NURS 209 Practice HESI Questions (IGGY BOOK)

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. "A callus is quickly deposited and transformed into bone." B. "A hematoma forms at the site of the fracture." C. "Calcium and vascular proliferation surround the fracture site." D. "Granulation tissue reabsorbs the hematoma and deposits new bone."

B. "A hematoma forms at the site of the fracture." In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? A. "Should we filter air circulation?" B. "Can we use less radiographic contrast dye?" C. "Should we add low-dose dobutamine?" D. "Should we decrease IV rates?"

B. "Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.

Which statement by a client with diabetic nephropathy indicates a need for further education about the disease? A. "Diabetes is the leading cause of kidney failure." B. "I need less insulin, so I am getting better." C. "My blood sugar may drop really low at times." D. "I must call my provider if the urine dipstick shows protein."

B. "I need less insulin, so I am getting better." When kidney function is reduced, insulin is available for a longer time and thus less of it is needed. Unfortunately, many clients believe this means that their diabetes is improving. It is true that diabetes mellitus is the leading cause of end-stage kidney disease among Caucasians in the United States. Clients with worsening kidney function may begin to have frequent hypoglycemic episodes. Proteinuria, which may be mild, moderate, or severe, indicates a need for follow-up.

An older adult client is discharged from the hospital for treatment of osteoporosis. What does the nurse include in client teaching related to the client's home safety? A. "Use area rugs on tile floors." B. "Keep walkways free of clutter." C. "Walk slowly on wet floor areas after mopping." D. "Keep light low to prevent glare."

B. "Keep walkways free of clutter." Walkways in the home must be clear of clutter and obstacles to help prevent falls. Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Clients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor.

Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? A. "How does that make you feel?" B. "The mood swings should diminish with treatment." C. "The medications will make the mood swings disappear completely." D. "Your family member is sick. You must be patient."

B. "The mood swings should diminish with treatment." Telling the family that the client's mood swings should diminish over time with treatment will provide information to the family, as well as reassurance. Asking how the family feels is important; however, the response should focus on the client. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick; telling them to be patient introduces guilt and does not address the family's concerns.

The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? A. A 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4° F (37.4° C) B. A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours C. A 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy D. A 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

B. A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client who has been receiving morphine sulfate may be oversedated and may not be aware of any discomfort caused by bladder distention. The 26-year-old admitted with urosepsis and slight fever, the 32-year-old scheduled for cystoscopy, and the 40-year-old with noninfectious urethritis are not at immediate risk for complications or deterioration.

A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? A. Advise the client to go to a calming environment. B. Ask whether the client has increased cold sensitivity or weight gain. C. Instruct the client to see his health care provider immediately. D. Tell the client to check his pulse again and call back later.

B. Ask whether the client has increased cold sensitivity or weight gain. Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. The client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.

The RN is working with unlicensed assistive personnel (UAP) in caring for a group of clients. Which action is best for the RN to delegate to UAP? A. Assessing the vital signs of a client who was just admitted with blunt flank trauma and hematuria B. Assisting a client who had a radical nephrectomy 2 days ago to turn in bed C. Helping the provider with a kidney biopsy for a client admitted with acute glomerulonephritis D. Palpating for bladder distention on a client recently admitted with a ureteral stricture

B. Assisting a client who had a radical nephrectomy 2 days ago to turn in bed UAP would be working within legal guidelines when assisting a client to turn in bed. Although assessment of vital signs is within the scope of practice for UAP, the trauma victim should be assessed by the RN because interpretation of the vital signs is needed. Assisting with procedures such as kidney biopsy and assessment for bladder distention are responsibilities of the professional nurse that should not be delegated to staff members with a limited scope of education.

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several options to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client

B. Assuming that the client is not totally confused Never assume that the client with Alzheimer's is totally confused and cannot understand what is being communicated. Choices should be limited; too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place.

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? A. Consuming a low-calcium diet B. Avoiding peas, nuts, and legumes C. Drinking cola beverages only once daily D. Increasing dairy products enriched with vitamin D

B. Avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? A. Client who has just returned from having a kidney artery angioplasty B. Client with polycystic kidney disease who is having a kidney ultrasound C. Client who is going for a cystoscopy and cystourethroscopy D. Client with glomerulonephritis who is having a kidney biopsy

B. Client with polycystic kidney disease who is having a kidney ultrasound Kidney ultrasounds are noninvasive procedures without complications; the LPN/LVN can provide this care. A kidney artery angioplasty is an invasive procedure that requires postprocedure monitoring for complications, especially hemorrhage; a registered nurse is needed. Cystoscopy and cystourethroscopy are procedures that are associated with potentially serious complications such as bleeding and infection. These clients should be assigned to RN staff members. Kidney biopsy is associated with potentially serious complications such as bleeding, and this client should be assigned to RN staff members.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4° F (38° C) C. Client with cirrhosis who has had a 3-pound weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain

B. Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? A. Client with dyspnea on exertion when ambulating to the bathroom B. Client with third-degree heart block on the monitor C. Client with normal sinus rhythm and PR interval of 0.28 second D. Client who refuses to take heparin or nitroglycerin

B. Client with third-degree heart block on the monitor Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved, so the client with the third-degree heart block should be seen first. Third-degree heart block usually requires pacemaker insertion. A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) A. Bradycardia B. Cool, diaphoretic skin C. Crackles in the lung fields D. Respiratory rate of 12 breaths/min E. Anxiety and restlessness F. Temperature of 100.4° F

B. Cool, diaphoretic skin C. Crackles in the lung fields E. Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Because of poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? A. Approaches the client on the affected side B. Covers the affected eye C. Encourages turning the head from side to side D. Places objects in the client's field of vision

B. Covers the affected eye Covering the client's eye with a patch prevents diplopia. The client who is recovering from a stroke should always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects should be placed in the field of vision for the client with a decreased visual field.

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? A. Urine output of 1500 mL on the preceding day B. Crackles in the lung fields C. Pedal edema D. Expectoration of yellow sputum

B. Crackles in the lung fields Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

When assessing a client with acute glomerulonephritis, which finding causes the nurse to notify the provider? A. Purulent wound on the leg B. Crackles throughout the lung fields C. History of diabetes D. Cola-colored urine

B. Crackles throughout the lung fields Crackles indicate fluid overload resulting from kidney damage; shortness of breath and dyspnea are typically associated. The provider should be notified of this finding. Glomerulonephritis may result from infection (e.g., purulent wound); it is not an emergency about which to notify the provider. The history of diabetes would have been obtained on admission. Dark urine is expected in glomerulonephritis.

Which laboratory test is the best indicator of kidney function? A. Blood urea nitrogen (BUN) B. Creatinine C. Aspartate aminotransferase (AST) D. Alkaline phosphatase

B. Creatinine Creatinine excretion, the end product of muscle metabolism, remains relatively steady and therefore is the best indicator of renal function. BUN may be affected by protein or fluid intake. AST and alkaline phosphatase are measures of hepatic function.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) A. Sharp, inspiratory chest pain B. Dyspnea C. Dizziness D. Extreme fatigue E. Anorexia

B. Dyspnea C. Dizziness D. Extreme fatigue Many women who experience an MI present with dyspnea, light-headedness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids

B. Elevating the head of the bed The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? A. Calls the provider B. Encourages the client to rest C. Immediately assesses cardiac status D. Tells the client to slow down

B. Encourages the client to rest The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse should accept the client's behavior and provide a calm, quiet, and comfortable environment. Because the client's behavior is expected, there is no need to call the provider. Monitoring the client's cardiac status is part of the nurse's routine assessment. Telling the client to slow down is unsupportive and unrealistic.

A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? A. Adherence to therapy B. Handwashing C. Monitoring for low-grade fever D. Strict clean technique

B. Handwashing The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.

A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? A. Edema at the surgical site B. Hoarseness C. Pain on moving the head D. Sore throat

B. Hoarseness Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Aphasia and cautiousness B. Impulsiveness and smiling C. Inability to discriminate words D. Quick to anger and frustration

B. Impulsiveness and smiling Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are symptoms indicative of a left hemisphere stroke.

Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) A. Premenopausal B. Increasing age C. Family history D. Abdominal obesity E. Breast cancer

B. Increasing age C. Family history D. Abdominal obesity Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. A large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder? A. Atenolol (Tenormin) B. Levothyroxine sodium (Synthroid) C. Methimazole (Tapazole) D. Propylthiouracil

B. Levothyroxine sodium (Synthroid) Levothyroxine is a synthetic form of thyroxine (T4) that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? A. Assessing for Turner's sign B. Maintaining PaCO2 levels at 35 mm Hg C. Placing the client in the Trendelenburg position D. Suctioning the client frequently

B. Maintaining PaCO2 levels at 35 mm Hg After the first 24 hours when a client is mechanically ventilated, keeping the PaCO2 levels at 35 mm Hg prevents vasodilation, which could increase ICP. CO2 is a powerful vasodilator. Turner's sign is a bluish gray discoloration in the flank region caused by acute pancreatitis. The head of the bed should be at 30 degrees; the Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning should be avoided because it increases ICP.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg.

