NURS FINALS 2

Arrange the order of tests chronologically to be performed to determine the neurologic status of a client. 1. Speak in normal voice 2.Speak in loud voice 3.Shake the client gently 4.Apply painful stimuli

1, 2, 3, 4 The assessment of neurologic status should start with speaking to the client in a normal voice. If the client does not respond, the nurse should speak loudly. If the client does not respond to this, the nurse should gently shake the client. The degree of shaking should be similar to that used in waking a child. If the client does not respond to this, painful stimuli can be applied.

Which hormone synthesis does the nurse state is inhibited by hypokalemia? A. Aldosterone B. Somatostatin C. Norepinephrine D. Androstenedione

A. Aldosterone Hypokalemia inhibits synthesis of aldosterone hormone. Somatostatin inhibits the synthesis of insulin. Norepinephrine also inhibits the synthesis of insulin. Androstenedione secretion may not be inhibited by hypokalemia.

Which feature in the client indicates hypersecretion of adrenocorticotrophic hormone? A. Moon face B. Lower jaw protrusion C. Heat intolerance D. Barrel-shaped chest

A. Moon face Hypersecretion of adrenocorticotrophic hormone results in Cushing's disease, which is characterized by "moon face" appearance, an abnormal distribution of fat in the face. Protrusion of the lower jaw is a feature of acromegaly, caused by excess secretion of growth hormone. Heat intolerance is seen in clients with excess secretion of thyrotropin. In acromegaly, the client presents with "barrel-shaped" chest appearance.

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? A. Panic B. Coma C. Euphoria D. Depression

A. Panic People in a panic may initiate a group panic reaction even in those who appear to be in control. Comatose individuals will not cause panic in others. Euphoric individuals will not adversely affect others. Depressed people will be quiet and not affect others.

While setting up a client's food tray, the nurse identifies tremoring of the hand when it lies in the client's lap. The tremor disappears when the client reaches for silverware. What type of tremor should the nurse document in the client's medical record? A. Resting tremor B. Intention tremor C. Voluntary tremor D. Idiopathic tremor

A. Resting tremor A resting tremor (nonintention tremor) typically is present when the hand is not involved in a purposeful activity. The tremor is caused by decreased neurotransmitters. An intention tremor is exhibited or intensified when purposeful movements are attempted. The word voluntary implies that the tremor is under the client's control, which is not true. The cause of the disease may be idiopathic, but the type of the tremor is known as a resting or nonintention tremor.

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? A. Third B. Fourth C. Second D. Seventh

A. Third The third cranial nerve (oculomotor) contains autonomic fibers that innervate the smooth muscle responsible for constriction of pupils. The trochlear nerve is concerned with eye movements; lesions result in diplopia, strabismus, and head tilt to the affected side. The optic nerve is concerned with vision; lesions result in visual field defects and loss of visual acuity. The facial nerve is concerned with facial expressions; lesions result in loss of taste and paralysis of the facial muscles and the eyelids (lids remain open).

The person with which type of blood is known to be the universal recipient? A B O AB

AB People with type AB blood have both A and B antigens on their red blood cells (RBCs) and no antibodies against either antigen in their plasma. They can receive packed RBCs of any ABO blood type. A, B, and O are not the universal recipient.

Which prostaglandin agonist is used in the treatment of clients with glaucoma? A. Carteolol B. Bimatoprost C. Brinzolamide D. Apraclonidine

B. Bimatoprost Bimatoprost is the prostaglandin agonist used in the treatment of glaucoma. Carteolol is the beta-adrenergic blocker used for treatment of glaucoma. Brinzolamide is the carbonic anhydrate inhibitor used for the treatment of glaucoma. Apraclonidine is the adrenergic agonist used in the treatment of glaucoma.

Which organ has only beta1-receptors? A. Liver B. Heart C. Bladder D. Pancreas

B. Heart The heart has only beta1 receptors, which increase heart rate and contractility. The liver has only alpha receptors. The bladder and pancreas have both alpha and beta receptors.

What are the neurologic manifestations of hyperthyroidism? Select all that apply. A. Fatigue B. Diaphoresis C. Blurred vision D. Exophthalmos E. Shallow respirations

C & D Blurred vision and exophthalmos are the neurological manifestations of hyerthyroidism. Fatigue is the metabolic manifestation of hyperthyroidism. Diaphoresis, or excessive sweating, is the skin manifestation of hyperthyroidism. Shallow respirations are the cardiopulmonary manifestation of hyperthyroidism.

Valsartan, an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply. A. Constipation B. Hypokalemia C. Irregular pulse rate D. Change in visual acuity E. Orthostatic hypotension

C & E Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan. It also may precipitate angina pectoris, myocardial infarction, and brain attack (cerebrovascular accident, CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.

A client is informed that he has developed a healthcare-associated upper respiratory tract infection and asks the nurse what this means. How should the nurse reply? A. "You developed an infection that requires antibiotics." B. "This is a highly contagious infection requiring isolation." C. "You acquired the infection after being admitted to the hospital." D. "An infection you had before beginning treatment has flared up."

C. "You acquired the infection after being admitted to the hospital." A healthcare-associated infection (formerly called nosocomial infection) is contracted during the course of receiving treatment. Although developing an infection that requires antibiotics may occur, this response does not explain a healthcare-associated infection. The need for precautions relates to the type of infection, not to the situation in which it was acquired. A preexisting infection is unrelated to a healthcare-associated infection.

What assessment is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy? A. Hemorrhage B. Thyrotoxic crisis C. Airway obstruction D. Hypocalcemic tetany

C. Airway obstruction Maintaining airway patency is always the priority to permit gas exchange necessary to maintain life. Although important, hemorrhage, thyrotoxic crisis, and hypocalcemic tetany do not exceed patency of the airway in priority.

