Nursing semester 2 practice questions test1

Which reaction is an example of a type 1 hypersensitivity reaction? 1:anaphylaxis 2:serum sickness 3:contact dermatitis 4:blood transfusion reaction

1

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1 rationale: Hyponatremia can occur in the client taking diuretics. -The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

A large family that is struggling is instructed by the home nurse about way to increase their dietary intake of calcium. Which suggestion would the nurse make? 1:collard greens or kale in one meal a day 2:fruit flavored yogurt every other day 3:bread made with cornmeal each morning 4:eight ounces of milk every meal

1 rationale: leafy green vegetable are an excellent source of calcium, are inexpensive, and can be home grown.

What findings would a nurse expect to find in a client with peripheral arterial disease? (select all that apply) 1:pallor of feet 2:warm extremities 3:ulcers on the toes 4:thick, hardened skin 5:delayed capillary refill

1,3,5 rationale: peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1,4

When teaching a client with hypertension about a 2 gram sodium diet, which foods would the nurse instruct the client to avoid? (select all that apply) 1:canned chili 2:ground beef 3:fresh salmon 4:luncheon meat 5:cooked broccoli

1,4

upon application, which degree of edema would the nurse document for a 6mm deep indentation? 1:4+ 2:3+ 3:2+ 4:1+

2

while inspecting her healthy newborn just delivered at 37 weeks gestation, the client asked, "whats this sticky white stuff all over the baby?" How would the nurse respond? 1:its a secretion from the baby's fat cells called milia 2:this is vernix. It helps protect the baby while it's in the uterus 3. Your baby was born several weeks early, so we expect to see this 4:its nothing to be concerned about. most newborns are covered with it

2 rationale: A factual response will allay the mother's concern. Vernix is a cheesy, white substance that covers the fetus and confers protection from the amniotic fluid while the fetus is in utero. Most of it disappears by 40 weeks gestation

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

2 rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

Which adverse effect would a RN monitor for when caring for a client with HTN who is prescribed metoprolol? 1:hirsutism 2:bradycardia 3:restlessness 4:angina

2 rationale: betablockers decrease heart rate and blood pressure

Which items would the nurse include in the assessment of the integumentary system for a preoperative client? (select all that apply) 1:inspect the neck for distended veins 2:assess the skin turgor for signs of dehydration 3:examine the skin for rashes or lesions 4:question the client about any skin disorders 5:palpate the chest for heaves or lifts

2,3,4 rationale: -examining the neck for distended neck veins or palpating the chest for heaves or lifts falls under the cardiovascular system

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1:The client taking diuretics and has tenting of the skin 2:The client with an ileostomy from a recent abdominal surgery 3:The client who requires intermittent gastrointestinal suctioning 4:The client with kidney disease and a 12-year his- tory of diabetes mellitus

4 Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

Which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? 1:stage 1 2:stage 2 3:stage 3 4:unstageable

4 rationale: a pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be stage.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

1 Rationale: Afluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phos- phate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1 rationale: Causative factors relate to malnutrition or starvation and the use of aluminum hydroxidebased or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

Which action is the priority after applying pressure to the nose of a client who is being treated for uncontrolled HTN and develops a nosebleed? 1:add humidity to the clients o2 2:teach the client how to avoid nosebleeds 3:assess the clients blood pressure 4:obtain the clients pulse rate

3

A client is admitted with severe diarrhea that resulted in hypokalemia. The RN would monitor for which clinical manifestations of the electrolyte deficiency? (select all that apply) 1:diplopia 2:skin rash 3:leg cramps 4:tachycardia 5:muscle weakness

3,5 rationale: potassium think CONTRACTION of the muscles. With a decrease in potassium, leg cramps occur. Muscle weakness occurs with hypokalemia also because of the alteration in the sodium potassium pump mechanism -bradycardia will occur

decreased skin turgor

caused by dehydration

A primary health-care provider orders a patient's IV fluids to be discontinued. Which is an essential nursing intervention when discontinuing the patient's intravenous infusion? 1. Withdraw the intravenous catheter along the same angle of its insertion. 2. Use an alcohol swab to scrub the insertion site. 3. Flush the line with normal saline. 4. Don sterile gloves.

