. If antibiotics are given before the blood cultures are drawn, the culture will be inaccurate, and the client cannot be treated appropriately. 1. Incorrect: Application of a cooling blanket is appropriate, but the key in this question is to "fix the problem" ASAP. To treat the infection, the blood cultures must be drawn ASAP and be done before starting the antibiotics. 2. Incorrect: Antibiotics are not given until the cultures have been drawn. Administering the antibiotic first would cause the culture to be inaccurate. 4. Incorrect: Preventing shivering is appropriate, but remember, always pick the answer that is most life-threatening. In this case, treating the bacteria as soon as possible is the priority answer. This requires the culture be obtained ASAP so the antibiotic therapy can be initiated.)

The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection? Select all that apply. 1. Dyspnea on exersion with nonproductive cough 2. Tachypnea with use of accessory muscles 3. Expectorating moderate amounts of thin, white sputum 4. White blood cell count of 18,000 cells per mcL 5. Crackles clearing with cough

3. Expectorating moderate amounts of thin, white sputum 5. Crackles clearing with cough (3. & 5. Correct: The client has no signs of active infection. A cough with thin, white sputum is expected for a while, but it is infection free. Crackles clearing with cough are signs of an effective cough effort. 1. Incorrect: The client still has signs of active infection and complaints of dyspnea. The client should not have a nonproductive cough on exertion. 2. Incorrect: The client still has signs of active infection, such as tachypnea with use of accessory muscles. The respiration rate for an adult is 12-20 per minute with no use of accessory muscles. 4. Incorrect: The white cell count is still too high. A normal range for white blood count is between 4,500 and 10,000 mcL. This is not a therapeutic response to the treatment.)

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 50 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)

3. Gradual increase of BUN levels. (3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure and that value alone would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL).)

The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Metabolic acidosis (3. Correct: A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO₂ level. 1. Incorrect: The fruity smelling breath indicates a metabolic problem. This is a result of an increase in the acetone level. The client may develop diabetic ketoacidosis (DKA). 2. Incorrect: The client is in metabolic acidosis. This is not a respiratory imbalance. 4. Incorrect: The client is experiencing a metabolic situation due to the increase in the ketones in the body, the client is in metabolic acidosis.)

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3. Place on droplet precautions. (3. Correct. When bacterial meningitis is suspected, the nurse should place the client on droplet precautions at once. Transmission can occur by the droplet/close contact route for up to 24 hours even after starting effective antibiotic therapy. The Centers for Disease Control and Prevention (CDC) recommends droplet precautions in addition to Standard Precautions for bacterial meningitis. 1. Incorrect. Penicillin is the drug of choice but would be initiated after blood cultures and other cultures are obtained. The client would be placed in isolation prior to starting penicillin. 2. Incorrect. Lumbar puncture is done to obtain cultures for diagnosis but would be done after placing in isolation. Blood cultures are obtained from the lumbar puncture and cultures may be obtained from blood, nasopharynx, urine, or skin lesions. The client would be placed in isolation first. 4. Incorrect. A lumbar puncture and cerebrospinal examination are needed to confirm a diagnosis. The lumbar puncture should be performed after placing the client in droplet precautions.)

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B₁₂ intramuscularly. What should the nurse include in discharge instructions? 1. B₁₂ can be stored in a lighted area. 2. The B₁₂ injections will be stopped when symptoms disappear. 3. The B₁₂ injections will be continued for the client's life. 4. Vitamin B₁₂ will be taken by mouth once the maintenance dose is determined.

3. The B₁₂ injections will be continued for the client's life. (3. Correct: With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B₁₂ cannot be absorbed. The client will require B₁₂ shots throughout the lifespan. 1. Incorrect: B₁₂ should be protected from the light. 2. Incorrect: Cannot be stopped once symptoms disappear due to lack of intrinsic factor. Must be continued throughout the lifespan. 4. Incorrect: B₁₂ cannot be administered orally. The client lacks the intrinsic factor, therefore B₁₂ cannot be absorbed in the GI tract. B₁₂ must be given by injection.)