What other name can the nurse use for vasopressin? A. Growth hormone B. Luteinizing hormone C. Antidiuretic hormone D. Thyroid-stimulating hormone

C. Antidiuretic hormone Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.

Four hours after surgery, the blood glucose level of a client who has type 1 diabetes is elevated. What intervention should the nurse implement? A. Administer an oral hypoglycemic B. Institute urine glucose monitoring C. Give supplemental doses of regular insulin D. Decrease the rate of the intravenous infusion

C. Give supplemental doses of regular insulin The blood glucose level needs to be reduced; regular insulin begins to act in 30 to 60 minutes. The client has type 1, not type 2, diabetes, and an oral hypoglycemic will not be effective. Blood glucose levels are far more accurate than urine glucose levels. The rate may be increased because polyuria often accompanies hyperglycemia.

A client is taking furosemide. At each clinic visit, the nurse should assess for what adverse effect? A. Rapid weight loss B. Xanthopsia C. Hyporeflexia D. Bronchospasm

C. Hyporeflexia Furosemide enhances the excretion of potassium, producing signs and symptoms of hypokalemia, such as hyporeflexia. Rapid weight loss, xanthopsia, and bronchospasm are not side effects of furosemide.

Which disorder would the nurse state is related to the tonsils? A. Rhinitis B. Sinusitis C. Pharyngitis D. Pneumonia

C. Pharyngitis Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

A client reports frequently taking calcium carbonate. What effect should the nurse advise the client that this can have? A. Diarrhea B. Water retention C. Rebound hyperacidity D. Bone demineralization

C. Rebound hyperacidity The antacid action of calcium carbonate adds alkalinity, neutralizing gastric pH; this in turn stimulates renewed secretion of acid by the gastric mucosa. This medication causes constipation, not diarrhea. Calcium carbonate does not contain sodium, as do some antacids; thus it does not promote fluid retention. This antacid provides a source of calcium, which helps prevent bone demineralization.

A nurse is planning to administer a prescribed intravenous solution that contains potassium chloride. What assessment should be brought to the healthcare provider's attention before administration of the intravenous line? A. Uncharacteristic irritability B. Poor tissue turgor with tenting C. Urinary output of 200 mL during the previous 8 hours D. Oral fluid intake of 300 mL during the previous 12 hours

C. Urinary output of 200 mL during the previous 8 hours Decreased urinary output will result in the retention of potassium, causing hyperkalemia. Reporting uncharacteristic irritability is unnecessary; this is a sign of dehydration, which can be corrected with appropriate hydration. Reporting poor tissue turgor with tenting is unnecessary; this may indicate dehydration, which is probably the rationale for the fluid prescribed. Reporting an oral fluid intake of 300 mL during the previous 12 hours is unnecessary; this can precipitate dehydration or can compound an existing dehydration, which can be treated with appropriate hydration.

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply. A. Drink a glass of wine. B. Engage in vigorous exercise before bedtime. C. Eat foods containing lysine. D. Follow the same bedtime ritual each night. E. Perform deep-breathing exercises.

D & E A bedtime ritual provides a familiar routine that promotes comfort and the self-fulfilling prophesy of sleep. Relaxation exercises slow body processes and reduce tension, both of which facilitate rest and promote sleep. People who drink alcohol may fall asleep more quickly but have depressed levels of rapid eye movement, less stage 4 sleep, and interruptions between sleep stages (sleep fragmentation). Physical exercise before bedtime has a stimulating rather than a relaxing effect. Lysine, an amino acid, maintains nitrogen equilibrium and promotes growth and development, but it does not influence sleep.

The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activity of the client might have led to this condition? A. Using nasal saline sprays B. Using drugs such as aspirin C. Blowing the nose vigorously D. Applying excess petroleum jelly to the nares

D. Applying excess petroleum jelly to the nares The sparing application of petroleum jelly to the nares helps to lubricate the area and provide comfort to the client. However, excess use may cause inhalation of the jelly into the lungs and may increase the risk of pneumonia. Nasal saline sprays are used to moisten the nares and prevent re-bleeding. Medications such as aspirin should be avoided after the placement of an epistaxis catheter to prevent bleeding. Vigorous nose blowing does not cause pneumonia.

While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this? A. Positive dipstick test B. Crackling of the skin on palpation C. Clearly visible fracture in the X-ray report D. Clear yellow halo ring structure on a filter paper

D. Clear yellow halo ring structure on a filter paper The drainage of cerebrospinal fluid (CSF) from the injured area indicates a skull fracture. The presence of a clear yellow halo ring-shape structure appearing on a piece of filter paper indicates the presence of CSF, an indication of a skull fracture. A positive dipstick test indicates the presence of sugar in the CSF. Crackling of the skin occurs with a normal nose injury. An X-ray may not detect the presence of CSF.

The nursing is caring for four different clients with eye disorders.Which client should be assessed for asthma before prescribing beta-adrenergic blockers? A. Client A B. Client B C. Client C D. Client D

D. Client D Reduced outflow of acqueous humor and increased intraocular pressure causes glaucoma, which can be treated with different types of drugs. Before prescribing beta-adrenergic blockers, the client should be assessed for moderate to severe asthma because if these drugs are absorbed systematically, they constrict pulmonary smooth muscle and narrow airways. Increased lens density and reduced visual sensory perception indicates cataracts that can be treated only with cataract surgery. Increased tear secretion and blood shot eye appearance is observed in a client with conjuctivitis; this can be treated with ophthalmic antibiotics. Degeneration of corneal tissue indicates keratoconus, which can be cured by performing a surgery called keratoplasty (corneal transplant).