B. Mean arterial pressure (MAP) is 58 mm Hg. To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A. Administers oxygen therapy B. Obtains the client's description of the chest discomfort C. Provides pain relief medication D. Remains calm and stays with the client

B. Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation; an assessment is needed first. Remaining calm and staying with the client are important, but are not matters of highest priority.

Prompt pain management with myocardial infarction is essential for which reason? A. The discomfort will increase client anxiety and reduce coping. B. Pain relief improves oxygen supply and decreases oxygen demand. C. Relief of pain indicates that the MI is resolving. D. Pain medication should not be used until a definitive diagnosis has been established.

B. Pain relief improves oxygen supply and decreases oxygen demand. The focus of pain relief is on reducing myocardial oxygen demand. Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain is secondary to the use of opiates or indicates that the tissue infarction is complete. Although it used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.

Which sign or symptom, when assessed in a client with chronic glomerulonephritis (GN), warrants a call to the health care provider? A. Mild proteinuria B. Third heart sound (S3) C. Serum potassium of 5.0 mEq/L D. Itchy skin

B. Third heart sound (S3) S3 indicates fluid overload secondary to failing kidneys; the provider should be notified and instructions obtained. Mild proteinuria is an expected finding in GN. A serum potassium of 5.0 mEq/L reflects a normal value; intervention would be needed for hyperkalemia. Although itchy skin may be present as kidney function declines, it is not a priority over fluid excess.

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis? A. Consuming 12 ounces of carbonated beverages daily B. Working at a desk and playing the piano for a hobby C. Having a hysterectomy and taking estrogen replacement therapy D. Consuming one alcoholic drink per week

B. Working at a desk and playing the piano for a hobby Sedentary lifestyle and prolonged immobility produce rapid bone loss. The client would have to consume large amounts of carbonated beverages daily (over 40 ounces) for this to be a risk factor for osteoporosis. Maintaining estrogen levels reduces the risk for osteoporosis. Alcohol has a direct toxic effect on bone tissue, resulting in decreased bone formation and increased bone resorption. For those who have excessive alcohol intake, alcohol calories decrease hunger and the need to take in adequate quantities of nutrients. This client's alcoholic intake is not high, so it is not a risk factor.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes The young adult client who is experiencing repeated seizures over the course of 30 minutes is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention; these are not medical emergencies. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) A. "Standing for long periods of time will help to prevent low back pain." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes."

C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes." Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects; this method will help prevent back injury. Wearing high-heeled shoes can increase back strain. The client should avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight should be kept within 10% of ideal body weight.

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed."

C. "I may still be able to get pregnant." Many women with spinal cord injury go on to get pregnant and give birth to healthy children. Spinal cord injury is not a disorder that can be inherited.

The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? A. "I should have more energy with this medication." B. "I should take it every morning." C. "If I continue to lose weight, I may need an increased dose." D. "If I gain weight and feel tired, I may need an increased dose."

C. "If I continue to lose weight, I may need an increased dose." Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the client have more energy. The correct time to take thyroid replacement therapy is in the morning. If the client is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."

C. "Make sure you take some time off and take care of yourself too." This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan is not a helpful response. A better response would be, "Take one day at a time." Suggesting that the spouse's comment was not nice is judgmental and inappropriate.

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? A. "My spouse will no longer need to take blood pressure medication." B. "Rehabilitation and physical therapy are the same thing." C. "The rehabilitation therapist will help identify changes needed at home." D. "Frequent stimulation will help with the rehabilitation process."

C. "The rehabilitation therapist will help identify changes needed at home." The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy. Any medication regimen for the client must be maintained. Rehabilitation is much more comprehensive than physical therapy. The family should develop a home routine that provides structure, repetition, and consistency.

The nurse is educating a female client about hygiene measures to reduce her risk for urinary tract infection. What does the nurse instruct the client to do? A. "Douche—but only once a month." B. "Use only white toilet paper." C. "Wipe from front to back." D. "Wipe with the softest toilet paper available."

C. "Wipe from front to back." Wiping front to back keeps organisms in the stool from coming close to the urethra, which increases the risk for infection. Douching is an unhealthy behavior because it removes beneficial organisms as well as the harmful ones. White toilet paper helps prevent allergies, not infections. Using soft toilet paper does not prevent infection.

An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A. A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain B. A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C C. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today D. A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia

C. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today The LPN/LVN scope of practice includes administration of medications to stable clients. Third-degree heart block is characterized by a very low heart rate and usually by required pacemaker insertion; the skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability; he will need medications and monitoring beyond the scope of practice of the LPN/LVN.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? A. Hemoglobin and hematocrit B. Leukocytes C. Alpha-fetoprotein D. Serum albumin

C. Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A. Amnesia B. Head laceration C. Asymmetric pupils D. Restlessness

C. Asymmetric pupils Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are a sign of a severe traumatic brain injury. Pupil changes are treated as herniation of the brain from increased intracranial pressure (ICP) until proven differently. The nurse should report and document any changes in pupil size, shape, and reactivity to the health care provider immediately because they could indicate an increase in ICP. Amnesia, a head laceration, and restlessness can be symptoms of mild traumatic brain injuries.

A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache

C. Classic migraine The client's symptoms match those of a classic migraine. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours.

After receiving change-of-shift report on the urology unit, which client does the nurse assess first? A. Client post radical nephrectomy whose temperature is 99.8° F (37.6° C) B. Client with glomerulonephritis who has cola-colored urine C. Client who was involved in a motor vehicle crash and has hematuria D. Client with nephrotic syndrome who has gained 2 kg since yesterday

C. Client who was involved in a motor vehicle crash and has hematuria The nurse should be aware of the risk for kidney trauma after a motor vehicle crash; this client needs further assessment and evaluation to determine the extent of blood loss and the reason for the hematuria because hemorrhage can be life-threatening. Although slightly elevated, the low-grade fever of the client who is post radical nephrectomy is not life-threatening in the same way as a trauma victim with bleeding. Cola-colored urine is an expected finding in glomerulonephritis. Because of loss of albumin, fluid shifts and weight gain can be anticipated in a client with nephrotic syndrome.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. Client who is taking lactulose and has diarrhea B. Client with hepatitis C who requires a dressing change C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet D. Obtunded client with alcoholic encephalopathy who needs a blood draw

C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? A. Client with Graves' disease who needs discharge teaching after a total thyroidectomy B. Client with hyperparathyroidism who is just being admitted for a parathyroidectomy C. Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) D. Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements

C. Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) Medication administration for the client with infiltrative ophthalmopathy is within the scope of practice of the LPN/LVN. Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications; teaching is a complex task that is appropriate for the RN.

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? A. Reduce abdominal fat. B. Avoid stress. C. Do not smoke or chew tobacco. D. Avoid alcoholic beverages.

C. Do not smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow; causes vasoconstriction, endothelial dysfunction, and thickening of the vessel walls; increases carbon monoxide; and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity, but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? A. Blood pressure of 118/78 mm Hg B. Weight loss of 3 pounds during hospitalization C. Dyspnea and anxiety at rest D. Central venous pressure (CVP) of 6 mm Hg

C. Dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing.

C. Help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important, but will not immediately reduce blood pressure.

A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home? A. Frequent home care B. Handrails in the bath C. Increased thermostat setting D. Strict infection-control measures

C. Increased thermostat setting Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A client with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.

Which option for prevention and early detection of breast cancer is the option of choice for a client with a high genetic risk? A. Breast self-examination (BSE) beginning at 20 years of age B. Hormone replacement therapy (HRT) combining estrogen and progesterone C. Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 D. Prophylactic mastectomy

C. Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 The American Cancer Society recommends that high-risk women (>20% lifetime risk) have an MRI and mammogram every year beginning at age 30. BSE is an option for everyone, not just those at high genetic risk for breast cancer. Use of HRT containing both estrogen and progestin increases risk; risk diminishes after 5 years of discontinuation. With a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue.

Which information suggests that a client with diabetes may be in the early stages of kidney damage? A. Elevation in blood urea nitrogen (BUN) B. Oliguria C. Microalbuminuria D. Painless hematuria

C. Microalbuminuria In the early stages of diabetic nephropathy, micro-levels of albumin are first detected in the urine. Progressive kidney damage occurs before dipstick procedures can detect protein in the urine. BUN may change in response to protein and fluid intake. Oliguria is a later finding in kidney disease and may also be present in dehydration. Painless hematuria often occurs with kidney cancer.