A nurse is caring for a client who has developed ventricular fibrillation. Where should the nurse place the conductive electrodes for maximum defibrillation effectiveness? 1. The left lower sternum and the right side of the thorax in the midclavicular line. 2. On the right shoulder and the left side of the sternum just below the rib cage. 3. The left upper chest to the left of the sternum and the lower right half of the sternum. 4. Below the right clavicle to the right of the sternum and just below the left nipple.

4. Below the right clavicle to the right of the sternum and just below the left nipple. (4. Correct: One electrode should be placed just below the clavicle to the right of the sternum, and the other electrode placement is on the left side just under the left nipple (pectoral area) and in the midaxillary line. 1. Incorrect: The position of these electrodes is not the recommended and acceptable placement for optimal defibrillation. The positioning of the electrodes is not anatomically correct to allow maximum delivery of the current through the heart. 2. Incorrect: The position of these electrodes is not the recommended and acceptable placement for optimal defibrillation. The positioning of the electrodes is not anatomically correct to allow maximum delivery of the current through the heart. 3. Incorrect: The position of these electrodes is not the recommended and acceptable placement for optimal defibrillation. The positioning of the electrodes is not anatomically correct to allow maximum delivery of the current through the heart.)

The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.

4. Increase fiber. (4. Correct: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation. 1. Incorrect: No, they need fewer calories, not more. Their metabolism is slowed. A client with hypothyroidism may gain weight due to decreased metabolism. The client should decrease their intake of carbohydrates. 2. Incorrect: To decrease constipation the client should increase fluid intake. When the client is hydrated the stool will be softer. 3. Incorrect: Avoiding shellfish is not a consideration unless there is an iodine allergy.)

The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver

4. Jaw thrust maneuver (4. Correct: This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine. 1. Incorrect: The endotracheal (ET) tube is a device for maintaining an open airway, not for opening it. 2. Incorrect: This is a trauma client who may have a C-spine injury. The head tilt-chin lift maneuver would manipulate the client's C-spine therefore is not used with this client to open the client's airway. 3. Incorrect: The oral airway is a device for maintaining an open airway, not for opening it.)

How would the nurse determine the correct size oropharyngeal airway for a client? 1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth.

4. Measure from the earlobe to the corner of the mouth. (4. Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face. 1. Incorrect: The size of the client's little finger does not determine the size of the oral airway that should be used. This would result in an inappropriate size oropharyngeal airway to be selected. 2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly measure it. In addition, the measurement would not determine the appropriate size oropharyngeal airway to use. 3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would make the oral airway too long.)

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.

4. Place an eye shield over eye. (4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement. 1. Incorrect: Everting the eyelid and examining for a foreign body are not measures that should be performed before placement of eye shield. You should never attempt to remove a foreign body, so examination would not be needed at this point. 2. Incorrect: Measuring visual acuity is not a priority and is not performed before placement of eye shield. The goal is to protect the eye from further injury and reduce movement of the eye. The shield will help accomplish this goal. 3. Incorrect: Notifying immediately for transfer should not be done before placement of eye shield. The eye should be protected first to reduce further injury.)

The nurse should question which prescription for a client diagnosed with acute heart failure? 1. 2 gram of sodium (Na⁺) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr.

4. Start IV with NS at 125 mL/hr. (4. Correct: The client is in fluid overload and does not need the normal saline (NS) at 125 mL/hr. NS is an isotonic solution. It goes in the vascular space and stays there without shifting out to the cells. This could cause additional overload in the vascular space as well as cause the BP to increase. The other prescriptions are acceptable. 1. Incorrect: This is an appropriate measure Na⁺ restricted diet will help to lower the serum Na⁺ and decrease H₂O retention. This does not need questioning. 2. Incorrect: Digoxin is a digitalis glycoside. It slows conduction and strengthens the force of contraction of the heart. Therefore, this medication that increases cardiac contractility and reduces the heart rate does not need questioning. 3. Incorrect: Furosemide is a diuretic. It enhances renal excretion of Na⁺ and H₂O and reduces systemic and pulmonary congestion. This medication prescription does not need questioning.)