A client underwent an external ear assessment and is diagnosed with hard nodules on the pinna. Which assessment finding indicates tophi? A. Ulcerative lesions at the site B. Crusted indurated lesions at the site C. Decreased calcium levels in the blood D. Increased uric acid levels in the blood

D. Increased uric acid levels in the blood Chronic gout is characterized by hard, irregular, painless nodules on the pinna or external ear known as tophi that form due to the accumulation of uric acid crystals. This condition is diagnosed by increased levels of uric acid in the blood. Squamous cell carcinoma is diagnosed by the appearance of small, crusted, ulcerated, or indurated lesions on the pinna that fail to heal. Decreased calcium levels in the blood are indications of osteoporosis.

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? A. Tremors B. Anasarca C. Bradypnea D. Tachycardia

D. Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurologic problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.

Which response should a nurse expect a client diagnosed with cerebellum dysfunction to exhibit? A. Dysphagia B. Hemiplegia C. Visual disturbances D. Uncoordinated movements

The cerebellum coordinates muscular activity and promotes balance and smooth, coordinated movements. Dysphagia, difficulty swallowing, is caused by cranial nerve damage. Damage to the motor cortex causes hemiplegia of the opposite side of the body. The occipital lobe of the cerebral cortex is involved with vision.

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ___ gtts/min

The ordered rate is 125 ml/hr. The drop factor of the tubing is 10 gtt/mL. Use the flow rate equation to determine the appropriate flow rate in drops/minute.

What is the most probable cause for Conn's syndrome in an adult client? A. Genetic cause B. Adrenal adenoma C. High level of angiotensin II D. Elevated level of plasma rennin

B. Adrenal adenoma Conn's syndrome is primary hyperaldosteronism. Excessive secretion of aldosterone by the adrenal glands due to an adrenal adenoma results in Conn's syndrome. Certain types of hyperaldosteronism that are diagnosed in childhood have genetic causes. High levels of angiotensin II that are stimulated by high levels of plasma rennin are a cause for secondary hyperaldosteronism.

A client with hypertension has received a prescription for metoprolol. Which information should the nurse include when teaching this client about metoprolol? A. Do not abruptly discontinue the medication. B. Consume alcoholic beverages in moderation. C. Report a heart rate of less than 70 beats per minute. D. Increase the medication dosage if chest pain occurs.

A. Do not abruptly discontinue the medication. Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. Clients should never increase medications without medical direction. The pulse rate can go lower than 70 beats per minute as long as the client feels well and is not dizzy.

Which hormonal deficiency would increase the client's risk for fractures? A. Growth hormone B. Follicle-stimulating hormone C. Thyroid-stimulating hormone D. Adrenocorticotropic hormone

A. Growth hormone Growth hormone deficiency causes decrease in bone density, thereby increasing the risk of fractures. Follicle-stimulating hormone deficiency causes amenorrhea, decreased libido, and infertility in women and impotence in men. Thyroid-stimulating hormone deficiency causes menstrual abnormalities and hirsutism. Adrenocorticotropic hormone deficiency causes hypoglycemia and hyponatremia.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin complains of tingling and numbness of the fingers and toes and shortness of breath. The cardiac monitor shows the appearance of a U wave. What complication does the nurse suspect? A. Hypokalemia B. Hypoglycemia C. Hypernatremia D. Hypercalcemia

A. Hypokalemia These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose. Symptoms of hypoglycemia are weakness, nervousness, tachycardia, diaphoresis, irritability, and pallor. Symptoms of hypernatremia are thirst, orthostatic hypotension, dry mouth and mucous membranes, concentrated urine, tachycardia, irregular heartbeat, irritability, fatigue, lethargy, labored breathing, and muscle twitching or seizures. Symptoms of hypercalcemia are lethargy, nausea, vomiting, paresthesias, and personality changes.

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment? A. Inhibition of tear production B. Inhibition of peripheral vision C. Impairment of eye movement D. Impairment of pupil constriction

A. Inhibition of tear production Injury to cranial nerve VII mainly leads to inhibition of tear production, a condition called keratoconjunctivitis sicca or dry eye syndrome. Any impairment to cranial nerve II may affect peripheral and central vision. Cranial nerves III, IV and VI affect eye movement. Therefore any injury to these nerves may affect eye movement. The function of cranial nerve III is constriction of the pupil. Any injury to this nerve may lead to impairment of pupil constriction.

Which statement appropriately describes tidal volume? A. It is the volume of air inhaled and exhaled with each breath. B. It is the amount of air remaining in the lungs after forced expiration. C. It is the additional air that can be forcefully inhaled after normal inhalation. D. It is the additional air that can be forcefully exhaled after normal exhalation.

A. It is the volume of air inhaled and exhaled with each breath. Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? A. Prepare for a thoracentesis. B. Apply a wound dressing. C. Obtain baseline vital signs. D. Suction fluid from the wound.

B. Apply a wound dressing. The wound must be covered to prevent atmospheric air from entering the pleural cavity until closed chest drainage can be instituted. While some sources specify an airtight dressing, others suggest that a side or corner of the dressing be left unsecured to prevent tension pneumothorax. A thoracentesis is used to drain fluid from lungs. Obtaining baseline vital signs will be done eventually; they are not the priority. Suctioning fluid from the wound is traumatic to lung tissue and is contraindicated.

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation.

A. Pain subsides as a result of arteriole and venous dilation. Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.

Which gland secretes melatonin? A. Pineal gland B. Thyroid gland C. Adrenal gland D. Parathyroid gland

A. Pineal gland The pineal gland secretes the hormone melatonin, which regulates the circadian rhythm and reproductive system at the onset of puberty. The thyroid gland secretes thyroid hormones. The adrenal gland secretes androgens, corticosteroids, and catecholamines. The parathyroid gland secretes the hormone calcitonin.

