nursing

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations

1.A client with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? 1.Malnutrition 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome

1.Malnutrition The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply 1.Respirations that are shallow 2.Respirations that are increased in rate 3.Respirations that are abnormally slow 4.Respirations that are abnormally deep 5.Respirations that cease for several seconds

2.Respirations that are increased in rate 4.Respirations that are abnormally deep Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

A patient who had a CABG is exhibiting signs of cardiac failure. What medications does the nurse anticipate administering for this patient? Select all that apply: A. Diuretics B. Digoxin C. Inotropic agents D. Dialysis E. Nitroprusside

A. Diuretics B. Digoxin C. Inotropic agents

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

A. Infuse 5% dextrose in water at 125 mL/hr.; Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses ofcontinuous opioids for control. Fluid intake should be increased to reduce blood viscosity andimprove perfusion. Rest is usually ordered to decrease metabolic requirements. Patients areinstructed about the need for dietary folic acid, but high-protein, high-calorie diets are notemphasized.

Which action will the admitting nurse include in the care plan for a patient who hasneutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for adeep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT)when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan ofcare? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to neverreceive heparin or LMWH. Warfarin is usually not given until the platelet count has returnedto 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion,and platelet transfusions increase the risk for thrombosis.

Which intervention will be included in the nursing care plan for a patient with immunethrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A softtoothbrush can be used for oral care. There is no need to restrict activity or place the patient ina private room.

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

Which statement by a patient indicates good understanding of the nurse's teaching aboutprevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilusinfluenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered.Although continuous dose opioids and oxygen may be administered during a crisis, patientsdo not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used todecrease the number of sickle cell crises.

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

ANS: D Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

A postpartum client with femoral thrombophlebitis has developed sudden shortness of breath and appears very anxious. What is the nurse's priority action for this client? Check the client's blood pressure immediately. Elevate the head of the bed to 30 to 45 degrees. Initiate an intravenous line if one is not already in place. Administer oxygen by face mask as per protocol at 8 to 10 L/min.

Administer oxygen by face mask as per protocol at 8 to 10 L/min. This client is at increased risk for pulmonary embolus and is exhibiting symptoms. Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Although the remaining options may be implemented, none of these is the priority nursing action.

Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.4 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity? Serum calcium level Serum potassium level Serum creatinine level Serum magnesium level

An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.8-2.6 mEq/L (0.74-1.07 mmol/L), and the results in the correct option are reflective of hypomagnesemia. Serum magnesium level

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide (Hydrodiuril) daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? A Weight loss of 2 lb B Blood pressure 128/86 C Absence of ankle edema D Output of 600 mL per 8 hours

B Blood pressure 128/86 Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

A patient's laboratory findings show an elevated hemoglobin and RBC count with microcytosis, as well as an elevated WBC count with basophilia. The nurse should provide what interventions? Select all that apply. A. Monitoring liver function tests B. Evaluating fluid intake and output C. Assessing the patient's nutritional status D. initiating active and passive leg exercises E. instructing the patient to avoid high altitudes

B. Evaluating fluid intake and output C. Assessing the patient's nutritional status D. Initiating active and passive leg exercises Rationale: In polycythemia vera, laboratory findings show an elevated hemoglobin and RBC count with microcytosis, as well as an elevated WBC count with basophilia. Fluid intake and output should be evaluated to avoid fluid overload, because this may further complicate circulatory congestion. Nutritional status should be assessed regularly, because inadequate food intake may result in gastrointestinal symptoms such as fullness, pain, and dyspepsia. Active and passive leg exercises should be initiated to prevent thrombus formation. Liver function tests should be monitored regularly in patients who require lifelong supplementation of iron. Patients with sickle cell disease should be advised to avoid high altitudes, because this may lead to hypoxia.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply. Back Axilla Eyelids Soles of the feet Palms of the hands

Back Soles of the feet Palms of the hands Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. Soak the feet in hot water daily. Be careful not to injure the legs or feet. Use a heating pad on the legs to aid vasodilation. Walk each day to increase circulation to the legs. Cut down on the amount of fats consumed in the diet.

Be careful not to injure the legs or feet. Walk each day to increase circulation to the legs. Cut down on the amount of fats consumed in the diet. Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Infection Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Inadequate formed white blood cells

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.