The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)

Progesterone (1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test)

Which statement made by a client post-thyroidectomy would require further investigation by the nurse? 1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak."

1. "I have a tingling feeling of my fingers." (1. Correct. After this procedure the nurse should worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result. 2. Incorrect. Pain is expected here. The incision is at the base of the neck, so movement of the head would increase the pain. 3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is being measured. You worry if you see carpal spasm (+ Trousseau's) which is indicative of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent removal of some of the parathyroids. 4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this case, we are concerned that the parathyroids may have been removed, resulting in hypoparathyroidism. The weakness in the legs is apparently from a different cause. However, the signs of possible hypoparathyroidism would be the priority to investigate.)

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? Select all that apply. 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." (1., 2., 4., & 5. Correct: Clients with a hiatal hernia should eat small frequent meals, because large meals cause them to be symptomatic with heartburn and other symptoms. Sitting up after eating will keep the stomach down as much as possible. If they lie down, the stomach will go upward and cause regurgitation, heartburn, nausea, and fullness. Placing blocks under the bed also helps keep the stomach downward and reduces symptoms when the client sleeps. One of the major causes and aggravating actions for a hiatal hernia is straining. Therefore, the clients do not need to be lifting heavy objects. 3. Incorrect: Since grapefruits are acidic, they can increase the amount of acid backing up into the esophagus. Eating grapefruits should be avoided. 6. Incorrect: Straining should be avoided so use of laxatives may be advised. Straining to have a bowel movement will cause increased abdominal pressure which may cause pressure on the hiatal hernia.)

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate? Select all that apply. 1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs

1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions (1., 2., 3., & 4. Correct: The symptoms presented are indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe. 5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided. 6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more.)

The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO₂ - 40, HCO₃⁻ - 30 2. pH - 7.32, pCO₂ - 48, HCO₃⁻ - 20 3. pH - 7.38, pCO₂ - 52, HCO₃⁻- 32 4. pH - 7.29, pCO₂ - 54, HCO₃⁻ - 26

1. pH - 7.49, pCO₂ - 40, HCO₃⁻ - 30 (1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO₂ is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis. 2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO₂ is high (acidosis) and the bicarb is low (acidosis). 3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO₂ is high (as with chronic retention) and the bicarb is high to help compensate. 4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO​₂ is high, and the bicarb is normal. No compensation has begun at this point.)

Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? 1. "I will read labels to be sure there is no hidden alcohol in food." 2. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." 3. "I can call the clinic or my sponsor whenever I feel tempted to drink alcohol." 4. "Even one glass of alcohol can cause me to start drinking regularly again."

2. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." (2. Correct: This statement indicates the need for further instruction for this client. When discharged home following rehabilitation for alcohol, clients are told to attend at least one AA meeting every single day, whether feeling the need to drink or not. Constant reinforcement is found to increase the rate of success following inpatient rehabilitation. 1. Incorrect: This statement by the client is correct. Many daily products contain small amounts of alcohol, such as salad dressings, cold medications, and even after shave. 3. Incorrect: This is also a correct statement, as clients who are recovering from alcoholism are designated a "sponsor", or support person, whom they can contact at any time for assistance. Also, there is a 24/7 hotline for most clinics to provide emotional support to clients 4. Incorrect: This statement by the client is also correct. No amount of alcohol is considered "safe" for an alcoholic and even one glass of alcohol or wine can defeat months of rehab since most alcoholics cannot stop at one drink.)