Which action performed by the nursing student during the chest examination of a client needs correction? A. Placing the stethoscope over bony prominences B. Palpating two ribs inferiorly in the midaxillary line C. Dividing the anterior and posterior lungs into thirds D. Listening to at least one cycle of inspiration and expiration

A. Placing the stethoscope over bony prominences The stethoscope should be placed over the lung tissue and not over bony prominences during chest auscultation. The nursing student should palpate the two ribs inferiorly in the midaxillary line and around the posterior chest. When documenting the location of lung sounds, the nursing student should divide the anterior and posterior lungs into thirds to describe the sounds. At each placement of the stethoscope, the nursing student should listen to at least one cycle of inspiration and expiration.

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5.Document findings in the client record

1, 2, 3, 4, 5 These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented accordingly.

A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include? A. Avoidance of cholinergics B. Surgical replacement of lens C. Continuation of therapy for life D. Prevention of high blood pressure

C. Continuation of therapy for life Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.

A client is to have a computed tomography (CT) scan with contrast to assess a potential brain tumor. The nurse should teach the client about which common expected responses to the contrast material? Select all that apply. A. Visual disturbances B. Flushing of the face C. Sensation of warmth D. Lemony taste in the mouth E. Small petechiae on the arms

B & C Contrast material precipitates common responses, such as flushing of the face and a sensation of warmth, that indicate sensitivity to the foreign substance. Hypersensitivity reactions (e.g., palpitations, respiratory distress, headache) may occur in some people. Visual disturbances are not caused by a CT scan with contrast material. A salty, not lemony, taste may occur. Petechiae do not result from a CT scan with contrast material.

Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. A. Impaired memory B. Intolerance to cold C. Difficulty breathing D. Decreased blood pressure E. Decreased body temperature

B & E Cold intolerance and decreased body temperature are the metabolic manifestations observed in a client with hypothyroidism. Impaired memory is the neuromuscular manifestation of hypothyroidism. Difficulty in breathing is the pulmonary manifestation observed in the client with hypothyroidism. Decreased blood pressure is the cardiovascular manifestation observed in the client with hypothyroidism.

In order to ensure a quality specimen and an accurate test result, which instruction should the nurse give a client who is scheduled to undergo urine endocrine testing? A. "Start the urine collection when the bladder is full." B. "Store the urine specimen in a cooler with ice." C. "Store the urine specimen in a home refrigerator." D. "Save the urine specimen that begins the collection."

B. "Store the urine specimen in a cooler with ice." The urine specimen that is collected for endocrine testing should be stored in a cooler with ice to prevent bacterial growth in the specimen. The nurse should instruct the client to start the urine collection after emptying the bladder. The client should be instructed not to store the urine specimen in a home refrigerator with other food and drinks as it could lead to cross-contamination. The client should be instructed to refrain from saving the urine specimen that begins the collection because the timing for urine collection starts from after the initial voiding specimen.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? A. Clamp the chest tubes when suctioning. B. Palpate the surrounding area for crepitus. C. Change the dressing daily using aseptic technique. D. Empty the drainage chamber at the end of the shift.

B. Palpate the surrounding area for crepitus. Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated; this is referred to as crepitus. Although hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system, clamping the tube is not otherwise necessary and could cause backpressure. The dressing is not routinely changed to minimize the risk for pneumothorax. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. The chambers are not emptied; if they are filled, a new system will be attached.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client? A. Sodium: 143 mEq/L B. Potassium: 2.9 mEq/L C. Bicarbonate: 25 mEq/L D. Total calcium: 10 mg/dL

B. Potassium: 2.9 mEq/L The normal level of potassium is 3.5 to 5.0 mEq/L. The laboratory value of the potassium in the client is 2.9 mEq/L, which is below the normal level. Therefore, it may indicate the presence of adrenal gland hyperfunction in the client. The normal value of sodium is 136 to 145 mEq/L, bicarbonate is 23 to 30 mEq/L, and total calcium is 9 to 10.5 mg/dL. Thus, the laboratory values of sodium (143 mEq/L), bicarbonate (25 mEq/L), and total calcium (10 mg/dL) lie in the normal range, which does not indicate hyperfunction of the adrenal gland in the client.

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? A. They are indicative of pleural rubbing. B. They are signs of bronchial constriction. C. Crackles are located in the smaller air passages. D. Crackles are heard during respiratory expiration.

C. Crackles are located in the smaller air passages. Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? A. To prevent dyspnea B. To prevent cyanosis C. To increase oxygen concentration to heart cells D. To increase oxygen tension in the circulating blood

C. To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

A client who is legally blind is admitted to the hospital for surgery. Which nursing action is most appropriate when caring for this client? A. Enter the room while speaking softly. B. Touch the client gently before speaking. C. Hold the client by the elbow when ambulating. D. Keep the furniture in the same location in the room.

D. Keep the furniture in the same location in the room. Placing furniture and objects in the same location in the room promotes safety and independence. Entering a room while speaking softly can increase anxiety because the client may not be able to identify what is happening. Touching the client gently before speaking can startle the client and increase anxiety; speak to the client before touching. The blind client should hold the nurse's elbow when ambulating.

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? A. Place a pillow under the thighs. B. Elevate the knee gatch of the bed. C. Encourage active range of motion. D. Maintain the feet at right angles to the legs.

D. Maintain the feet at right angles to the legs. Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures. The client will not have the ability or strength to perform range-of-motion exercises unassisted at this time.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last several days."

C. "I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.

A client with tuberculosis asks the nurse why vitamin B6 (pyridoxine) is given with isoniazid. What explanation should the nurse provide? A. "It will improve your immunologic defenses." B. "The tuberculostatic effect of isoniazid is enhanced." C. "Isoniazid interferes with the synthesis of this vitamin." D. "Destruction of the tuberculosis organisms is accelerated."