When caring for a client with uremia, the nurse assesses for which symptom? A. Tenderness at the costovertebral angle (CVA) B. Cyanosis of the skin C. Nausea and vomiting D. Insomnia

C. Nausea and vomiting Manifestations of uremia include anorexia, nausea, vomiting, weakness, and fatigue. CVA tenderness is a sign of inflammation or infection in the renal pelvis. Cyanosis is related to poor tissue perfusion. Insomnia is nonspecific and may be caused by psychoemotional factors, medications, or other problems.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.

C. Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.

Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake

C. Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A. Frequent ambulation B. Encouraging nutrition C. Regular turning and re-positioning D. Special pressure-relief devices

C. Regular turning and re-positioning Regular turning and re-positioning are the best way to prevent complications of immobility in clients with spinal cord problems. Frequent ambulation may not be possible for these clients. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Use of special pressure-relief devices is important, but is not the best way to prevent immobility complications in clients with spinal cord problems.

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association

C. Safe Return Program The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.

Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise? A. Functional B. Overflow C. Stress D. Urge

C. Stress Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence. Functional incontinence is not caused by a weakened pelvic floor; rather, it is due to structural problems often resulting from injury or trauma. Overflow incontinence is caused by too much urine being stored in the bladder. Urge incontinence is caused by a problem (i.e., neurologic) with the client's urge to urinate.

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

C. The client's chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm. Symptoms often worsen after injury because of swelling. Bradycardia is consistent with spinal shock and will need to be addressed, but this is not the nurse's first priority. Flaccid paralysis below the level of injury will need to be addressed, but this is not compromising the client's cardiopulmonary status. Systolic blood pressure remaining at 80 mm Hg is consistent with spinal shock and will need to be addressed, but this is not the first priority.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? A. Embolic stroke B. Hemorrhagic stroke C. Thrombotic stroke D. Transient ischemic attack

C. Thrombotic stroke The client's symptoms fit the description of a thrombotic stroke. Symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. The client would be in a coma if a hemorrhagic stroke had occurred. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? A. The client eating a morning meal of cereal and fruit B. The physical therapist walking with the client in the hallway C. Unlicensed assistive personnel pulling the client up in bed by the shoulders D. Visitors talking with the client about going home

C. Unlicensed assistive personnel pulling the client up in bed by the shoulders The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet should be used to re-position the client. The client with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.

Which factor represents a sign or symptom of digoxin toxicity? A. Serum digoxin level of 1.2 ng/mL B. Polyphagia C. Visual changes D. Serum potassium of 5.0 mEq/L

C. Visual changes Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A. Auscultation of crackles B. Pedal edema C. Weight loss of 6 pounds since the last visit D. Reports sucking on ice chips all day for dry mouth

C. Weight loss of 6 pounds since the last visit Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "Compound fracture does not extend through the skin." C. "Simple fracture is accompanied by damage to the blood vessels." D. "Compound fracture involves a break in the bone, with damage to the skin."

D. "Compound fracture involves a break in the bone, with damage to the skin." A compound fracture involves a break in the bone with damage to the skin. A simple fracture does not extend through the skin. A compound fracture is accompanied by damage to blood vessels.

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Begin driving 1 week after discharge." B. "Avoid using a pillow under the head while sleeping." C. "Swimming is recommended to keep active." D. "Keep straws available for drinking fluids."

D. "Keep straws available for drinking fluids." Keeping straws available makes it easier to drink fluids because the device makes it difficult to bring a cup or a glass to the mouth. Driving should be avoided because vision is impaired with the device. The head should be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Swimming should be avoided to prevent the risk for infection.

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? A. "Next time you eat, try lifting your chin when you swallow." B. "Let's advance your diet to solid food." C. "Let's see if the dietitian can help." D. "Let's see if the speech-language pathologist can help."

D. "Let's see if the speech-language pathologist can help." The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The correct technique to improve swallowing is the chin-tuck method; however, the speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side. Solid food is not appropriate for the client with chewing and swallowing challenges. The dietitian consults with the health care team if the client has had weight loss problems, or if abnormal laboratory results indicate a nutritional deficit.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage." Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A. "Every injury is different, and it is too soon to have any real answers right now." B. "Only time will tell." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the health care provider."

D. "Please request a meeting with the health care provider." Questions concerning prognosis and potential for recovery should be referred to the health care provider. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

During discharge teaching for a client with kidney disease, what does the nurse teach the client to do? A. "Drink 2 liters of fluid and urinate at the same time every day." B. "Eat breakfast and go to bed at the same time every day." C. "Check your blood sugar and do a urine dipstick test." D. "Weigh yourself and take your blood pressure."

D. "Weigh yourself and take your blood pressure." Regular weight assessment monitors fluid restriction control, while blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction. Fluid intake and urination, and breakfast time and bedtime, do not need to be at the same time each day. Clients with diabetes, not kidney disease, should regularly check their blood sugar and perform a urine dipstick test.

A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? A. "All of this is new. What can't you do?" B. "Are you afraid of dying?" C. "How are you doing this morning?" D. "What concerns do you have about your kidney disease?"

D. "What concerns do you have about your kidney disease?" Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? A. "You are right. Work on your diet then." B. "You must find someplace to walk." C. "Walk around the edge of your apartment complex." D. "Where might you be able to walk?"

D. "Where might you be able to walk?" Asking the client where he or she might be able to walk calls for cooperation and participation from the client; increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

Which client does the nurse manager on the medical unit assign to an experienced LPN/LVN? A. A 42-year-old with painless hematuria who needs an admission assessment B. A 46-year-old scheduled for cystectomy who needs help in selecting a stoma site C. A 48-year-old receiving intravesical chemotherapy for bladder cancer D. A 55-year-old with incontinence who has intermittent catheterization prescribed

D. A 55-year-old with incontinence who has intermittent catheterization prescribed Insertion of catheters is within the education and legal scope of practice for LPN/LVNs. Admission assessments and intravesical chemotherapy should be done by an RN. Preoperative preparation for cystectomy and stoma site selection should be done by an RN and either a Certified Wound, Ostomy, and Continence Nurse or an enterostomal therapy nurse.

The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next? A. Administers acetaminophen B. Alerts the Rapid Response Team C. Asks any visitors to leave D. Assesses the client's cardiac status completely

D. Assesses the client's cardiac status completely If the client's temperature has increased by even 1°, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the client, this would be contraindicated.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis

D. Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? A. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase B. Homocysteine and C-reactive protein C. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol D. CK-MB and troponin

D. CK-MB and troponin CK-MB and troponin are the cardiac markers used to determine whether MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? A. Client with Hashimoto's thyroiditis and a large goiter B. Client with hypothyroidism and an apical pulse of 51 beats/min C. Client with parathyroid adenoma and flank pain due to a kidney stone D. Client who had a parathyroidectomy yesterday and has muscle twitching

D. Client who had a parathyroidectomy yesterday and has muscle twitching A client who is 1 day postoperative for parathyroidectomy and has muscle twitching is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed. Clients with Hashimoto's thyroiditis are usually stable; this client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and should be asked about pain medication as soon as possible, but this client does not need to be assessed first.

Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? A. Recent radical mastectomy client requiring chemotherapy administration B. Modified radical mastectomy client needing discharge teaching C. Stage III breast cancer client requesting information about radiation and chemotherapy D. Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy

D. Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy A nurse working in the ICU would be familiar with postoperative monitoring and care of clients with Jackson-Pratt drains. The recent radical mastectomy client requires chemotherapy, so it is more appropriate to assign her to nurses who are familiar with teaching, monitoring, and providing chemotherapy for clients with breast cancer. The modified radical mastectomy client who requires discharge teaching, and the stage III breast cancer client requiring information about radiation and chemotherapy are more appropriate to assign to nurses who are familiar with breast cancer.

The nurse has these client assignments. Which client does the nurse encourage to consume 2 to 3 liters of fluid each day? A. Client with chronic kidney disease B. Client with heart failure C. Client with complete bowel obstruction D. Client with hyperparathyroidism

D. Client with hyperparathyroidism A major feature of hyperparathyroidism is hypercalcemia, which predisposes a client to kidney stones; this client should remain hydrated. A client with chronic kidney disease should not consume 2 to 3 liters of water because the kidneys are not functioning properly, and this could lead to fluid retention. People with heart failure typically have fluid volume excess. A client with complete bowel obstruction may experience vomiting and should be NPO.

What does the nurse teach a client to do to decrease the risk for urinary tract infection (UTI)? A. Limit fluid intake. B. Increase caffeine consumption. C. Limit sugar intake. D. Drink about 3 liters of fluid daily.

D. Drink about 3 liters of fluid daily. Drinking about 3 liters of fluid daily, if another medical problem does not require fluid restriction, helps prevent dehydration and UTIs. Fluids flush the system and should not be limited. Increased caffeine intake and limiting sugar intake will not prevent UTIs.

What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client? A. Bradycardia and decreased level of consciousness B. Decreased respiratory rate C. Hypotension and shock D. Hypertension and heart failure

D. Hypertension and heart failure Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state. The client would be tachycardic, not bradycardic. The client may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."

Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? A. Hematocrit of 26.7% B. Potassium within normal range C. Absence of spontaneous fractures D. Less fatigue

D. Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.

Which goal for a client with diabetes will best help to prevent diabetic nephropathy? A. Heed the urge to void. B. Avoid carbohydrates in the diet. C. Take insulin at the same time every day. D. Maintain glycosylated hemoglobin (HbA1c).

D. Maintain glycosylated hemoglobin (HbA1c). Maintaining long-term control of blood glucose will help prevent the progression of diabetic nephropathy. Voiding when the client has the urge prevents the backflow of urine and infection. The diabetic diet is composed of carbohydrates, proteins, and fats. Although taking insulin at the same time each day may indirectly help control blood glucose, it is not the best option.

The nurse plans to refer a client diagnosed with osteoporosis to which community resource? A. American Bone Society B. CanSurmount C. I Can Cope D. National Osteoporosis Foundation

D. National Osteoporosis Foundation Clients with musculoskeletal problems should be referred to appropriate community resources, such as the National Osteoporosis Foundation, for help and support for their diagnosis. There is no organization known as the American Bone Society. CanSurmount is a cancer support group geared toward client and family education. I Can Cope is also a support group for clients with cancer.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A. Hospital library B. Internet C. Provider's office D. National Spinal Cord Injury Association

D. National Spinal Cord Injury Association The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting. The hospital library is not typically consumer-oriented; most information available there is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. The health care provider's office typically does not provide information about spinal cord injury support groups.

Which assessment finding indicates to the nurse that a client is at high risk for a malignant breast lesion? A. A 1-cm freely mobile rubbery mass discovered by the client B. Ill-defined painful rubbery lump in the outer breast quadrant C. Backache and breast fungal infection D. Nipple discharge and dimpling

D. Nipple discharge and dimpling Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion. On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses usually discovered by the woman herself; their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter. Although the immediate fear is breast cancer, the risk of its occurring within a fibroadenoma is very small. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition; the lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

D. Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? A. Encouraging them to drink fluids B. Irrigating all catheters daily with sterile saline C. Recommending that catheters be placed in all clients D. Periodically re-evaluating the need for indwelling catheters

D. Periodically re-evaluating the need for indwelling catheters Studies have shown that re-evaluating the need for indwelling catheters in clients is the most effective way to prevent UTIs in the hospital setting. Encouraging fluids, although it is a valuable practice for clients with catheters, will not necessarily prevent the occurrence of UTIs in the hospital setting. In some clients, their conditions do not permit an increase in fluids, such as those with congestive heart failure and kidney failure. Irrigating catheters daily is contraindicated; any time a closed system is opened, bacteria may be introduced. Placing catheters in all clients is unnecessary and unrealistic. This practice would place more clients at risk for the development of UTI.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowler's position

D. Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential

D. Positioning the client to maximize ventilation potential Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm. Although assessing bowel sounds is important as a sign of neurogenic shock, this is not the priority intervention on admission. Bladder retraining begins as necessary after evaluation of urinary function; a catheter is initially inserted. Monitoring nutritional status is essential only after stabilization from the acute injury.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? A. Homeless people B. Hospital staff C. Politicians D. Prison staff and inmates

D. Prison staff and inmates High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.

A large-breasted client reports discomfort, backaches, and fungal infections because of her excessive breast size. The nurse provides information to the client about which breast treatment option? A. Augmentation B. Compression C. Reconstruction D. Reduction mammoplasty

D. Reduction mammoplasty Breast reduction mammoplasty surgery removes excess breast tissue and repositions the nipple and remaining skin flaps to produce the best cosmetic effect. Breast augmentation surgery enhances the size, shape, or symmetry of breasts. Breast compression is not a treatment. Breast reconstruction surgery is typically performed for women after a mastectomy.

A client who is 6 months pregnant comes to the prenatal clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client? A. Discharges the client to her home for strict bedrest for the duration of the pregnancy B. Instructs the client to drink a minimum of 3 liters of fluids, especially water, every day to "flush out" bacteria C. Recommends that the client refrain from having sexual intercourse until after she has delivered her baby D. Refers the client to the clinic nurse practitioner for immediate follow-up

D. Refers the client to the clinic nurse practitioner for immediate follow-up Pregnant women with UTIs require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor with adverse effects for the fetus. It is unsafe for the client to be sent home without analysis of the symptoms that she has. Her problem needs to be investigated without delay. Although drinking increased amounts of fluids is helpful, it will not cure an infection. Having sexual intercourse (or not having it) is not related to the client's problem. The client's symptoms need follow-up with a health care provider.

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? A. Bleeding B. Head injury C. Pain D. Respiratory distress

D. Respiratory distress The client should first be assessed for respiratory distress, and any oxygen interventions instituted accordingly. Bleeding is the second assessment priority, head injury is the third assessment priority, and pain is the fourth assessment priority in this case.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy

D. Respiratory therapy A client with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? A. Chest pain brought on by exertion or stress B. Substernal chest discomfort occurring at rest C. Substernal chest discomfort relieved by nitroglycerin or rest D. Substernal chest pressure relieved only by opioids

D. Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI; it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

Which statement about the early detection of breast masses is correct? A. Clinical breast examinations should be done yearly starting at age 20. B. Detection of breast cancer before or after axillary node invasion yields the same survival rate. C. Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. D. The goal of screening for breast cancer is early detection.

D. The goal of screening for breast cancer is early detection. The purpose of screening is early detection of cancer before it spreads. It is recommended that the clinical breast examination be part of a periodic health assessment at least every 3 years for women in their 20s and 30s, and every year for asymptomatic women who are at least 40 years of age. Detection of breast cancer before axillary node invasion increases the chance of survival. The American Cancer Society recommends screening with mammography annually beginning at age 40.

A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection. Which nursing action can the home health RN delegate to the home health aide (unlicensed assistive personnel [UAP])? A. Assisting the client in developing a schedule for when to take prescribed antibiotics B. Inserting a straight catheter as necessary if the client is unable to empty the bladder C. Teaching the client how to use the Credé maneuver to empty the bladder more fully D. Using a bladder scanner (with training) to check residual bladder volume after the client voids

D. Using a bladder scanner (with training) to check residual bladder volume after the client voids Use of a bladder scanner is noninvasive and can be accomplished by a home health aide (UAP) who has been trained and evaluated in this skill. Assisting the client in developing a schedule for when to take prescribed antibiotics, inserting a straight catheter, and teaching the client to use the Credé maneuver all require more education and are in the legal scope of practice of the LPN/LVN or RN.

Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? A. Increase nutritional intake of calcium. B. Engage in high-impact exercise, such as running. C. Increase nutritional intake of phosphorus. D. Walk for 30 minutes three times a week.

D. Walk for 30 minutes three times a week. Walking for 30 minutes three to five times a week is the single most effective exercise for osteoporosis prevention. Walking is a safe way to promote weight bearing and muscle strength. A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

The client in shock has the following vital signs: T 99.8° F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure.

1.22 mmHg Pulse pressure is the difference between the systolic and diastolic pressures: 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)

A client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the nurse's best response? A. "Because the kidneys cannot get rid of fluid, blood pressure goes up." B. "The damaged kidneys no longer release a hormone that prevents high blood pressure." C. "The waste products in the blood interfere with other mechanisms that control blood pressure." D. "This is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products."

A. "Because the kidneys cannot get rid of fluid, blood pressure goes up." In chronic kidney disease, fluid levels increase in the circulatory system. The statements asserting that damaged kidneys no longer release a hormone to prevent high blood pressure, waste products in the blood interfere with other mechanisms controlling blood pressure, and high blood pressure is a compensatory mechanism that increases blood flow through the kidneys in attempt excrete waste products are not accurate regarding the relationship between chronic kidney disease and high blood pressure.

The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Exelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. Memantine (Namenda) is indicated for advanced Alzheimer's disease. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors are antidepressants and may be used in Alzheimer's clients who develop depression. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a check-up?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."

A. "Have you taken her for a check-up?" The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a health care provider. The nurse cannot diagnose Alzheimer's disease. The mother's behavior is not normal age-related behavior. Respite care is for caregivers, not for clients.

A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? A. "I can return to my job at the nursing home." B. "I must call if my urine is dark." C. "I must faithfully take the drug every 8 hours." D. "I need to report weight gain."

A. "I can return to my job at the nursing home." The client should avoid large crowds and people who are ill because PTU reduces blood cell counts and the immune response, which increases the risk for infection. The client does not, however, need to remain completely at home. Dark urine may indicate liver toxicity or failure, and the client must notify the provider immediately. Taking PTU regularly at the same time each day provides better drug levels and ensures better drug action. The client must notify the provider of weight gain because this may indicate hypothyroidism; a lower drug dose may be required.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A. "I should avoid eating hamburgers." B. "I must cut out bacon and canned foods." C. "I shouldn't put the salt shaker on the table anymore." D. "I should avoid lunchmeats but may cook my own turkey."