A 67-year-old woman with a history of coronary artery disease and prior myocardial infarction is admitted to the emergency department with a blood pressure of 234/148 mm Hg and started on IV nitroprusside (Nitropress). What should the nurse determine as an appropriate goal for the first hour of treatment? A Mean arterial pressure lower than 70 mm Hg B Mean arterial pressure no more than 120 mm Hg C Mean arterial pressure no lower than 133 mm Hg D Mean arterial pressure between 70 and 110 mm Hg

C Mean arterial pressure no lower than 133 mm Hg Mean arterial pressure no lower than 133 mm Hg The initial treatment goal is to decrease mean arterial pressure by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours. Lowering the blood pressure too much may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. Additional gradual reductions toward a normal blood pressure should be implemented over the next 24 to 48 hours if the patient is clinically stable.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? A BUN of 15 mg/dL B Serum uric acid of 3.8 mg/dL C Serum creatinine of 2.6 mg/dL D Serum potassium of 3.5 mEq/L

C Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits.

A patient with cancer who is receiving methotrexate therapy has developed anemia. The nurse recognizes that which therapies may benefit this patient? Select all that apply. A. Oral iron B. Epoetin alfa C. Oral folic acid D. Blood transfusion E. Parenteral vitamin B12

C. Oral folic acid B. Epoetin alfa Rationale: Epoetin alfa is used to treat anemia related to cancer and its therapies. Methotrexate leads to folic acid deficiency resulting in megaloblastic anemia. Therefore folic acid therapy is given to treat the patient. Oral iron is administered to patients with iron deficiency anemia, which is seen mostly in premenopausal and pregnant women. Blood transfusions are required to keep the approximate hemoglobin level to at least 10 g/dL in the case of thalassemia and severe anemia. Parenteral vitamin B 12 is administered to treat cobalamin deficiency caused by pernicious anemia.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures.The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications.

The postoperative patient has dry skin and reports pruritus on both legs. What nursing actions can help stop the itch-scratch cycle? (Select all that apply.) Moisturize the skin on the legs. Provide a warm blanket and room. Administer antihistamines at bedtime. Vigorously rub the patient's legs after bathing. Cleanse the legs with a saline solution twice daily.

Correct Answer: Moisturize the skin on the legs. Administer antihistamines at bedtime. Rationale: Moisturizing the skin to decrease the dryness and the itch sensation and bedtime antihistamines to decrease a potential allergic reaction and provide some sedation will help the patient sleep since pruritus is often worse at night and the patient needs sleep for healing. Using nonallergic sheets may also help. Anything causing vasodilation, such as warmth or rubbing, should be avoided. Saline solution would only further dry the skin, so it should not be used on the patient's legs.

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply. Strict bedrest Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism

Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism Standard management for the client with DVT includes maintaining the activity level as prescribed by the physician; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Strict bedrest is not likely to be prescribed; recent research is showing that ambulation does not cause pulmonary embolism and does not cause the existing DVT to worsen. Additionally, bedrest can cause complications such as skin integrity problems, weakness due to immobility, and respiratory problems. The level of activity varies from patient to patient and is prescribed at the PCP's discretion.

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. Encourage coughing with deep breathing. Place in high-Fowler's position for eating. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client. Place sequential compression boots on the client. Encourage the intake of dark green, leafy vegetables.

Encourage coughing with deep breathing. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client. The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high-Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

The nurse is planning care for a client who had abdominal surgery. To prevent pulmonary emboli in this client, the nurse should take which action? Have the client perform leg exercises every hour while awake. Massage the client's calves. Have the client wear antiembolism stockings when out of bed. Encourage the client to cough and deep breathe.

Have the patient perform leg exercises every hour while awake. Performing leg exercises, including ankle pumping and ankle rotation, will help prevent stasis of blood in the lower extremities which can lead to blood clot formation. Encouraging the patient to cough and deep breathe is an important postoperative intervention; however, it is directed at preventing pneumonia, not pulmonary emboli. The nurse should NOT massage the calves because a deep vein thrombus could dislodge and travel to the pulmonary vasculature. Antiembolism stockings should be worn continuously during the postoperative period.

Which laboratory result indicates thrombocytopenia? Select all that apply. 1 Hemoglobin value is 9 g/dL. 2 Platelet count is 200,000/µL. 3 Bleeding time is 20 minutes. 4 Hematocrit value is 42%. 5 Levels of megakaryocytes are elevated.