C. "Isoniazid interferes with the synthesis of this vitamin." Isoniazid often leads to vitamin B6 (pyridoxine) deficiency because it competes with the vitamin for the same enzyme; this deficiency most often is manifested by peripheral neuritis, which can be controlled by regular administration of vitamin B6. Vitamin B6 does not improve immune status. Pyridoxine does not enhance isoniazid effects. Pyridoxine does not destroy organisms.

A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. On what fact should the nurse base her response? A. Hypothyroidism is a gradual slowing of the body's function. B. There will be a decrease in pituitary thyroid-stimulating hormone (TSH). C. There may not be enough thyroid tissue to supply adequate thyroid hormone. D. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

C. There may not be enough thyroid tissue to supply adequate thyroid hormone. After a subtotal thyroidectomy the thyroxine output may be inadequate to maintain an appropriate metabolic rate. Hypothyroidism is a decrease in thyroid functioning, not a slowing of the entire body's functions. In hypothyroidism the level of TSH from the pituitary usually is increased. Atrophy of the remaining thyroid tissue does not occur.

A client with tuberculosis asks the nurse how long drug therapy will be continued. What is the nurse's most accurate reply? A. 1 to 2 weeks B. 4 to 5 months C. 6 to 12 months D. 3 years or longer

C. 6 to 12 months The tubercle bacillus is a drug-resistant organism and takes a long time to be eradicated; usually a combination of three medications is used for a minimum of 6 months, and at least 6 months beyond culture conversion. One to 2 weeks or 4 to 5 months are too short a time for eradication of this organism. Usually, the organism can be eradicated in a shorter period of time than 3 years, unless a resistant strain of the bacillus has developed.

A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? A. "The use of salt probably contributed to the disease." B. "Excess weight will be gained if sodium is not limited." C. "The loss of excess sodium and potassium in the urine requires less renal stimulation." D. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

D. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium." Clients with Cushing syndrome must limit their intake of salt and increase their intake of potassium. The kidneys are retaining sodium and excreting potassium. An excessive secretion of adrenocortical hormones in Cushing syndrome, not increased or high sodium intake, is the problem. Although sodium retention causes fluid retention and weight gain, the need for increased potassium also must be considered. Because of steroid therapy, excess sodium may be retained, although potassium may be excreted.

A nurse is providing instructions to a client with glaucoma. Which statements made by the client indicate the nurse needs to intervene? Select all that apply. A. "I should take stool softeners." B. "I can wear loose collar shirts." C. "I should refrain from sneezing and coughing." D. "I can lift objects that weigh more than 10 lbs (4.5 kg)." E. "I should keep my head in a dependent position."

D & E Glaucoma is a group of eye disorders that result in increased intraocular pressure. Therefore the nurse should intervene to correct the misconceptions of keeping the head in a dependent position and lifting objects that weigh more than 10 lbs (4.5 kg). All the rest are correct statements and need no follow up. Straining to have a bowel movement leads to increased intraocular pressure. Therefore the client should be instructed to use stool softeners. Wearing tight shirt collars is to be avoided; loose collar shirts are appropriate to wear. Sneezing and coughing also lead to increased intraocular pressure and should be avoided.

A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? A. Mannitol B. Dexamethasone C. Chlorpromazine D. Morphine

D. Morphine Morphine injection is contraindicated for an unconscious, neurologically impaired client because it depresses respirations. Mannitol, an osmotic diuretic, is used to reduce increased intracranial pressure. Dexamethasone, a corticosteroid antiinflammatory agent, is used to help reduce increased intracranial pressure. Chlorpromazine, an antipsychotic/neuroleptic/antiemetic, can be given safely to a neurologically impaired client for restlessness.

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? A. Diazepam B. Meperidine C. Flurazepam D. Morphine sulfate

D. Morphine sulfate For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.

A hospice client who has severe pain asks for another dose of oxycodone. What is the nurse's primary consideration when responding to the client's request? A. Prevent addiction B. Determine why the drug is needed C. Provide alternative comfort measures D. Reduce the client's pain

D. Reduce the client's pain Hospice clients with severe pain need increasing levels of analgesics and should be maintained at a pain-free level, even if addiction occurs. Pain management, not the prevention of addiction, is the priority. The client has severe pain, and the priority is to relieve the pain. Comfort measures should augment, not be substitutes for, pharmacologic interventions when clients are experiencing severe pain.

A client is scheduled to receive an intravenous (IV) solution of lactated Ringer to run at 150 mL/hr. To deliver the solution, the nurse plans to use an administration set that delivers 15 gtt/mL. At how many drops per minute should the nurse set the IV to administer the prescribed amount of fluid? Record your answer using a whole number. ___ gtt/min.

The ordered rate is 150 mL/h. The drop factor of the administration set is 15 gtt/mL. Use the Flow Rate Equation to determine the appropriate flow rate.

A healthcare provider prescribes cefazolin sodium 375 mg intravenous piggyback (IVPB) every 8 hours. The vial of powder contains 500 mg of the medication. This must be reconstituted with 2 mL of 0.9% sodium chloride. In the resulting solution 1 mL contains 225 mg of cefazolin. How many mL of cefazolin solution should the nurse administer? Record your answer using one decimal place. ____mL

The prescribed medication is 375 mg. The available concentration is 225 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A. Count the client's respirations. B. Document the intensity of the client's pain. C. Withhold the medication if the client reports pruritus. D. Verify the number of doses in the locked cabinet before administering the prescribed dose. E. Discard the medication in the client's toilet before leaving the room if the medication is refused.