A. "I should avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows a correct understanding of what the nurse has taught? A. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." B. "It is a good idea for me to reduce germs by taking a tub bath daily." C. "Trying to get to the bathroom to urinate every 6 hours is important for me." D. "Urinating 1000 mL on a daily basis is a good amount for me."

A. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." To reduce the number of UTIs, clients should be drinking a minimum of 1.5 to 2.5 liters of fluid (mostly water) each day. Showers, rather than tub baths, are recommended for women who have recurrent UTIs. Urinating every 3 to 4 hours is ideal for reducing the occurrence of UTI. This is advisable rather than waiting until the bladder is full to urinate. Urinary output should be at least 1.5 liters daily. Ensuring this amount "out" is a good indicator that the client is drinking an adequate amount of fluid.

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? A. "I should spend all my time with my husband in case I'm needed." B. "My husband may get depressed." C. "My husband must take his medicine every day to prevent another stroke." D. "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

A. "I should spend all my time with my husband in case I'm needed." Family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor. The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke should maintain a regular medication regimen, such as anticoagulant therapy, to prevent another stroke. Once the home health nurse has assessed the home environment, he or she will notify the health care provider of the need for ancillary services, such as a physical therapist. The physical therapist will identify adaptive equipment needs, will request them, and then will instruct the client about their use, along with developing an exercise program.

A client who was previously diagnosed with a urinary tract infection (UTI) and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen, the client states, "I only took the first dose because after that, I felt better." How does the nurse respond? A. "Not completing your medication can lead to return of your infection." B. "That means your treatment will be prolonged with this new infection." C. "This means you will now have to take two drugs instead of one." D. "What you did was okay; however, let's get you started on something else."

A. "Not completing your medication can lead to return of your infection." Not completing the drug regimen can lead to recurrence of an infection and bacterial drug resistance. Needing to be re-treated does not mean that the client will have a prolonged treatment regimen. Some treatment modalities are given over a 3-day period. Given this client's history, larger doses for a shorter time span may be a wise plan. The client does not need to take two drugs, and this response is punitive rather than instructive. Saying that the client's actions were okay does not inform the client with respect to nonadherence. The client needed to take all the prescribed medication to make certain that the infection was properly treated.

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? A. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." B. "Angina is just a temporary interruption of blood flow to my heart." C. "I need to tell my wife I've had a heart attack." D. "Because this was temporary, I will not need to take any medications for my heart."

A. "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." Among people who have unstable angina, 10% to 30% have a myocardial infarction within 1 year. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, anti-anginals, or antihypertensives.

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A. Achieving the highest level of functioning B. Increasing cerebral perfusion C. Preventing further injury D. Preventing respiratory distress

A. Achieving the highest level of functioning The nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible. The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of respiratory distress is also part of a larger goal for this client.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) E. Osteomyelitis ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair, but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care

A. Arranges for respite care Respite care can give the wife some time to re-energize and will provide a social outlet for the client. Providing positive reinforcement and support is encouraging, but does not help the wife's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? (Select all that apply.) A. Ask family members to stay with the client. B. Call the health care provider. C. Increase IV and oxygen rates. D. Remain with the client. E. Reassure the client that everything is being done for him or her.

A. Ask family members to stay with the client. D. Remain with the client. E. Reassure the client that everything is being done for him or her. Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A. Assesses airway, breathing, and circulation B. Calls the provider C. Performs a neurologic check D. Assists the client to a sitting position

A. Assesses airway, breathing, and circulation The client must be evaluated within 10 minutes of having a stroke. The priority is assessment of the "ABCs"—airway, breathing, and circulation. Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. A neurologic check may be performed later, but is not the priority in this situation. A sitting position is used for hyperreflexia in the client with spinal cord injury to assist in lowering blood pressure.

A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association

A. Assigning a case manager Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Ensuring all questions are answered and providing a safe environment are necessary for family support, but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral, but is not relevant for continuity of care.

A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Auscultate for pericardial friction rub. B. Assess for crackles. C. Monitor for decreased peripheral pulses. D. Determine if the client is able to ambulate.

A. Auscultate for pericardial friction rub. The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Chair pad B. Thromboembolism-deterrent (TED) hose C. Trapeze D. Water bottle

A. Chair pad In addition to regular turning and re-positioning, special pressure-relief devices such as chair pads may be used in the wheelchair to prevent pressure ulcers in the client with spinal cord injury. TED hose help prevent thrombus, not pressure ulcers. A trapeze helps the client reposition him- or herself; it is not a pressure-relief device. A water bottle is not indicated for the client with spinal cord injury.

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? A. Changes in breathing pattern B. Dizziness C. Increasing level of consciousness D. Reactive pupils

A. Changes in breathing pattern Changes in breathing pattern may cause hypoxia and hypercapnia, which can increase ICP. Dizziness is indicative of brain injury. Increasing level of consciousness and reactive pupils are desired outcomes for this client.

For which clients scheduled for a computed tomography (CT) scan with contrast does the nurse communicate safety concerns to the health care provider? (Select all that apply.) A. Client with an allergy to shrimp B. Client with a history of asthma C. Client who requests morphine sulfate every 3 hours D. Client with a blood urea nitrogen of 62 mg/dL and a creatinine of 2.0 mg/dL E. Client who took metformin (Glucophage) 4 hours ago

A. Client with an allergy to shrimp B. Client with a history of asthma D. Client with a blood urea nitrogen of 62 mg/dL and a creatinine of 2.0 mg/dL E. Client who took metformin (Glucophage) 4 hours ago The client who will be undergoing a CT scan with contrast should be asked about known hay fever or food or drug allergies, especially to seafood, eggs, milk, or chocolate. Contrast reactions have been reported to be as high as 15% in these clients. Clients with asthma have been shown to be at greater risk for contrast reactions than the general public. When reactions do occur, they are more likely to be severe. The risk for contrast-induced nephropathy is increased in clients who have pre-existing renal insufficiency (e.g., serum creatinine levels greater than 1.5 mg/dL or estimated glomerular filtration rate less than 45 mL/min). Metformin must be discontinued at least 24 hours before and for at least 48 hours after any study using contrast media because the life-threatening complication of lactic acidosis, although rare, could occur. There are no contraindications to undergo CT with contrast while taking morphine sulfate. CT with contrast may help to identify the underlying cause of pain.

The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily B. Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing C. Client with Graves' disease who is experiencing increasing anxiety and diaphoresis D. Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy

A. Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN. A client with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse.

The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? A. Client with chronic kidney failure who was just admitted with shortness of breath B. Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted C. Client with azotemia whose blood urea nitrogen and creatinine are increasing D. Client receiving peritoneal dialysis who needs help changing the dialysate bag

A. Client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? A. Construction worker B. Office secretary C. Schoolteacher D. Taxicab driver

A. Construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

Which age-related change can cause nocturia? A. Decreased ability to concentrate urine B. Decreased production of antidiuretic hormone C. Increased production of erythropoietin D. Increased secretion of aldosterone

A. Decreased ability to concentrate urine Nocturia may result from decreased kidney-concentrating ability associated with aging. Increased production of antidiuretic hormone, decreased production of erythropoietin, and decreased secretion of aldosterone are age-related changes.

The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? (Select all that apply.) A. Dysuria B. Enuresis C. Frequency D. Nocturia E. Urgency F. Polyuria

A. Dysuria C. Frequency D. Nocturia E. Urgency Dysuria (painful urination), frequency, nocturia (frequent urinating at night), and urgency (having the urge to urinate quickly) are symptoms of UTI. Enuresis (bed-wetting) and polyuria (increased amounts of urine production) are not signs of a UTI.

The client with which problem is at highest risk for hypovolemic shock? A. Esophageal varices B. Kidney failure C. Arthritis and daily acetaminophen use D. Kidney stone

A. Esophageal varices Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen, not acetaminophen, predispose the client to gastrointestinal bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss or hypovolemia.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A. Esophageal varices D. Ascites E. Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) A. Football player in preseason practice B. Client who underwent contrast dye radiology C. Accident victim recovering from a severe hemorrhage D. Accountant with diabetes E. Client in the intensive care unit on high doses of antibiotics F. Client recovering from gastrointestinal influenza

A. Football player in preseason practice B. Client who underwent contrast dye radiology C. Accident victim recovering from a severe hemorrhage E. Client in the intensive care unit on high doses of antibiotics F. Client recovering from gastrointestinal influenza To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

Which are risk factors for stroke? (Select all that apply.) A. High blood pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives E. Female gender

A. High blood pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives, specifically in women over the age of 35 and in women over the age of 30 who smoke. Other risk factors include high blood pressure and history of a previous TIA. Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Which urinary assessment information for a client indicates the potential need for increased fluids? A. Increased blood urea nitrogen B. Increased creatinine C. Pale-colored urine D. Decreased sodium

A. Increased blood urea nitrogen Increased blood urea nitrogen can indicate dehydration. Increased creatinine indicates kidney impairment. Pale-colored urine signifies diluted urine, which indicates adequate fluid intake. Increased, not decreased, sodium indicates dehydration.