A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? 1. "I will try to keep my legs together as close as possible." 2. "I will not elevate the head of the bed." 3. "I know that I cannot ever swim again." 4. "I can resume my exercises at the gym within one month."

2. "I will not elevate the head of the bed." (2. Correct: Flexion of the hip should be avoided after hip surgery. Elevating the HOB would cause flexion, which could cause hip dislocation. 1. Incorrect: The legs should be kept in an abducted (legs apart) position following surgery to keep the head of the femur in the acetabulum (hip in the socket). An abductor pillow is often used to accomplish this and prevent the legs being close together or crossing. 3. Incorrect: Swimming is a non-weight bearing exercise that is encouraged during rehabilitation for post hip replacement clients. Walking is another good exercise for these clients. 4. Incorrect: Stressors on the hip joint should be kept to a minimum for the first 3 to 6 months. Some exercises in the gym could put too much strain on the new hip joint and cause dislocation.)

The nurse on a neuro rehabilitation unit is caring for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? Select all that apply. 1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal.

2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal. (2., 3., 4., 5. & 6. Correct: The client is experiencing autonomic dysreflexia, which is a potentially dangerous syndrome that can develop in clients with spinal cord injuries. The cause of autonomic dysreflexia with these associated symptoms is a strong sensory or noxious stimulus. The most common stimulus is bowel, bladder distention, or irritation. Any painful, irritating or strong stimulus including environmental temperature changes, drafts, etc. can trigger autonomic dysreflexia. It is considered a medical emergency and must be promptly treated. 1. Incorrect: The client should be placed immediately in a sitting position to lower blood pressure. The supine position with the legs elevated could increase the BP to higher and more dangerous levels.)

Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? Select all that apply. 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia

2. Bibasilar crackles 3. Orthopnea (2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs. 1. Incorrect: Ascites is seen with right sided heart failure because fluid backs up into the systemic venous circulation causing stasis in the abdominal organs. 4. Incorrect: Hepatomegaly is seen with right sided heart failure because of the venous engorgement and stasis in the liver. 5. Incorrect: Anorexia is seen in right sided heart failure due to venous engorgement and venous stasis within the abdominal organs.)

Which factors should the nurse include when teaching a parent about risk factors for otitis media? Select all that apply. 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5

2. Contact with siblings 3. Day care attendance 4. Season of the year (2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter months. 1. Incorrect: Breast-feeding decreases the incidence of otitis media. Ear infections are more common in children who drink from bottles or sippy cups, especially when lying on their back. 5. Incorrect: Age under 5 is a risk factor. The Eustachian tube is shorter, narrower, and more vulnerable to blockage in the younger children. It also lies more horizontal and does not drain as well as older children and adults. This, along with immature immune systems, puts the younger child at higher risks for otitis media.)

What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? Select all that apply. 1. Jogging 2. Volleyball 3. Tennis 4. Bicycle riding 5. Swimming

4. Bicycle riding 5. Swimming (4., & 5. Correct: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding. 1. Incorrect: Jogging is a high impact activity for joints. This is not appropriate for a client with rheumatoid arthritis. 2. Incorrect: Playing volleyball is a high impact activity for joints and would not be appropriate for a client with rheumatoid arthritis. The pressure on the joints may result in additional damage to the joints. 3. Incorrect: Playing tennis is a high impact activity for joints, and tennis should not be a recommended sport for a client with rheumatoid arthritis.)

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation? 1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving?

2. Do you have periods of muscle jerking? (2. Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal. 1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue. 3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority. 4. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address.)

A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms? Select all that apply. 1. Weight gain 2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia

2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia (2., 3., 4. & 5. Correct: Feeling tired all the time, loss of appetite, fever, coughing up blood, and night sweats are the most common signs and symptoms of active TB. 1. Incorrect: A symptom of TB is a decreased desire for food. This will result in weight loss rather than weight gain.)