Hemoglobin value is 9 g/dL. Bleeding time is 20 minutes. Levels of megakaryocytes are elevated. The normal hemoglobin value is in the range of 12 to 13 g/dL. Therefore hemoglobin value of 9 g/dL is a result of thrombocytopenia. Thrombocytopenia is deficiency of platelets in the blood. The normal bleeding time is in the range of 3 to 10 minutes. Because platelets are involved in clotting, a deficiency of platelets increases the bleeding time. A bleeding time of 20 minutes is due to deficiency of platelets. When thrombocytopenia is caused by the destruction of platelets, the megakaryocyte count will be normal or increased in bone marrow examination. Thrombocytopenia is associated with a reduced hemoglobin level in the patient. The normal range of platelet count is in the range of 150,000 to 450,000/µL, so a platelet count of 200,000/µL is normal. The normal hematocrit value is in the range of 42% to 54%.

Which assessment findings indicate that a patient may be experiencing thrombotic thrombocytopenic purpura (TTP)? Select all that apply. 1 Increased haptoglobin 2 Increased reticulocytes 3 Decreased hemoglobin 4 Decreased schistocytes 5 Decreased indirect bilirubin

Increased reticulocytes Decreased hemoglobin TTP is characterized by hemolytic anemia, which increases reticulocytes because of bleeding. Hemoglobin is decreased in TTP because of bleeding. The laboratory reports that a patient with TTP will show decreased haptoglobin, increased schistocytes, and increased indirect bilirubin.

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Multiple straight or wavy thread-like lines underneath the skin Brown-red macules with scales Pustules on the trunk of the body White patches noted on the elbows and knees

Multiple straight or wavy thread-like lines underneath the skin Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.

An adult with hypertension is taking propranolol hydrochloride. What should the nurse instruct the client to do? Discontinue the drug if nausea occurs. Monitor blood pressure every week, and adjust the medication dose accordingly. Notify the health care provider of an irregular or slowed pulse rate. Measure partial thromboplastin time weekly to evaluate blood clotting status

Notify the health care provider of an irregular or slowed pulse rate.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. Nuts Corn Liver Apples Lentils Bananas

Nuts Liver Lentils Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. Obtain an intravenous (IV) infusion pump. Monitor urine output during administration. Prepare the medication for bolus administration. Monitor the IV site for signs of infiltration or phlebitis. Ensure that the medication is diluted in the appropriate volume of fluid. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Obtain an intravenous (IV) infusion pump. Monitor urine output during administration. Monitor the IV site for signs of infiltration or phlebitis. Ensure that the medication is diluted in the appropriate volume of fluid. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? Nuts and milk Coffee and tea Cooked rolled oats and fish Oranges and dark green leafy vegetables

Oranges and dark green leafy vegetables Dark green leafy vegetables are a good source of iron, and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Intact skin Full-thickness skin loss Exposed bone, tendon, or muscle Partial-thickness skin loss of the dermis

Partial-thickness skin loss of the dermis In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. Perform vital signs and oxygen saturation on a client returning from the catheterization lab. Assess pedal pulses on a client who just returned from a cardiac angiogram. Obtain intake and output on a client experiencing heart failure. Administer oxygen via nasal cannula to a client with a saturation of 89%. Administer acetaminophen to a client with a pain level of 5 on a scale of 0 to 10.

Perform vital signs and oxygen saturation on a client returning from the catheterization lab. Obtain intake and output on a client experiencing heart failure. Performing vital signs and obtaining intake and output are tasks that can be delegated to UAP. Assessing pedal pulses and administering medications and oxygen are skills that require nursing judgment.

