NCLEX -silversteri -physiological integrity first 100 qs

acidosis vs alkalkosis

I. Metabolic alkalosis 1 client who has been *vomiting* for 2 days and the client 2, receiving *furosemide* daily. II. Metabolic acidosis 1. *diarrhea* 2. Aspirin overdose 3. Kidney disease III. Respiratory Alkalosis 1. emphysema and 2. hyperventilation are at risk for a

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material

1 Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

clear liquid diet vs. full liquid

1. Clear liquid -clear fruit juice - coffee / tea/ ginger ale - broth -Popsicle -gellatin -hard candy -bouillon

Which clients would the nurse determine is at risk for development of *metabolic alkalosis*? Select all that apply.

1. Client with emphysema 2. Client who is hyperventilating 3. Client with chronic kidney disease 4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily 6. Client admitted with acetylsalicylic acid overdose ans: 4,5

hypo vs. hyper Na +

1. Postural blood pressure changes occur in the client with hyponatremia. 2. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. 3. A slow, bounding pulse is not indicative of hyponatremia. 4. In a client with hyponatremia, a rapid, thready pulse is noted.

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply. 1. Beans 2. Apples 3. Cabbage 4. Brussels sprouts 5. Whole-grain bread

A high-fiber, high-residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products. Gas-forming foods such as beans, cabbage, and Brussels sprouts should be limited. ans: 2.5

infilteration symptoms

An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. 1. The pallor, 2. coolness, and 3. swelling are the result of IV fluid being deposited into the subcutaneous tissue.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing *Allen's test* before drawing the blood to determine the adequacy of which?

Before performing a radial puncture to obtain an arterial specimen for ABG values, Allen's test should be performed to determine adequate *ulnar circulation*

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?

Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

Fluid volume deficit

Causes of a fluid volume deficit include 1. vomiting, 2. diarrhea, 3. conditions that cause increased respirations or increased urinary output, 4. insufficient intravenous fluid replacement, 5. draining fistulas, 6. ileostomy, and ileostomy. FV Excess 1. A client with cirrhosis, 2. heart failure (HF), or 3. decreased kidney function is at risk for fluid volume excess.

Fl.vol deficit ?

Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include 1. increased respiration and 3. heart rate, 3. decreased central venous pressure, 4. weight loss, 5. poor skin turgor, 6. dry mucous membranes, 7. decreased urine volume, 8. *increased specific gravity of the urine* ( Too much solute in the solution - salty urine ) , 8. dark-colored and odorous urine, 9. an increased hematocrit level, and an 10. altered level of consciousness. Gurgling respirations, 2. increased blood pressure, and 3. decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

third spacing

Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

Food sources of riboflavin

Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.

The nurse is caring for a client with a suspected diagnosis of *hypercalcemia*. Which sign/symptom would be an indication of this electrolyte imbalance?

Generalized muscle weakness is seen in clients with *hypercalcemia*. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes ans: 4

Kernigs sign

Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.

NSAIDs Drug reactions

NSAIDs can amplify the effects of anticoagulants, such as 1. *warfarin*, therefore these medications should not be taken together. 2. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as *glimepiride*; 3. *Calcium-channel blocker* such as amlodipine; therefore this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take?

Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing. 4

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply. 1. "I will bend over to tie my shoes." 2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds." 6. "I will resume my exercise routine including pushups."

Rationale: After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and damage the lens implant. 1. The client should not sleep on the side of the body that was operated on. 2.The client may resume activities such as sitting upright at a table or 3.sitting in a recliner with the feet elevated. 4. The client should not lift anything heavier than 10 lbs. 5. The client should not perform activities that would increase the pressure within the eye, such as bending over to tie shoes or performing pushups. 2,3,4,5

A PTT

The normal aPTT varies between 28 seconds and 35 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 40 seconds or greater than 87.5 seconds. Thus the client's aPTT is within the therapeutic range, and the dose should remain unchanged.

opioid analgesics

The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, BP, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should notify the registered nurse as the next step after attempting to arouse the client. The nurse would also then document the findings after all data is collected, the client is stabilized, and if an abnormality * still exists after arousing the client.*

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. A urinary output of 20 mL/hour 2. A temperature of 37.6° C (99.6° F) 3. A blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1 Rationale: Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.Rationale: Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients 1. A premature infant 2. A 101-year-old man 3. A client with heart failure 4. A client with diabetes mellitus 5. A client receiving renal dialysis 6. A 29-year-old client with pneumonia

1, 2, 3, 5

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply.