A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding? 1. Perianal irritation from frequent diarrhea 2. Fistula formation with an abscess 3. Stricture formation 4. Impaired immunologic response to infectious microorganisms

2. Fistula formation with an abscess (2. Correct: Clients who suffer from Crohn's disease are at risk for developing fistulas, and an abscess can result from the fistula. 1. Incorrect: Perianal irritation from frequent diarrhea can occur, but irritation does not result in an infection. 3. Incorrect: Stricture formation is a complication, however, these s/s indicate an abscess. 4. Incorrect: Impaired immunologic response is not associated with Crohn's disease.)

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important? 1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently?

2. Have you recently worked with any farm animals or any animal-skin products? (2. Correct: Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals. 1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary. 3. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe respiratory distress. 4. Incorrect: This question would be appropriate if botulism were suspected in a client.)

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? Select all that apply. 1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area.

2. Increase oral intake to at least 2000 mL/day. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area. (2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration. 1. Incorrect: This does not get rid of secretions. This monitors respiratory effectiveness. 3. Incorrect: The nurse knows that client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the sputum will remain in the lungs, providing a medium for bacterial growth.)

The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? 1. Dilated pupils after 1 minute of CPR 2. Presence of a carotid pulse with each compression 3. Cardiac rhythm on the monitor 4. Rise and fall of client's chest with ventilations

2. Presence of a carotid pulse with each compression (2. Correct: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression. 1. Incorrect: Dilated pupils are a neurological sign. Pupils should constrict if CPR is effective and is not the priority assessment for determining effective CPR. 3. Incorrect: The cardiac rhythm reflects the electrical activity of the heart. It does not indicate effective cardiac compressions with CPR. 4. Incorrect: Responsiveness is a neurological check. It determines if the client responds to stimuli. Responsiveness is documented as alert, responds to verbal stimuli, and responds to painful stimuli, or unresponsive.)

A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? Select all that apply. 1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain

2. Tachypnea 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain (2., 4., 5. & 6. Correct: The normal range for CVP is 2-8 cm H​₂O or 2-6 mmHg. Therefore, the readings of 13 cm H​₂O are high and may be the result of fluid volume excess. The signs and symptoms of FVE include: tachynea, rales, and jugular vein distention from the increased volume and preload. Acute weight gain is one of the best indicators of FVE due to circulatory overload. 1. Incorrect: The CVP is high and correlates with fluid volume excess. Dry oral mucous membranes indicate fluid volume deficit. 3. Incorrect: The CVP is high and correlates with fluid volume excess. Orthostatic hypertension indicates fluid volume deficit.)

The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? 1. It is not necessary to treat mild hypoglycemia indicated by irritability. 2. Treat a mild episode with 10-15 grams of carbohydrate. 3. The client should consume 12 ounces of regular cola. 4. The client should consume 2 cups of orange juice without added sugar.

2. Treat a mild episode with 10-15 grams of carbohydrate. (2. Correct. 10-15 grams of carbohydrate should raise the blood sugar 40 - 50 mg/dL. Then the family can check the blood sugar and repeat the carbohydrate if necessary. 1. Incorrect. The blood sugar level may drop rapidly and result in changes in level of consciousness. The family should be taught to always worry about hypoglycemia. 3. Incorrect. Twelve ounces of cola would raise the blood sugar too high. Twelve ounces of cola contains about 39 grams of carbohydrates. 4. Incorrect. Two cups of orange juice would equal approximately 52 grams of carbohydrates. This would raise the blood sugar too high.)

What should the nurse include when teaching a client in renal failure about peritoneal dialysis? Select all that apply, 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.

3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 6. A sweet taste may be experienced when peritoneal dialysis is used. (3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.)