1 rationale: Removing a n intravenous catheter by withdrawing it along the same path of its insertion minimizes injury to the vein and trauma to the surrounding tissue. This action limits seepage of blood and promotes healing of the puncture wound.

Which data would the nurse use to determine a client score on the Braden scale to predict a client's risk for developing pressure injuries (select all that apply) 1:age 2:anorexia 3:hemiplegia 4:history of diabetes 5:urinary incontinence

2,3,4,5 rationale: -anorexia: causes nutritional problems and a category on the Braden scale -hemiplegia: causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden scale -diabetes: peripheral neuropathy, causing numbness or loss of sensation in the hands in feet, a category on the Braden scale -urinary incontinence: causes moisture, a category on the Braden scale

What is a patch test tested for? 1:herpes 2:scabies 3:onychomycosis 4:allergic dermatitis

4

Aclient receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/ 78 mm Hg. The client's temperature is 100.8 °F (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction

1 rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. -Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. -Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. -Adelayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse is assessing a client with a suspected diag- nosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1 rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitch- ing, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dys- pneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1. Slow the iV infusion. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the health care provider (HCP).

1 rationale: The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence.

A nurse evaluates a patient's fluid balance by monitoring the patient's intake and output. Which must the nurse understand about the ratio of the patient's fluid intake to output? 1. Intake should be slightly more than the output. 2. Intake should be higher than the fl uid output. 3. Intake should be lower than the urine output. 4. Intake should be equal to the urine output.

1 rationale: The volume and composition of body fluids are kept in a delicate balance (total intake is slightly more than total output) by a harmonious interaction ofthe kidneys and the endocrine, respiratory, cardiovascular, integumentary, and gastrointestinal systems.

Which action is likely to help prevent pressure injuries for a client who has paraplegia? 1: inspecting the skin every day 2: Provide a rubber seat cushion 3:massaging body lotion over reddened areas 4: applying a heating pad to bony prominences

1 rationale: because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas or lesions is necessary so that treatment can be initiated quickly

The RN teaches a student nurse regarding the management of increased potassium levels in a client. Which action preformed by the student nurse indicates effective learning? 1:administering sodium polystyrene sulfonate 2:instructing a client to increase potassium and sodium intake 3:monitoring glucose levels hourly 4:providing potassium sparing diuretics

1 rationale: increased potassium levels indicate hyperkalemia and are observed in clients with adrenal insufficiency. Administering potassium binding and excreting resin, such as sodium polystyrene sulfonate, can reduce the potassium levels.

Which ion is the regulator of extracellular osmolarity? 1:sodium 2:potassium 3:chloride 4:calcium

1 rationale: sodium is extracellular fluids cation and regulates serum osmolarity, as well as nerve impulse transmission and acid base balance. -potassium: major intracellular osmolarity regulator

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which lab results? 1:sodium and chloride levels 2:bicarbonate and sulfate levels 3:magnesium and protein levels 4:calcium and phosphate levels

1 rationale: sodium, which helps regulate the ECF, is lost with vomiting. Chloride, which balances cations in the ECF compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia.

An emaciated older adult with dementia develops a large pressure injury after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which factor is considered when determining the source of blame for the pressure injury? 1:the client should have been turned regularly 2:older clients frequently develop pressure injuries 3:the nurse is not responsible to the clients family 4:nurses should respect a clients right not to be moved

1 rationale: the client was cognitively impaired. If a capable client refuses, the nurse would educate them and if they still refuse, we would have to respect that

Which action would the nurse take initially after discovering a client has a stage 1 pressure ulcer upon admission? 1:turn and reposition the client every 2 hours 2:cover the ulcer with an occlusive, transparent dressing 3:clean the ulcer with hydrogen peroxide and leave it open to the air 4:provide the client with a diet high in vitamin C, zinc, and protein