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? A. Increased blood urea nitrogen (BUN) B. Increased creatinine level C. Pale-colored urine D. Decreased sodium level

A. Increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today

A. Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Obtain the client's pre-hemodialysis weight. B. Check the arteriovenous (AV) fistula for a thrill and bruit. C. Document the amount the client drinks throughout the shift. D. Auscultate the client's lung sounds every 4 hours. E. Explain the components of a low-sodium diet.

A. Obtain the client's pre-hemodialysis weight. C. Document the amount the client drinks throughout the shift.

Which client has the highest risk for breast cancer? A. Older adult woman with high breast density B. Nullipara older adult woman C. Obese older adult male with gynecomastia D. Middle-aged woman with high breast density

A. Older adult woman with high breast density People at high increased risk for breast cancer include women age 65 years and older with high breast density. Nullipara women are at low increased risk for breast cancer. Men are not at high increased risk for breast cancer, but obesity can cause gynecomastia. Being middle-aged does not indicate a high increased risk for breast cancer.

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Patent airway B. Indication of allergies C. Level of consciousness D. Loss of sensation

A. Patent airway Clients with injuries at or above T6 are at risk for respiratory complications. After assessment of cardiorespiratory status, the level of consciousness must be assessed using the Glasgow Coma Scale. In the ED, determining allergies or loss of sensation is not the first priority in assessing the client with spinal cord injury.

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes

A. Potential for injury related to chronic confusion and physical deficits The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. The rest of the problems are usually the result of long-term care and not a priority for a short hospital stay.

When taking the health history of a client with acute glomerulonephritis (GN), the nurse questions the client about which related cause of the problem? A. Recent respiratory infection B. Hypertension C. Unexplained weight loss D. Neoplastic disease

A. Recent respiratory infection An infection often occurs before the kidney manifestations of acute GN. The onset of symptoms is about 10 days from the time of infection. Hypertension is a result of glomerulonephritis, not a cause. Weight gain, not weight loss, is symptomatic of fluid retention in GN. Cancers are not part of the cause of GN.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) A. Restricted protein B. Liberal sodium C. Restricted fluids D. Low potassium E. Low fat

A. Restricted protein C. Restricted fluids D. Low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A. Temperature B. Pulse C. Respiration D. Blood pressure

A. Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? A. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea B. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min D. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

A. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; this client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate; the client with dyspnea should be seen first.

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (Select all that apply.) A. Truncal obesity B. Hypercholesterolemia C. Elevated homocysteine levels D. Glucose intolerance E. Client taking losartan (Cozaar)

A. Truncal obesity B. Hypercholesterolemia D. Glucose intolerance E. Client taking losartan (Cozaar) A large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome. Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

Which clients are at immediate risk for hypovolemic shock? (Select all that apply.) A. Unrestrained client in motor vehicle accident B. Construction worker C. Athlete D. Surgical intensive care client E. 85-year-old with gastrointestinal virus

A. Unrestrained client in motor vehicle accident D. Surgical intensive care client E. 85-year-old with gastrointestinal virus The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

In discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? A. "Have you had sex with men or women or both?" B. "I hope you use condoms to protect your partners." C. "You must tell me all of your partners' names, so I can let them know about possibly having AIDS." D. "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

A. "Have you had sex with men or women or both?" The straightforward approach of asking the client about having sex with men or women is nonjudgmental and most appropriate. "I hope you use..." is a judgmental statement. Naming partners is voluntary; also, assuming that more than one partner exists is judgmental and presumptuous. Asking for information in the name of the public health department is not straightforward, and the tone of this entire statement is judgmental.

The nurse presents a seminar on human immune deficiency virus (HIV) testing to a group of seniors and their caregivers in an assisted-living facility. Which responses fit the recommendations of the Centers for Disease Control and Prevention regarding HIV testing? (Select all that apply.) A. "I am 78 years old, and I was treated and cured of syphilis many years ago." B. "In 1986, I received a transfusion of platelets." C. "Seven years ago, I was released from a penitentiary." D. "I used to smoke marijuana 30 years ago, but I have not done any drugs since that time." E. "At 68, I am going to get married for the fourth time."

A. "I am 78 years old, and I was treated and cured of syphilis many years ago." C. "Seven years ago, I was released from a penitentiary." E. "At 68, I am going to get married for the fourth time." People who have had a sexually transmitted disease should be tested. People who are in or have been in correctional institutions such as jails or prisons and people who are planning to get married should be tested for HIV. HIV testing is recommended for clients who received a blood transfusion between 1978 and 1985. People who have used injectable drugs (not marijuana) should be tested.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

A. "I am here to receive the yearly pneumonia shot again." Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? A. "With this treatment, I probably cannot spread this virus to others." B. "This treatment does not kill the virus." C. "This medication prevents the virus from replicating in my body." D. "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

A. "With this treatment, I probably cannot spread this virus to others." HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids. HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

The nurse is caring for a client who has developed a bradycardia. Which possible causes does the nurse investigate? (Select all that apply.) A. Bearing down for a bowel movement B. Possible inferior wall myocardial infarction (MI) C. Client stating that he just had a cup of coffee D. Client becoming emotional when visitors arrived E. Diltiazem (Cardizem) administered 1 hour ago

A. Bearing down for a bowel movement B. Possible inferior wall myocardial infarction (MI) E. Diltiazem (Cardizem) administered 1 hour ago Excessive vagal (parasympathetic) stimulation to the heart causes a decreased rate of sinus node discharge. It may result from carotid sinus massage, vomiting, suctioning, Valsalva maneuvers (e.g., bearing down for a bowel movement or gagging), ocular pressure, or pain. Inferior wall MI is a cause of bradycardia and heart block. Calcium channel blockers such as diltiazem may cause bradycardia. Caffeine intake results in an increased heart rate. Stress, such as an emotional encounter, can result in tachycardia.

Which factors are possible transmission routes for human immune deficiency virus (HIV)? (Select all that apply.) A. Breast-feeding B. Anal intercourse C. Mosquito bites D. Toileting facilities E. Oral sex

A. Breast-feeding B. Anal intercourse E. Oral sex HIV can be transmitted via breast milk from an infected mother to the child. Anal intercourse not only allows seminal fluid to make contact with the mucous membranes of the rectum, but it also tears the mucous membranes, making infection more likely. Oral sexual contact exposes the mucous membranes to infected semen or vaginal secretions. HIV is not spread by mosquito bites or by other insects. HIV is not transmitted by casual contact, and sharing toilet facilities does not allow transmission of HIV.

When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor

A. Bruises C. Petechiae D. Epistaxis E. Pallor Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.

Which interventions does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)-related dementia? (Select all that apply.) A. Change the decorations in the home according to the season. B. Put the bed close to the window. C. Write out detailed instructions, and have the client read them over before performing a task. D. Ask the client what time he or she prefers to shower or bathe. E. Mark off the days of the calendar, leaving open the current date.

A. Change the decorations in the home according to the season. B. Put the bed close to the window. D. Ask the client what time he or she prefers to shower or bathe. E. Mark off the days of the calendar, leaving open the current date. Changing decorations according to the season and using a calendar to mark off the days will help to keep the client oriented. Keeping the bed close to the window may help keep the client oriented. The client should be included in planning the daily schedule. Directions should be short and uncomplicated.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) A. Chest discomfort or pain B. Tachycardia C. Expectorating thick, yellow sputum D. Sleeping on back without a pillow E. Fatigue

A. Chest discomfort or pain B. Tachycardia E. Fatigue Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.

The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? A. Compare these vital signs with the last several readings. B. Request that the surgeon see the client. C. Increase the rate of intravenous fluids. D. Reassess vital signs using different equipment.

A. Compare these vital signs with the last several readings. Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? A. Fatigue B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities

A. Fatigue Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A. Hemoglobin of 7.4 and hematocrit of 21.8 B. Potassium level of 2.9 mEq/L and diarrhea C. 250,000 platelets/mm3 D. 5000 white blood cells/mm3

A. Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.

The client with which laboratory result is at risk for hemorrhagic shock? A. International normalized ratio (INR) 7.9 B. Partial thromboplastin time (PTT) 12.5 seconds C. Platelets 170,000/mm3 D. Hemoglobin 8.2 g/dL

A. International normalized ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 seconds and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking D. Type 2 diabetes Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL D. Man who is sedentary and reports four episodes of strep throat

A. Man who smokes and whose father died at 49 of myocardial infarction (MI) Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A. Monitor weight B. Trend red blood cells and hemoglobin and hematocrit C. Monitor platelets D. Observe for motor deficits

A. Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.