A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers? 1. Types of contact sports played 2. Amount of acetaminophen intake 3. Recent sore throat 4. Recent exposure to salmonella

3. Recent sore throat (3. Correct: Acute post-streptococcal glomerulonephritis (APSGN) results from a group A beta-hemolytic streptococci infection that originates typically in the throat (strep throat) or the skin (impetigo). The strep bacterial infection can cause the filtering units of the kidneys (glomeruli) to become inflamed and results in a decreased ability of the kidneys to filter the urine. The disorder may develop 1-2 weeks after an untreated throat infection or 3-4 weeks after a skin infection. 1. Incorrect: Glomerulonephritis is not associated with trauma over the kidney region, so questioning about contact sports would not be relevant to glomerulonephritis. 2. Incorrect: Excessive acetaminophen intake can cause liver damage but is not associated with glomerulonephritis. 4. Incorrect: Salmonella is not an organism that is linked to the development of glomerulonephritis. Group A beta-hemolytic streptococci is the causative organism for acute glomerulonephritis.)

One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts drunk" and cannot control the right foot and arm. Based on this data, what should the nurse suspect? 1. Meningitis 2. Transient ischemic attack 3. Subdural hematoma 4. Meniere's disease

3. Subdural hematoma (3. Correct: Yes, subacute subdural hematoma is a head injury with slow venous bleed. The body does not have symptoms until compensation is exhausted. 1. Incorrect: No, fever and nuchal rigidity are symptoms of meningitis. 2. Incorrect: No, because of the motor vehicle crash, the nurse should think subdural hematoma first due to the risk of increasing intracranial pressure (ICP). 4. Incorrect: No, whirling vertigo and vomiting would be expected with Meniere's disease.)

Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? Complete Blood Count RBCs: 5 million/mm³ (5 × 10⁶/mm³)​ (5 × 10¹²/L​) WBCs: 5,000 (5 × 103/mm³) ​(5 × 10⁹/L​) Urinalysis RBCs: 2-3/hpf WBCs: > 5/hpf. 1. Gross hematuria 2. Septicemia 3. Urinary tract infection 4. Anemia

3. Urinary tract infection (3. Correct: The urinalysis results of red blood cells (RBC) of 2/hpf or greater and urine white blood cells (WBC) of greater than 4/hpf indicate a urinary tract infection (UTI). 1. Incorrect: The urinalysis results of 2-3/hpf RBCs is not indicative of gross hematuria. 2. Incorrect: The blood WBCs are normal. In septicemia, the blood WBCs are elevated. 4. Incorrect: Blood RBCs of 5 million/mm³ (5 × 10⁶​/mm³) (5 × 10¹²/mm³) is a normal finding.)

A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply? 1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing."

4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing." (4. Correct: This is the best, most accurate response. Radiation can cause tissue trauma and changes that can delay wound healing. 1. Incorrect: The nurse should know not to put work off on someone else. This answer avoids responsibility and does not provide the client with the information requested. 2. Incorrect: This answer assumes the client has financial concerns, but this is not the question the client asked. It also dismisses the client by being told not to worry. 3. Incorrect: This answer brushes off the client. Never pick an answer that brushes off the client's concern.)

What is most important for the nurse to do prior to initiating peritoneal dialysis? 1. Aspirate for placement. 2. Have the client void. 3. Irrigate the catheter for patency. 4. Warm the dialysate fluid.

4. Warm the dialysate fluid. (4. Correct: The peritoneal fluid is inserted into the abdominal cavity. To promote the exchange of wastes and fluid through the peritoneal membrane, the peritoneal fluid should be warmed. This will promote vasodilation of the capillaries in the peritoneal cavity. 1. Incorrect: The peritoneal catheter should not be aspirated. This would not tell you anything and could irritate the peritoneal membrane. After the cover of the dialysate fluid is removed, the tubing should be connected to the peritoneal catheter. 2. Incorrect: This is not a bad choice, just not the most important. Voiding would make the client more comfortable during the procedure but will not affect the success. 3. Incorrect: It is not necessary to irrigate a peritoneal catheter because you are irrigating with the dialysate.)