1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide ans: 1,2,3

Normal ranges

1. platelets 150,000 mm3 to 400,000 mm3 (150-400 × 109/L); 2. sodium 135 mEq/L to 145 mEq/L (135-145 mmol/L); 3. potassium, 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L); 4. segmented neutrophils 60% to 70% (0.60-0.70); 5. serum creatinine, 0.6 mg/dL to 1.3 mg/dL (53-115 mcmol/L); and 6. white blood cells 5000 mm3 to 10,000 mm3 (5.0-10.0 × 109/L).

full liquid diet

2 .Full liquid diet -milk -ice cream -veg. juice -cream -butter -yogurt -pudding -custard -shabert

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client? 1. Stridor and cyanotic lips 2. Diminished breath sounds and fever 3. Wheezes and use of accessory muscles 4. Pleural friction rub and inspirational chest pain

3 Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position? 1. High-Fowler's position 2. Supine with no head elevation 3. Left lateral (side-lying) position 4. Supine with head elevation no greater than 30 degrees

4 Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period to prevent arterial occlusion or bleeding and hematoma. With a femoral approach, -the client's affected extremity is kept straight and the head elevated no more than 30 degrees (some PHCPs prefer a lower head position or the flat position) until hemostasis is adequately achieved. -The client may turn from side to side. Bathroom privileges are not allowed during the immediate postcatheterization period. High-Fowler's (90-degree elevation), flat, and side lying on the puncture site are not effective in preventing complications or allowing for client comfort.

The nurse is caring for a client who has been taking *diuretics* on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine ans: 4

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? 1. Every hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours

ans: 1 Rationale: Safe nursing practice includes monitoring an IV infusion at least once every 1 hour for an adult client. The remaining options do not provide time frames that are safe or acceptable.

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 1. An increased hematocrit level 2. An increased hemoglobin level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4, Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells.

bruzinski sign

A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner and the client reports pain in the vertebral column.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body.

1,2,3,4,5 Rationale: A drain is a tube that is placed to drain out fluid and blood near the surgical site and could lead to infection. The tube is connected to a bulb, which is compressed to create a vacuum and pull out the fluid. The nurse should check for patency and that fluid is being pulled out. The bulb should be, and look, decompressed in order to create the vacuum. The drainage usually is dark red as a result of blood content, but may be pale yellow with serous fluid. Aseptic technique must be used when emptying the drainage container to avoid contamination of the wound. The bulb of the drain should be emptied when it is half full and at least every 8 to 12 hours. The amount of drainage is documented in the client medical record under intake and output. Curling or folding the drain prevents the flow of the drainage.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition? K+ = ACID

1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives ans: 2 1. A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) is indicative of hyperkalemia. 2. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. 3. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

1. Potassium-rich gastrointestinal (GI) fluids are lost through --GI suction, which places the client at risk for hypokalemia. 2. The client with intestinal obstruction, i) Addison's disease, and ii) metabolic acidosis is at risk for hyperkalemia.

1. Normal fasting bld glucose level 2. Values to be reported

1. The normal fasting blood glucose level is 70 mg/dL to 100 mg/dL (4-6 mmol/L) in the adult client. 2. Values above the normal range should be evaluated to determine whether further intervention is needed. The most critical value is 2-2. 240 mg/dL (13.7 mmol/L).