The nurse is caring for a client with heart rate of 143 beats/min. For which manifestations does the nurse observe? (Select all that apply.) A. Palpitations B. Increased energy C. Chest discomfort D. Flushing of the skin E. Hypotension

A. Palpitations C. Chest discomfort E. Hypotension Tachycardia is a heart rate greater than 100 beats/min; the client with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.

Which client is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? A. The 64-year-old client admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min B. The 71-year-old client admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min C. The 88-year-old client admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min D. The 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min

A. The 64-year-old client admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 64-year-old has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the client develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This client can be managed by a nurse with less cardiac dysrhythmia training. The 71-year-old is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? A. The client will be treated for 5 to 7 days. B. The client will require IV antibiotics for 7 to 10 days. C. The client will complete 6 days of therapy. D. The client must be afebrile for 24 hours.

A. The client will be treated for 5 to 7 days. Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? A. The dietary worker hands the disposable meal trays to the LPN assigned to the client. B. The social worker encourages the client to verbalize about stressors at home. C. A member of the housekeeping staff thoroughly cleans and disinfects the hallways near the client's room. D. The health care provider orders vital signs, including temperature, every 8 hours.

A. The dietary worker hands the disposable meal trays to the LPN assigned to the client. The dietary worker giving the meal tray to the LPN limits the number of health care personnel entering the room, thus reducing the risk for infection. Verbalizing stressors does not reduce the risk for infection. Cleaning of bathrooms, not hallways, at least once daily by housekeeping staff reduces risk for infection. Vital signs, including temperature, should be taken every 4 hours to detect potential infection, but this does not reduce the risk for infection.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a 18 mg/dL

A. Troponin 3.2 ng/mL B. Myoglobin 234 mcg/L Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? A.Fluconazole (Diflucan) B. Trimethoprim/sulfamethoxazole (Bactrim) C. Rifampin (Rifadin) D. Acyclovir (Zovirax)

A.Fluconazole (Diflucan) Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent.

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? A. "Condoms should be used when lesions are present on the penis." B. "Always position the condom with a space at the tip of an erect penis." C. "Make sure it fits loosely to allow for penile erection." D. "Use adequate lubrication, such as petroleum jelly."

B. "Always position the condom with a space at the tip of an erect penis." Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom. Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only.

A client diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The client asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? A. "This will not make any difference in the viral load." B. "Blood concentrations will be decreased, which will lead to increased viral replication." C. "If only one dose of medication is missed, this will not make a difference." D. "This will cause an increase in opportunistic infections."

B. "Blood concentrations will be decreased, which will lead to increased viral replication." When doses are missed, blood concentrations become lower than what is needed for inhibition of viral replication (often called the inhibitory concentration). When this concentration is too low, the organism can replicate and produce new organisms that are resistant to the drugs being used. Therefore, it is critical to ensure that highly active antiretroviral therapy (HAART) doses are not missed, delayed, or administered in lower-than-prescribed dosages in the inpatient setting. Teach clients the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART.

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery by his family? A. "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" B. "Is there somewhere private in the home where we can go and talk?" C. "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick." D. "It is your duty to protect your family members from getting AIDS."

B. "Is there somewhere private in the home where we can go and talk?" A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently.

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? A. "I told family members they need to wash their hands when they enter and leave the room." B. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." C. "Yes, I understand the reasons why I have to wear gloves when I bathe the client." D. "The client's spouse told me she got HIV from a blood transfusion."

B. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality.

Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined.

B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the client? A. Clean toothbrushes once a week. B. Bathe daily using an antimicrobial soap. C. Eat salad at least once a day. D. Wash dishes in cool water.

B. Bathe daily using an antimicrobial soap. Bathing daily and using an antimicrobial soap will help decrease the risk for opportunistic infections by reducing the number of bacteria found on the skin. Toothbrushes should be cleaned daily through the dishwasher or by rinsing in liquid laundry bleach. Salads and raw fruits and vegetables could be contaminated and should be avoided. Dishes should be washed in hot, soapy water or in a dishwasher.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? A. Hourly urine output 10 to 12 mL/hr B. Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg C. Blood glucose 245 mg/dL D. Serum creatinine 3.6 mg/dL

B. Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

The nurse is assigned to care for four clients. Which client does the nurse assess first? A. Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm B. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature C. Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia D. Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

B. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring; the client is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C. Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur

B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the mid-abdomen and profound diaphoresis C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue

B. Client with pressure in the mid-abdomen and profound diaphoresis Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A. Client receiving a blood transfusion B. Client with severe ascites C. Client with myocardial infarction D. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

B. Client with severe ascites Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the health care provider to administer a positive inotropic agent. C. Administer a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.

B. Collaborate with the health care provider to administer a positive inotropic agent. A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

Which laboratory result is seen in late sepsis? A. Decreased serum lactate B. Decreased segmented neutrophil count C. Increased numbers of monocytes D. Increased platelet count

B. Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain

B. Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking

B. Elevated C-reactive protein levels E. Smoking Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? A. Administer the antibiotic immediately. B. Ensure that blood cultures were drawn. C. Obtain signature for informed consent. D. Take the client's vital signs.

B. Ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours; timing is essential.

Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.) A. Use of beta-adrenergic blockers B. Excessive alcohol use C. Advancing age D. High blood pressure E. Palpitations

B. Excessive alcohol use C. Advancing age D. High blood pressure The incidence of atrial fibrillation increases with age. Risk factors include hypertension, previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, Caucasian race, and excessive alcohol. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? A. Crackles on auscultation B. Fever C. Headache D. Wheezing

B. Fever Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

Which factor relates most directly to a diagnosis of primary immune deficiency? A. History of viral infection B. Full-term infant surfactant deficiency C. Contact with anthrax toxin D. Corticosteroid therapy

B. Full-term infant surfactant deficiency Genetic mutation causes surfactant deficiency; this is a primary immune deficiency. Viral infection can cause a secondary immune deficiency. Anthrax and medical therapy are examples of a secondary immune deficiency.

The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? A. ST segment B. Heart rate C. Troponin D. Myoglobin

B. Heart rate The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? A. PaCO2 58 mm Hg B. Lactate 9.0 mmol/L C. Partial thromboplastin time 64 seconds D. Potassium 2.8 mEq/L

B. Lactate 9.0 mmol/L Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis; this value is decreased and is not consistent with septic shock.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? A. Localized erythema and edema B. Low-grade fever and mild hypotension C. Low oxygen saturation rate and decreased cognition D. Reduced urinary output and increased respiratory rate

B. Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and increased respiratory rate indicate severe sepsis.

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? A. Urine output 20 to 30 mL/hr for the last 4 hours B. Mean arterial pressure (MAP) 70 mm Hg C. Albumin 3.5 g/dL D. Hemoglobin 7.6 g/dL

B. Mean arterial pressure (MAP) 70 mm Hg Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr, or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.

A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? A. Obtain vital signs every 15 minutes. B. Measure hourly urine output. C. Check oxygen saturation. D. Assess level of alertness.

B. Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

The nurse receives a report that a client with a pacemaker has experienced loss of capture. Which situation is consistent with this? A. The pacemaker spike falls on the T wave. B. Pacemaker spikes are noted, but no P wave or QRS complex follows. C. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. D. The client demonstrates hiccups.

B. Pacemaker spikes are noted, but no P wave or QRS complex follows. Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly; demand pacing should cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L B. Potassium 3.0 mEq/L C. Magnesium 2.1 mEq/L D. International normalized ratio (INR) of 1.0

B. Potassium 3.0 mEq/L Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Potential for injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction

B. Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? A. Collaborate with the client to select foods that are high in calories. B. Provide oral care to the client before meals to enhance appetite. C. Assess the perianal area every 8 hours for signs of skin breakdown. D. Discuss the need to avoid foods that are spicy or irritating.

B. Provide oral care to the client before meals to enhance appetite. Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice; these actions should be done by licensed staff.

The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the client's survival time

B. Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L B. Serum potassium level of 2.8 mEq/L C. Serum creatinine of 1.0 mg/dL D. Serum magnesium level of 1.9 mEq/L

B. Serum potassium level of 2.8 mEq/L Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. C. The client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

B. The client develops wheezes and dyspnea after eating crab or lobster. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? A. Administer antibiotics as prescribed. B. Transfuse ordered packed red blood cells. C. Teach pursed-lip breathing. D. Encourage increased fluid intake.

B. Transfuse ordered packed red blood cells. Packed red blood cells increase hemoglobin molecules; this increases sites at which oxygen can attach and improves gas exchange. Antibiotics treat infection; they do not improve oxygenation. Mouth breathing does not improve oxygenation related to anemia. Fluid intake does not have an effect on improving oxygenation.