The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply. Sulfa allergy Osteoporosis Hypokalemia Hypouricemia Hyperglycemia Hypercalcemia

Sulfa allergy Osteoporosis Hypokalemia Hypouricemia Hyperglycemia Hypercalcemia Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

When a patient is prescribed iron tablets for the treatment of anemia, which measures ensure maximum absorption? Select all that apply. 1 Taking the tablet with food 2 Taking the tablet after exercise 3 Taking the tablet before exercise 4 Taking the tablet with orange juice5Taking the tablet an hour before meals

Taking the tablet with orange juice Taking the tablet an hour before meals Taking iron tablets an hour before food ensures maximum absorption because iron will not get bound to food. When iron binds with food, absorption of iron falls. Orange juice and ascorbic acid enhance iron absorption. Taking iron tablets with food can reduce iron absorption. Taking iron tablets before or after exercise does not affect absorption.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Presence of striae Palpable radial pulses Absence of any ecchymosis on the extremities Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms

Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

The nurse is preparing information to help a client with neutropenia and limited mobility reduce the risk of infection. Which information will the nurse include in this teaching? Select all that apply. Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider. Avoid working in the garden. Increase the intake of fluids to 3 L per day. Encourage socialization with others.

Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider. Avoid working in the garden. Increase the intake of fluids to 3 L per day. Neutropenia is the result of decreased production of neutrophils or increased destruction of cells. Neutrophils are essential in preventing and limiting bacterial infection. A client with neutropenia is at increased risk for infection from both exogenous and endogenous sources. Actions to reduce the risk of an infection include avoiding working in the garden because of microorganisms in the soil. Fluid intake should be increased to 3 L per day. An incentive spirometer may be used every 4 hours while awake for clients with neutropenia who have limited mobility. Any indications of an infection such as a fever should be reported to the health care provider. The client would be advised to avoid people with infections and avoid crowds and not increase the amount of time out of doors with other people.

After receiving change of shift report on a heart failure unit, which patient should the nurse assess first. a. a patient who is cool and clammy, with new onset confusion and restlessness b. a patient who has crackles bilaterally in the lung bases and is receiving oxygen c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

a. a patient who is cool and clammy, with new onset confusion and restlessnessrationale: The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management.

After receiving change of shift report on a heart failure unit, which patient should the nurse assess first. a. patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. patient who is taking digoxin and has potassium level of 3.1 mEq/L c. patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. patient who is taking captopril (Capoten) and has a frequent nonproductive cough

b. patient who is taking digoxin and has a potassium level of 3.1 mEq/Lrationale: the patients low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias.

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy b. a dry, hacking cough c. a systolic BP <90 mm Hg d. a heart rate <50 beats/min

c. a systolic BP <90 mm Hg rationale: sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that thepatient understands the teaching about the disorder when the patient states a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

c. "I could choose nasal spray rather than injections of vitamin B12." Because pernicious anemia prevents the absorption of vitamin B12, this patient requiresinjections or intranasal administration of cobalamin. Alcohol use does not cause cobalamindeficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foodsrich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of thevitamin.

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective. a. I will be sure to take the medication with food b. I will need to eat more potassium-rich foods in my diet. c. I will call for help when I need to get to use the bathroom d. I will expect to feel more short of breath for the next few days.

c. I will call for help when I need to get up to use the bathroom. rationale: captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5 pound weight gain in the last 3 days. The nurses priority action will be to a. have the patient recall the dietary intake for the last 3 days b. ask the patient about the use of the prescribed medications c. assess the patient for clinical manifestations of acute heart failure d. teach the patient about the importance of restricting dietary sodium

c. assess the patient for clinical manifestations of acute heart failurerationale: the 5 pound weight gain over the 3 days indicates that the patients chronic heart failure may be worsening.

While assessing a 68 yr old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates a. Decreased fluid volume b. jugular vein atherosclerosis c. increased right atrial pressure d. incompetent jugular vein valves

c. increased right atrial pressure rationale: the jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45 degree angle reflects increased right atrial pressure.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hyprochlorothiazide (HydroDIRUIL). Appropriate instructions for the patient include. a. Limit dietary sources of potassium b. take the hydrochlorothiazide before bedtime c. notify the HCP if nausea develops d. skip the digoxin if the pulse is below 60 beats/min

c. notify the HCP if nausea develops. rationale: Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the dose, if necessary

The nurse is assessing an individual with peripheral artery disease. Which finding indicates complete arterial obstruction in the lower left leg? aching pain in the left calf numbness and tingling in the left leg coldness of the left foot and ankle burning pain in the left calf

coldness of the left foot and ankle Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would includeparalysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction. CN: Physiological

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient has two cups of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

d. The patient has a glass of low-fat milk with each meal. For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

Following an acute myocardial infarction, a previously healthy 63 yr old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations b. b-adrenergic blockers c. calcium channel blockers d. angiotensin-converting enzyme (ACE) inhibitors.

d. angiotensin-converting enzyme (ACE) inhibitorsrationale: ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a MI and as a first line therapy for patients with CHF.