1. Normal hemo globin 2. What increases? 3. What decreases hemoglobin?

1. The normal hemoglobin level for an adult female client is 12 g/dL to 16 g/dL (120-160 g/L) . 2. Iron deficiency anemia can result in *lower hemoglobin levels*. 3. Dehydration may *increase the hemoglobin* level by hemoconcentration. 4. Heart failure and chronic obstructive pulmonary disease may *increase the hemoglobin level* as a result of the body's need for more oxygen-carrying capacity.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value?

A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a 1. wide, flat P wave; 2. a prolonged PR interval; 3. a widened QRS complex; 4. narrow, peaked T waves.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. 4. Explain to the client that obesity is a risk factor and weight loss should be a future goal. 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

2.3 Rationale: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The registered nurse (RN) and primary health care provider (PHCP) need to be notified. The client should assume a low-Fowler's position with knees bent to avoid further stress on the incision. Obesity is a risk factor for dehiscence, but now is not the appropriate time for this teaching. The nurse should not explore the incision because this may actually cause evisceration, a more serious complication.

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client 2. Replacing the plastic utensils with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Allowing the client to unwrap the utensils and prepare his own meal for eating

Rationale: Kosher meals arrive on paper plates and with plastic utensils sealed. Primary health care providers should not unwrap the utensils or transfer the food to another serving dish. Although the nurse may want to be helpful by assisting the client with the meal, the only appropriate option for this client is option 4. 4

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. 1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg's position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

1,2,4,6 Rationale: Manually lifting or transferring clients can result in work-related injuries and back problems for health care workers. In addition, the shearing of the client's skin over bony prominences may occur when health care workers move clients independently. The nurse should get assistance from another caregiver, utilize correct body mechanics while utilizing mechanical aids such as a ceiling lift or friction-reducing slide sheet. Placing the client in Trendelenburg is not a useful technique for repositioning and could be harmful to the client because of the pressure this position places on the diaphragm. Administering oral pain medication is necessary, but oral medications need to be given at least 30 minutes before the activity to provide time for the medication to work and provide relief of pain.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply. 1 Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when eating and swallows twice after each bite.

1,3 A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking. Decreasing the light in the environment is done if a client has photophobia (sensitive to light). Clients with a shuffling gait as with Parkinson's disease should lift their legs high when walking. Clients experiencing dysphagia, which often occurs with stroke, should eat sitting upright and perform double swallowing.

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions should the nurse take? Select all that apply. 1. Ask if the client is thirsty and assist with drinking a glass of water. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 4. Review the client record to determine whether the client has voided postoperatively. 5. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

Rationale: If complications such as hemorrhage or shock are developing, early intervention is extremely important. Determining 1. how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs. 2. Accessing the medical record to determine the most recent analgesic administration is pertinent because hypotension is a frequent side/adverse effect of analgesics, especially opioids. 3. Reviewing the client's record gives the nurse data on the client's vital signs during and after surgery in the PACU, and the nurse can evaluate whether there has been a change. 4. Giving the client oral fluids is an intervention if the client has a fluid volume deficit and this has not been established. Oral fluids would not correct the problem as quickly as administering IV fluids would. Collecting data about the client voiding is not directly related to the vital signs. Encouraging leg exercises is a correct postoperative intervention, but is not appropriate for evaluating the vital signs. 2,3,6

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep venous thrombosis in right leg 10 years earlier

Rationale: 1. The nurse reports any client allergies, especially an antibiotic allergy to avoid an allergic reaction perioperatively. 2. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. 3. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). 4. A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. 5. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that needs to be reported specifically.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1. Slight redness along the incision 2. The presence of purulent drainage 3. A temperature of 98.8° F (37.1° C) 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision

Rationale: A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort. 2,6

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds. 2. Determine whether the client has a pulse deficit. 3. Instruct the client to use an incentive spirometer. 4. Determine the client's ability to follow verbal commands.

Rationale: Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and postoperatively. 4

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.e Care Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Elimination Strategy(ies): Subject 1. Have the client void before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

Rationale: The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client. 1.4