The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? A. "When I injected heroin, I was exposed to HIV." B. "I don't understand how the antiretroviral drugs work." C. "I remember to take my antiretroviral drugs almost every day." D. "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

C. "I remember to take my antiretroviral drugs almost every day." Because inconsistent use of antiretroviral medications can lead to unsuccessful therapy and the development of drug-resistant HIV strains, it is important that clients take these drugs consistently. The nurse should immediately assess the reasons why the client does not take the medications daily and then should implement a plan to improve adherence. The nurse should assess whether the client is still injecting drugs and should make certain the client understands the risks for infection with another strain of HIV or other bloodborne pathogens and the risk for spreading HIV, but this does not need to be addressed immediately. The nurse must provide further education about how the medications work and assess how the lack of knowledge or decreased libido influences compliance, but this does not need to be addressed immediately.

Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I may lose my hair during this treatment." B. "I must be positioned in the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company."

C. "I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency virus (HIV) who also has active genital herpes. Which statement by the health care worker indicates effective teaching of Standard Precautions? A. "I need to know my HIV status, so I must get tested before caring for any clients." B. "Putting on a gown and gloves will cover up the itchy sores on my elbows." C. "Washing my hands and putting on a gown and gloves is what I must do before starting care." D. "I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client's genitals."

C. "Washing my hands and putting on a gown and gloves is what I must do before starting care." Standard Precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes. Knowing HIV status is important for preventing transmission of HIV, but is not a Standard Precaution. Health care workers with weeping dermatitis should not provide direct client care regardless of the use of a gown and gloves. Unlicensed health care workers cannot make the determination of what is required for PPE or Standard Precautions.

A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A. A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr

C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.

Which waveform indicates proper function of the sinoatrial (SA) node? A. The QRS complex is present. B. The PR interval is 0.24 second. C. A P wave precedes every QRS complex. D. The ST segment is elevated.

C. A P wave precedes every QRS complex. A P wave is generated by the SA node and represents atrial depolarization. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead. The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Elevation of the ST segment indicates myocardial injury.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A. Serum potassium level of 3.2 mEq/L B. Ejection fraction of 60% C. B-type natriuretic peptide (BNP) of 760 ng/dL D. Chest x-ray report showing right middle lobe consolidation

C. B-type natriuretic peptide (BNP) of 760 ng/dL BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds in 1 day

C. Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. Client with diabetic ketoacidosis (DKA) B. Client with atrial fibrillation C. Client with aspiration pneumonia D. Client with acute kidney failure

C. Client with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Clients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? A. Client with bacterial pneumonia and a cough productive of green sputum B. Client with neutropenia and pneumonia caused by Candida albicans C. Client with possible pulmonary tuberculosis who currently has hemoptysis D. Client with right empyema who has a chest tube and a fever of 103.2° F

C. Client with possible pulmonary tuberculosis who currently has hemoptysis A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A. Bathe in cold water. B. Wear cotton gloves when cooking. C. Consume a diet high in fiber. D. Make sure shoes are snug.

C. Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring D. Restricted activity

C. Daily weight monitoring A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? A. Admission to rehabilitation hospital for ambulatory retraining B. Collaboration with home care agency for return to home C. Discussion with family and provider regarding palliative care D. Enrollment in a cardiac transplantation program

C. Discussion with family and provider regarding palliative care In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care should be considered. Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.

When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A. Drug toxicity B. Polycythemia C. Infection D. Dose-limiting side effects

C. Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? A. Obtain a 12-lead electrocardiogram (ECG). B. Call for a portable chest x-ray. C. Obtain blood cultures from two sites. D. Give cefazolin (Kefzol) 500 mg IV.

C. Obtain blood cultures from two sites. Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out.

Which nursing action may be delegated to a nursing assistant working on the medical unit? A. Determine the usual alcohol intake for a client with cardiomyopathy. B. Monitor the pain level for a client with acute pericarditis. C. Obtain daily weights for several clients with class IV heart failure. D. Check for peripheral edema in a client with endocarditis.

C. Obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Monitor pulse oximetry and cardiac rate and rhythm. B. Reassure the client that his distress can be relieved with proper intervention. C. Place the client in high-Fowler's position with the legs down. D. Ask a family member to remain with the client.

C. Place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

Which problem places a client at highest risk for sepsis? A. Pernicious anemia B. Pericarditis C. Post kidney transplant D. Client owns an iguana

C. Post kidney transplant The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a very high risk for infection, sepsis, and death.

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? A. Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma B. Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency C. Potential for infection transmission related to recurring opportunistic infections D. High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans

C. Potential for infection transmission related to recurring opportunistic infections Protecting the client from further opportunistic infection such as Candida albicans is a priority. Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be the secondary concern because Candida albicans causes the mouth sores. Nutrition will be affected because of Candida albicans; however, it is not a priority.

When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions have resolved

C. Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level D. C-reactive protein

C. Serum troponin I level Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

A client's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sinus rhythm with premature ventricular contractions

C. Sinus tachycardia These are the characteristics of sinus tachycardia. A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

What typical sign/symptom indicates the early stage of septic shock? A. Pallor and cool skin B. Blood pressure 84/50 mm Hg C. Tachypnea and tachycardia D. Respiratory acidosis

C. Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precedes sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.

The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? A. The client is semi-recumbent in bed. B. Chest leads are placed as for the previous ECG. C. The client is instructed to breathe deeply through the mouth. D. The client is instructed to lie still.

C. The client is instructed to breathe deeply through the mouth. While obtaining a 12-lead ECG, remind the client to be as still as possible in a semi-reclined position, breathing normally. Any repetitive movement will cause artifact and could lead to inaccurate interpretation of the ECG. Normal breathing is required or artifacts will be observed, perhaps leading to inaccurate interpretation of the ECG. Placing the client in a semi-reclined position is correct and does not require the nurse to intervene. ECGs are valid when electrode placement is identical at each test. The client must lie still to avoid artifacts and inaccurate interpretation of the ECG.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when he becomes tachycardic.

C. The nurse obtains a bedside commode before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A. The student scrubs the hub of IV tubing before administering an antibiotic. B. The nurse overhears the student explaining to the client the importance of handwashing. C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. D. The nurse observes the student providing oral hygiene and perineal care.

C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.

The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A. Monitoring platelets B. Administering packed red blood cells C. Using strict aseptic technique to prevent infection D. Administering low-dose heparin therapy for clients on bedrest

C. Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

In teaching clients at risk for bradydysrhythmias, what information does the nurse include? A. "Avoid potassium-containing foods." B. "Stop smoking and avoid caffeine." C. "Take nitroglycerin for a slow heartbeat." D. "Use a stool softener."

D. "Use a stool softener." Clients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps prevent this. Clients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the client is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people should stop smoking, clients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

Which problem places a person at highest risk for septic shock? A. Kidney failure B. Cirrhosis C. Lung cancer D. 40% burn injury

D. 40% burn injury The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A. Veins of the legs B. Lung C. Heart D. Abdominal cavity

D. Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A. Explain that this occurs in some clients and is usually permanent. B. Inform the client that a small glass of wine may help her relax. C. Protect the client from infection. D. Allow the client an opportunity to express her feelings.

D. Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? A. Obtain IV access and hang prescribed fluid infusions. B. Apply the automatic blood pressure cuff. C. Assess level of consciousness and pupil reaction to light. D. Check the airway and respiratory status.

D. Check the airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? A. Give the digoxin; reassess the heart rate in 30 minutes. B. Give the digoxin; document assessment findings in the medical record. C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D. Hold the digoxin, and obtain a prescription for a potassium supplement.

D. Hold the digoxin, and obtain a prescription for a potassium supplement. Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

A client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? A. Therapeutic highly active antiretroviral therapy (HAART) level B. Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot C. Positive Papanicolaou (Pap) test D. Improved CD4+ T-cell count and reduced viral load

D. Improved CD4+ T-cell count and reduced viral load Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication. Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG).

D. Obtain client vital signs and a resting electrocardiogram (ECG). Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? A. Hypotension B. Bradypnea C. Heart blocks D. Tachycardia

D. Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A. The client has diuresis of 400 mL in 24 hours. B. The client's blood pressure is 122/84 mm Hg. C. The client has an apical pulse of 82 beats/min. D. The client's weight decreases by 2.5 kg.

D. The client's weight decreases by 2.5 kg. The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? A. C-reactive protein of 1 mg/dL B. Homocysteine level of 13 mmol/L C. Creatine kinase (CK) of 125 mg/dL D. Troponin of 5.2 ng/mL

D. Troponin of 5.2 ng/mL The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? A. Keeping the head of the bed elevated 30 to 45 degrees B. Performing oral care after suctioning the oropharynx C. Washing hands and donning gloves prior to the procedure D. Wearing a disposable particulate mask respirator and protective eyewear

D. Wearing a disposable particulate mask respirator and protective eyewear To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms.

D. Women may experience extreme fatigue and dizziness as sole symptoms. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.