1 rationale: turning and repositioning immobile clients at least every 2 hours is the best initial nursing action to prevent further skin breakdown -providing the client with a diet high in vitamin C zinc, and protein will help prevent further breakdown but is not the priority action -Coving the ulcer and cleaning with hydrogen peroxide is NOT recommended for this situation

Which statement made by the nursing student about interventions that reduce the risk of pressure ulcers in a client indicates effective learning? (select all that apply) 1:I will elevate the head f the clients bed to no more than 30 degrees 2:i will ensure that the client is turned and repositioned at least every 2 hours 3:i will advise the client to apply talc directly to the perineum 4:i will ensure that the clients fluid intake is 2000-3000 mL/day 5:i will teach the client to refrain from eating a high protein and calorie diet

1,2,4 rationale: -the clients bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk -turning frequently improves circulation, and redistributes body weight over bony prominences -2000-3000 fluid intake nourish the skin

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1:Obtain an intravenous (IV) infusion pump. 2: Monitor urine output during administration. 3:Prepare the medication for bolus administration. 4:Monitor the IV site for signs of infiltration or phlebitis. 5:Ensure that the medication is diluted in the appropriate volume of fluid. 6:Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

1,2,4,5,6 rationale: Potassium chloride administered intravenously must always be diluted in IVfluid 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 IVbag 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 health care provider if the uri- nary output is less than 30 mL/hour.

The RN delegates the tasks of caring for a client with pressure injuries. The client suffers further tissue necrosis during treatment. Which factor could result in further tissue damage? 1: cleaning of the wound by the RN 2: irrigation of the wound by the UAP 3: administering of oral analgesics by the licensed practical nurse (LPN) 4:repositioning the client every 1 to 2 hours by the LPN

2

which method is an efficient way to correct decreased serum chloride levels found in a client with an acute episode of ulcerative colitis? 1:low residue diet 2:IV therapy 3:oral electrolyte solution 4:total parenteral nutrition

2 rationale: IV ensures a rapid, well controlled technique for electrolyte replacement. -There is not assurance that adequate chloride will be ingested and absorbed

which process would the nurse consider when formulating a response to a client with acute kidney injury who states "why am I experiencing twitching and tingling of my fingers and toes?" 1:acidosis 2:calcium depletion 3:potassium retention 4:sodium chloride depletion

2 rationale: in kidney failure, as the glomerular filtration rate decreases, phosphorus is retained As hyperphosphatemia occurs, calcium is excreted. Calcium depletion causes tetany, which causes twitching and tingling of the extremities, among other symptoms.

Which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a NG tube attached to continuous low suction? (select all that apply) 1:irritability 2:dysrhythmias 3:muscle weakness 4:abdominal cramps 5:acidosis

2,3 rationale: dysrhythmias are a sign of potassium depletion in cardiac muscles. Other cardiovascular effects include irregular, rapid, and weak pulse; decreased blood pressure; flattened and inverted Twaves -signs of hyperkalemia: acidosis, abdominal cramps, irritability

arrange the order of pathophysiology involved with the development of pressure injuries on the sacrum, hips, and ankles of a client with quadriplegia 1:local cell death 2:local tissue compression 3:restriction of blood flow 4:development of pressure injuries 5:reduced tissue perfusion

2,3,5,1,4

Which predisposing condition may be present in a client with pitting edema? 1:shock 2:kidney disease 3:hypothyroidism 4:severe dehydration

2:kidney disease rationale: kidney disease may be a predisposing condition associated with pitting edema -shock: decreased temp -hypothyroidism: non-pitting edema -severe dehydration: decreased elasticity of the dermis

Which reason describes the purpose of restricting sodium for a client with hypertension? 1:to chemically stimulate the loop of Henle 2:to diminish the thirst response of the client 3:to prevent reabsorption of water in the distal tubules 4:to cause fluid to move toward the interstitial compartment