A, B, D Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? Select all that apply. A. Left leg B. Left arm C. Right leg D. Right arm E. Left side of face

A, B, E Because nerves decussate (cross over), paralysis occurs on the side of the body opposite to the area of cerebral involvement. The right leg and right arm will not be affected because the insult is to the right cerebral cortex and nerve fibers decussate before reaching the periphery. The face is innervated by the seventh cranial nerve, which comes in pairs (right and left) that do not decussate; therefore, because injury is to the right cerebral cortex, the left seventh cranial nerve is damaged. This leads to paralysis of the left side of the face.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. Which information in the client's history supports the healthcare provider's diagnosis of pulmonary tuberculosis? Select all that apply. A. Fever B. Dry cough C. Night sweats D. Frothy sputum E. Engorged neck veins F. Blood-tinged sputum

A, C, F Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, not dry, because the inflammatory process causes purulent mucus. Frothy sputum is present with pulmonary edema, not tuberculosis. Engorged neck veins are symptomatic of heart failure or fluid overload.

The nurse is teaching a nursing student about the use of magnetic resonance imaging (MRIs). Which statement of the nursing student indicates effective learning? A. "Clients with claustrophobia can have an MRI." B. "Clients who are allergic to iodine should not have an MRI." C. "Clients with pacemakers can have an MRI." D. "Clients with surgical clips can go through an MRI."

A. "Clients with claustrophobia can have an MRI." Clients with a fear of closed spaces may develop anxiety; a closed MRI can be used, but the nurse should provide relaxation techniques or other modes to cope. MRIs do not involve the use of iodine or iodized products, so any clients allergic to iodine can still undergo the procedure. The magnetic field of an MRI may cause dysfunctions in pacemaker activity. Clients with surgical clips should remove all metal accessories before an MRI.

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? A. 1 to 2 hours B. 3 to 4 hours C. 15 to 20 minutes D. 30 to 40 minutes

A. 1 to 2 hours Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility [1] [2]. Too protracted a period of time in one position, such as every 3 to 4 hours, increases the potential for respiratory, urinary, and neuromuscular impairment; prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals; too frequent repositioning may interfere with the client's rest.

A client is admitted with a diagnosis of chronic adrenal insufficiency. Which roommate should be avoided when assigning a room for this client? A. A young adult client with pneumonia B. An adolescent client with a fractured leg C. An older adult client who had a brain attack D. A middle-aged client who has cholecystitis

A. A young adult client with pneumonia Circulatory collapse can be caused by exposure to an infection, cold, or overexertion of a client with chronic adrenocortical insufficiency (Addison disease). Roommates with a fractured leg, a brain attack, or cholecystitis are appropriate room assignments because they do not have communicable infections.

A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations? A. Blurred vision along with episodes of vertigo B. Tremors of the hands when attempting to lift objects C. Partial improvement of muscle strength with mild exercise D. Involvement of the distal muscles rather than the proximal muscles

A. Blurred vision along with episodes of vertigo Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.

A nurse is planning to teach facts about hyperglycemia to a client with diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis? A. Breakdown of fat stores for energy B. Ingestion of too many highly acidic foods C. Excessive secretion of endogenous insulin D. Increased amounts of cholesterol in the extracellular compartment

A. Breakdown of fat stores for energy In the absence of insulin, which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35). The pH of food ingested has no effect on the development of acidosis. The opposite of excessive secretion of endogenous insulin is true. Cholesterol level has no effect on the development of acidosis.

A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect? A. Retinol (vitamin A) B. Thiamine (vitamin B1) C. Pyridoxine (vitamin B6) D. Ascorbic acid (vitamin C)

A. Retinol (vitamin A) Joint pain, hair loss, jaundice, anemia, irritability, pruritus, and enlarged liver and spleen are signs of vitamin A toxicity. Unlike retinol, which is lipid soluble and eliminated by the liver, thiamine, pyridoxine, and ascorbic acid are water soluble, so they are typically excreted in the urine before toxic blood levels can be achieved. However, excess thiamine may elicit an allergic reaction in some individuals, excess vitamin C (ascorbic acid) may cause diarrhea or renal calculi, and ultrahigh doses (about 800 times the normal dose) of pyridoxine (vitamin B6) can promote neuropathy. Remember that lipid-soluble vitamins normally take longer to eliminate and accumulate faster than water-soluble vitamins.

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client? A. Drink alcoholic beverages in moderation. B. Avoid abruptly discontinuing the medication. C. Increase the medication if chest pain develops. D. Report a pulse rate less than 70 beats per minute.

B. Avoid abruptly discontinuing the medication. An abrupt discontinuation of atenolol may cause an acute myocardial infarction. Alcohol is contraindicated for clients taking atenolol because it can cause additive hypotension. Clients should never increase medications without a healthcare provider's direction. The pulse rate can go much lower as long as the client feels well and is not dizzy.

The nurse is assessing the clinical data of four clients. Which client is characterized with mixed conductive-sensorineural type of hearing loss? A. Client A B. Client B C. Client C D. Client D

B. Client B Client B is diagnosed with a retraction in the tympanic membrane, causing obstruction to sound wave transmission. Damaged cochlear hair results in decreased sensory perception. Therefore, this client is characterized by a mixed conductive-sensorineural type of hearing loss. Client A is diagnosed with inflammation in the tympanic membrane resulting in retraction or bulging of the tympanic membrane, leading to obstruction of sound wave transmission thereby causing conductive hearing loss. The type of hearing loss diagnosed in client C is characterized as sensorineural hearing loss, as there is damage to the vestibulocochlear cranial nerve. Client D is diagnosed with fused bony ossicles, which obstructs sound wave transmission thereby causing conductive hearing loss.

A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? A. Increased respiratory rate B. Decreased workload of the heart C. Reduced size of the clot blocking the coronary artery D. Diminished metabolites within the ischemic heart muscle

B. Decreased workload of the heart Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine; it is not the intended therapeutic effect for a client being treated for myocardial infarction. Decreasing the size of the clot blocking the coronary artery is the action of antithrombolytic therapy. Decreasing metabolites within the ischemic heart muscle is not the action of morphine.