When teaching the patient with newly diagnosed heart failure about a 2000 mg sodium diet, the nurse explains that foods to be restricted include. a. canned and frozen fruits b. fresh or frozen vegetables c. eggs and other high protein foods d. milk, yogurt, and other milk products

d. milk, yogurt, and other milk productsrationale: milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily.

An expected action by the nurse caring for a patient who has an acute exacerbation ofpolycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

d. monitor fluid intake and output. Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis.Iron is contraindicated in patients with polycythemia vera

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia istoa. provide a diet high in vitamin K.b. alternate periods of rest and activity.c. teach the patient how to avoid injury.d. place the patient on protective isolation. a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

b. alternate periods of rest and activity. Nursing care for patients with anemia should alternate periods of rest and activity toencourage activity without causing undue fatigue. There is no indication that the patient has ableeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is notneeded. Protective isolation might be used for a patient with aplastic anemia, but it is notindicated for hemolytic anemia.

A young adult who has von Willebrand disease is admitted to the hospital for minor kneesurgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time d. prothrombin time.

b. bleeding time. The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time,and thrombin time are normal in von Willebrand disease.

The nurse is preparing a presentation related to complications of hypertension. Which information should the nurse include?Select all that apply. 1 Stroke as a result of atherosclerosis 2 Heart failure as a result of increased heart contractility 3 Blurring of vision or loss of vision secondary to retinal damage 4 Right ventricular hypertrophy as a result of increased workload 5 Coronary artery disease caused by an increase in the elasticity of arterial walls

1 Stroke as a result of atherosclerosis 3 Blurring of vision or loss of vision secondary to retinal damage Embolic stroke may be a result of cerebral blood flow obstruction by a portion of atherosclerotic plaque or a blood clot formed in the carotid arteries. Hypertension leads to retinal damage that is manifested by blurred vision or loss of vision and retinal hemorrhage. Heart failure is a result of decreased heart contractility along with decreased stroke volume and cardiac output. Hypertension leads to increased cardiac workload that causes left ventricular hypertrophy. Coronary artery disease is caused by decreased elasticity of arterial walls and narrowing of the lumen. Text Reference - pp. 685-687

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1.Nausea 2.Confusion 3.Bradypnea 4.Tachycardia 5.Hyperkalemia 6.Lightheadedness

1.Nausea 2.Confusion 4.Tachycardia 6.Lightheadedness Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

Which statements would the emergency department nurse use to explain the cause of a patient's respiratory alkalosis to the patient and family? 1"This acid-base imbalance is not triggered by central nervous system disorders. "2"Hyperventilation can occur without any physiologic need, such as pain or anxiety. "3"This acid-base imbalance can be caused by hyperventilation as a result of increased body temperatures. "4"Hypoxemia from acute pulmonary disorders, such as pneumonia, is the primary cause of this acid-base imbalance. "5"The primary cause of the acid-base imbalance is hypercarbia from an acute pulmonary disorder, such as a pulmonary embolism."

2,3,4 Respiratory alkalosis is primarily caused by hypoxemia related to pulmonary disorders preventing appropriate gas exchange. Such examples of pulmonary disorders include pulmonary embolism or pneumonia. Hyperventilation decreases the level of CO 2 in the blood; this condition can lead to respiratory alkalosis. Hyperventilation can occur with or without physiologic need from increased body temperatures (fevers), pain, or anxiety. Severe pneumonia leads to acidosis ---KEY word acute pulmonary disorders

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1.Sodium level of 145 mEq/L (145 mmol/L) 2.Potassium level of 3.0 mEq/L (3.0 mmol/L) 3.Magnesium level of 1.8 (0.74 mmol/L) 4.Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

2.Potassium level of 3.0 mEq/L (3.0 mmol/L) Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3.Hyperactive bowel sounds

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine

3.Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment

4.Prolonged QT interval 5.Prolonged ST segment Rationale: A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

A. "Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

The nurse is assessing a post op pt. who had a PTCA. Which possible complication should the nurse monitor for? Select all that apply: A. Abrupt closure of the artery B. Arterial dissection C. Coronary artery vasospasm D. Aortic dissection E. Nerve root pressure