A client is diagnosed with hyperthyroidism, and surgery is scheduled because the client refuses ablation therapy. While awaiting the surgical date, what instruction should the nurse teach the client? A. Consciously attempt to calm down. B. Eliminate coffee, tea, and cola from the diet. C. Keep the home warm, and use an extra blanket at night. D. Schedule activities during the day to overcome lethargy.

B. Eliminate coffee, tea, and cola from the diet. Coffee, tea, and cola contain caffeine, which may increase thyroid activity. Hyperactivity is a physiological response; it is not under conscious control. The increased metabolic rate associated with hyperthyroidism will make the client feel warm; a cool environment is needed. Hyperactivity is a problem, and the client should be encouraged to rest.

A client is admitted with a tentative diagnosis of pneumonia. On admission the client is not in respiratory distress, but later develops chest pain and a fever of 103° F (39.4° C). A productive cough produces rust-colored sputum. How should the nurse interpret these findings? A. Onset of pulmonary edema B. Expected course of pneumonia C. Presence of a pulmonary embolus D. Insidious onset of tuberculosis (TB)

B. Expected course of pneumonia Chest pain, fever, productive cough, and rust-colored sputum are cardinal signs of pneumonia [1] [2]. Chest pain results from excessive coughing; fever, increased sputum, and rust-colored sputum result from the infectious process. Dependent edema, respiratory distress, and crackles on auscultation of the lungs are associated with pulmonary edema. Although chest pain is expected with a pulmonary embolus, rust-colored sputum and a high fever are not. Pulmonary TB is associated with a low-grade fever, nonproductive or mucopurulent blood-tinged sputum, night sweats, and fatigue.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? A. Administer continuous oxygen B. Increase fluid intake to at least 2 L a day C. Place the client in a high-Fowler position D. Instruct the client to gargle deep in the throat using warmed normal saline

B. Increase fluid intake to at least 2 L a day Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.

A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition? A. Sodium bicarbonate, causing alkalosis B. Ketones as a result of rapid fat breakdown, causing acidosis C. Nitrogen from protein catabolism, causing ammonia intoxication D. Glucose from rapid carbohydrate metabolism, causing drowsiness

B. Ketones as a result of rapid fat breakdown, causing acidosis Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate. Diabetes does not interfere with removal of nitrogenous wastes. Carbohydrate metabolism is impaired in the client with diabetes.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? A. Encourage bed rest. B. Space activities throughout the day. C. Teach the limitations imposed by the disease. D. Have one of the client's relatives stay at the bedside.

B. Space activities throughout the day. Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, what is the most important nursing intervention? A. Assess for signs of hemoptysis B. Have the client rest in the supine position C. Check the client's level of consciousness frequently D. Ensure nothing by mouth (NPO) until the gag reflex returns

D. Ensure nothing by mouth (NPO) until the gag reflex returns Ensuring nothing by mouth until the gag reflex returns prevents aspiration. Although assessing for signs of hemoptysis is important because hemoptysis can occur after these procedures, it is not the priority. The supine position can promote aspiration. Checking for level of consciousness is unnecessary after this procedure.

Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" Which is the nurse's best response? A. "There are many clients who have had this operation. You'll talk again." B. "That's a good question. I'll have the healthcare provider talk with you." C. "You seem very concerned. Tell me what you know about your surgery." D. "Not like before but there is nothing to worry about. We do a lot of these surgeries."

C. "You seem very concerned. Tell me what you know about your surgery." The nurse should strive to clarify misconceptions and fears before a client signs a consent form; this response promotes further communication and begins where the client is. The fact that others have had the surgery provides little solace; the remainder of the response is false reassurance and does not truthfully answer the client's question. The response "That's a good question. I'll have the healthcare provider talk with you" avoids assuming the responsibility of answering the client's question; the client needs an immediate clarification. The response "Not like before but there is nothing to worry about" denies the client's feelings and cuts off communication.

The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? A. Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration B. Be able to identify dietary restrictions and plan menus C. Achieve relief of symptoms and maintain kidney function D. Recognize signs of bleeding, a complication associated with this type of procedure

C. Achieve relief of symptoms and maintain kidney function Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.

The nurse reviews teaching with a client who has laryngeal cancer and is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client makes which statement about what he will be able to do after recovering from surgery? A. After surgery, I will still be able to blow my nose. B. After surgery, I will still be able to sip through a straw. C. After surgery, I will still be able to chew and swallow food. D. After surgery, I will still be able to smell and differentiate odors.

C. After surgery, I will still be able to chew and swallow food. There is still a pathway from the mouth to the stomach; eating patterns are not lost when a laryngectomy is performed. Air passes through a tracheal stoma that bypasses the nose and olfactory organs. There is no passage of air from the lungs to the nose; air is expelled through a tracheal stoma.

A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication? A. As needed B. With meals C. At bedtime D. When indigestion occurs

C. At bedtime Ranitidine is administered typically in a single dose at bedtime. This medication is used for 4 to 6 weeks in combination with other therapy; it is not used as needed, with meals, or when indigestion occurs.

A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have? A. Retinal detachment B. Infection of the cornea C. Changes in tear composition D. Hemorrhage in the vitreous humor

C. Changes in tear composition Decreased tear formation or changes in the tear composition because of aging or various systemic diseases may cause dryness in the eye. This may manifest in eye discomfort and a sandy, gritty, or burning sensation. Retinal detachment may cause blurred vision. Infection of the cornea may result in photophobia. A vitreous humor hemorrhage manifests as spots or floaters seen in the field of vision.

Four clients who sustained head injuries are presented below. Which client has the least score on the Glasgow coma scale? A. Client A B. Client B C. Client C D. Client D

C. Client C The Glasgow coma scale is used to establish baseline data in eye opening, motor response, and verbal response in acute care settings. According to the Glasgow coma scale:Eye opening: spontaneous-4, to sound-3, to pain-2, never-1.Motor answer: obeys commands-6, localizes pain-5, normal flexion (withdrawal) -4, abnormal flexion-3, extension-2, none-1.Verbal answer: oriented-5, confused conversation-4, inappropriate words-3, incomprehensible sounds-2, none-1.Based on this scale, the score in client C is 9, while the score in client A is 14, client B is 12, and client D is 11. Lower the score, the lower the client's neurological function. Therefore client C has the least neurological function.

The client who takes furosemide and digoxin reports that everything looks yellow. How will the nurse respond? A. "This is related to your heart problems, not to the medication." B. "It is a medication that is necessary, and that side effect is only temporary." C. "Take this dose, and when I see your healthcare provider I will ask about it." D. "I will hold the medication until I consult with your healthcare provider."

D. "I will hold the medication until I consult with your healthcare provider." The response "I will hold the medication until I consult with your healthcare provider" is a safe practice because yellow vision indicates digitalis toxicity. The response "This is related to your heart problems, not to the medication" is incorrect; yellow vision is not a symptom of heart disease. The response "It is a medication that is necessary, and that side effect is only temporary" is incorrect; yellow vision is not a temporary side effect. The response "Take this dose, and when I see your healthcare provider I will ask about it" is unsafe.

A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic? A. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) B. 80 to 99 mg/dL (4.5 to 5.5 mmol/L) C. 100 to 125 mg/dL (5.6 to 6.9 mmol/L) D. 126 to 140 mg/dL (7.0 to 7.8 mmol/L)

D. 126 to 140 mg/dL (7.0 to 7.8 mmol/L) Results in the range 126 to 140 mg/dL (7.0 to 7.8 mmol/L) indicate diabetes. Results in the range 40 to 60 mg/dL (2.2 to 3.3 mmol/L) indicate hypoglycemia. Results in the range 80 to 99 mg/dL (4.5 to 5.5 mmol/L) are considered expected (normal). Results in the range 100 to 125 mg/dL (5.6 to 6.9 mmol/L) indicate prediabetes according to the American Diabetes Association. (Results in the range of 6.1 to 6.9 mmol/L indicate prediabetes according to the Canadian Diabetes Association Guidelines.)

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? A. Check the client's temperature. B. Take the client's blood pressure. C. Obtain the client's pulse oximetry. D. Assess the client's respiratory status.

D. Assess the client's respiratory status. The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.

A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? A. Routine hygiene B. Liquid formula diet C. Prevention of aspiration D. Effective communication

D. Effective communication Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration.

During the evening after a paracentesis, the nurse identifies that the client, although denying any discomfort, is very anxious. Which action is best for the nurse to take? A. Offer the client a back rub B. Administer the prescribed opioid C. Reinforce the primary healthcare provider's explanation of the procedure D. Explore the client's concerns while administering the prescribed anxiolytic

D. Explore the client's concerns while administering the prescribed anxiolytic Sharing and discussing concerns often release anxieties; giving the prescribed anxiolytic will produce relaxation. Offering the client a back rub might relax the client but will do little to reduce the client's level of anxiety. The client is not in pain at this time but needs to share concerns. The procedure is over; this might be appropriate before the paracentesis.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? A. Increased appetite B. Recent weight loss C. Feelings of warmth D. Fluttering in the chest

D. Fluttering in the chest Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

Which chest examination findings can be observed in a client with pneumonia? A. Absent sounds on auscultation B. Hyperresonance on percussion C. Prolonged expiration on inspection D. Increased fremitus over the affected area on palpation

D. Increased fremitus over the affected area on palpation Palpation in clients with pneumonia reveals increased fremitus over the affected area. Clients with pneumonia may have bronchial sounds initially and crackles, rhonchi, egophony later. Clients with atelectasis, however, may have absent sounds on auscultation. Hyperresonance on percussion may be observed in clients with asthma exacerbation or chronic obstructive pulmonary disease. Percussion in clients with pneumonia, however, may reveal dull sounds over the affected areas. Prolonged expiration on inspection is observed in clients with asthma exacerbations. However, clients with pneumonia may have tachypnea.

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? A. Ensuring sufficient rest B. Changing lifestyle routines C. Breathing clean outdoor air D. Taking medications as prescribed

D. Taking medications as prescribed Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish. Although a balance between activity and rest is desirable, it is not the priority. A change in lifestyle is not necessary. Although clean, fresh air is desirable, it is not the priority.

Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? A. The client is a chain smoker. B. The client works in a cement factory. C. The client has a history of a minor hand fracture. D. The client has a history of travel to central parts of North America.

D. The client has a history of travel to central parts of North America. Travel and geographic area of residence reveal the potential for exposure to certain diseases. Histoplasmosis is a fungal disease caused by inhalation of contaminated dust in the central parts of America and Canada. Smoking will not lead to histoplasmosis. Working in a cement factory is not related to histoplasmosis. A minor hand fracture is not related to histoplasmosis.

A client with quadriplegia is placed on a tilt table daily. The client asks why the angle of the head of the table is gradually increased. How should the nurse respond? A. It facilitates turning. B. This prevents pressure ulcers. C. It promotes hyperextension of the spine. D. This limits loss of calcium from the bones.

D. This limits loss of calcium from the bones. During prolonged inactivity, bone resorption proceeds faster than bone formation, and lack of therapeutic weight bearing on bone results in demineralization. A tilt table provides gradual progressive weight bearing, which counters these effects. Lateral turning is possible and necessary if a client is immobile, but a tilt table does not make this possible. The tilt table is used for scheduled periods in physical therapy. The nursing care required to prevent pressure ulcers must be consistently and frequently performed throughout the day and night. The tilt table does not cause hyperextension of the spine; the spine remains in functional body alignment.