A. Abrupt closure of the artery B. Arterial dissection C. Coronary artery vasospasm

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. Administering oxygen Inserting a Foley catheter Administering furosemide Administering morphine sulfate intravenously Transporting the client to the coronary care unit Placing the client in a low-Fowler's side-lying position

Administering oxygen Inserting a Foley catheter Administering furosemide Administering morphine sulfate intravenously Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful

The nurse is developing a plan of care for a client following pericardiocentesis. Which interventions should the nurse implement? Choose all that apply. Assess vital signs every 15 minutes for the first hour. Monitor heart and lung sounds. Place the client in a supine position. Evaluate the cardiac rhythm. Record fluid output.

Assess vital signs every 15 minutes for the first hour. Monitor heart and lung sounds. Evaluate the cardiac rhythm. Record fluid output. Explanation:The nurse should monitor the vital signs for any client who has undergone surgery. Because this procedure requires entering the pericardial sac, assessing heart and lung sounds assists in determining heart failure. The pericardial fluid is recorded as output and assessing the cardiac rhythm allows to assess for cardiac failure. The client should be kept in the semi-Fowler's position, not flat.

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

B. Check the patient's blood pressure.Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority.Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

20. The nurse determines that treatment of HF has been successful when the patient experiences a. weight loss and diuresis. b. warm skin and less fatigue. c. clear lung sounds and decreased HR. d. absence of chest pain and improved level of consciousness (LOC).

C. Successful treatment of HF is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal HR. Weight loss and diuresis, warm skin, less fatigue, and improved level of consciousness (LOC) may occur without resolution of pulmonary symptoms. Chest pain is not a common finding in HF unless coronary artery perfusion is impaired.

A client has undergone dermabrasion to decrease scarring from severe acne as a teen. After completion of the procedure, the nurse reviews the client's home care instructions. Which instruction is appropriate for this client? Dermabrasion is a painless procedure. Wash the area three times daily until healed. Don't touch the area treated. Apply moisturizer after each washing until the area is healed.

Correct response: Don't touch the area treated. Explanation:The client also must refrain from picking and touching the area because contact with the fingers might cause infection or scarring from secondary trauma.

19. The nurse is collecting data for a patient who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? A) "I feel hot all of the time." B) "I have a difficult time falling asleep at night." C) "I have an increase in my appetite." D) "I have difficulty breathing when walking 30 feet.

D Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigue and able to sleep often with a decrease in appetite, not an increase.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving. a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg

D. Carvedilol (Coreg) 3.125 mgrationale Although carbedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure.

the nurse is caring for a patient admitted to the ICU with heart failure. The patient is prescribed IV sodium nitroprusside. Which actions should the nurse take while administering this medication? SATA Monitor arterial BP ensure slow rate of administration place the patient in high fowlers position monitor the IV site for extravasation record baseline BP throughout administration Monitor for paresthesias

Monitor arterial BP ensure slow rate of administration record baseline BP throughout administration the main adverse effect of this drug is hypotension. This drug does not cause parasthesias. BP assessments must be completed accurately and arterial BP monitoring is recommended. This drug is used almost exclusively in ICU settings and should be administered slowly since a sudden reduction of BP can occur. There is no need to monitor the IV site for extravasation because there is not an increased risk. Patients with trouble breathing are place in high fowlers position.

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. Emotional stress Atrial fibrillation Nutritional anemia Peptic ulcer disease Recent upper respiratory infection

Recent upper respiratory infection Emotional stress Atrial fibrillation Nutritional anemia Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Peptic ulcer disease is not an exacerbating factor.

A patient with initial symptoms of immune thrombocytopenic purpura (ITP) receives corticosteroid therapy. The nurse recalls that the medication will produce which results? Select all that apply 1 Lyse activated B cells 2 Increased CD4 +T cells 3 Reduced capillary leakage 4 Depressed antibody formation 5 Increased platelet production

Reduced capillary leakage Depressed antibody formation Corticosteroids reduce capillary leakage by altering capillary permeability. Corticosteroids also depress antibody formation by decreasing immunoglobulin synthesis and by lympholytic action. Rituximab has the ability to lyse activated B cells. Danazol increases CD4+T cells. Romiplostim increases platelet production.