3 rationale: sodium absorbs water in the kidneys renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced -furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules

Which statement shows ineffective learning after the nurse teaches self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer? 1:I will use tepid rather than hot water 2:i will clean my skin as soon as soiling occurs 3:i will apply powders and talc on the perineum 4:i will pat my skin gently rather than rubbing it dry

3:i will apply powders and talc on the perineum rationale: The client with a pressure ulcer should not apply powders and talc directly on the perineum

Which action would the nurse take after obtaining client blood pressures of 172/104 mmhg and 164/98mmhg during a blood pressure screening? 1:provide health teaching about a low sodium diet 2:call the paramedics for transport to the hospital 3:suggest ways to decrease the clients stress level 4:refer the client to a primary HCP

4

Which finding indicates that a newborn has vernix caseosa? 1:brown hair on the skin 2:rosy to yellowish skin 3:light to pink to reddish brown skin 4:cheese like substance on the skin

4

Which info will the nurse teach a client with venous insufficiency about prevention of venous thrombosis? 1: wear snug fitting pants 2:sit with the knees flexed 3:apply warm soaks to the legs daily 4:put on compression stockings before arising

4

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4 The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkale- mia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which IV fluid is a hypertonic solution? 1:ringer solution 2:5% dextrose in water 3:lactaced ringer solution 4:5% dextrose in normal saline

4 rationale: A hypertonic solution has a higher osmolarity than body fluids; it pulls fluid from cells, causing them to shrink and the ECF to expand. -ringer and lactated ringer are isotonic solution -5% dextrose in water is slightly hypotonic

A client with hypertension has been told to main- tain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2. Boiled shrimp 3. Instant oatmeal 4. Summer squash

4 rationale: Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium.

Which response would a nurse give to the daughter of an 80 year old client admitted to the hospital with severe dehydration who ask how her mother could have become dehydrated? 1:the body's fluid needs decrease with age because of tissue changes 2:access to fluid may be insufficient to meet the daily needs of the older adults 3:memory declines with age, and the older adult may forget to ingest adequate amounts of fluid 4:the thirst reflex diminishes with age, and the recognition of the need for fluid is decreased

4 rationale: For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake.

A patient receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea? 1. Icteric 2. Isotonic 3. Hypotonic 4. Hypertonic

4 rationale: Hypertonic solutions have a greater concentration of solutes than does the blood. The high osmolarity of a hypertonic enteral feeding exerts an osmotic force that pulls fluid into the gastrointestinal tract , resulting in intestinal cramping and diarrhea.

Which finding will be most important to communication to the HCP when the clinic nurse is assessing a client with thromboangiitis obliterans 1:age 41 2:burning leg pains 3:taking daily nifedipine 4:continued tobacco use

4 rationale: this condition is highly associated with smoking and needs to be told to stop

Which clinical manifestation would the nurse observe in a client experiencing anaphylactic shock from a type 1 latex allergic reaction? (select all that apply) 1:stridor 2:fissuring 3:hypotension 4:dyspnea 5:cracking of the skin

1,3,4 rationale: anaphylactic shock produces stridor, hypotension, and dyspnea -fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis

A client with end stage renal disease receiving hemodialysis has a prescribed diet restricting proteins, sodium, and potassium. Which client statement indicates understanding of provided dietary instructions? 1:I should avoid using salt substitutes 2:i should exclude meat from my diet 3:i may not add seasoning to my food 4:i may eat low sodium canned vegetables

1 rationale: commercially prepared salt substitutes are high in potassium. Some complete protein foods must be included in the protein restricted diet.

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 Rationale: Afluid 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 has just received a prescription to trans- fuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? 1. Check a set of vital signs. 2. Order the blood from the blood bank. 3. Obtain Y-site blood administration tubing. 4. Check to be sure that consent for the transfusion has been signed.

1 rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? 1. "Have you ever had a transfusion before? "2. "Why do you think that you need the transfusion? "3. "Have you ever gone into shock for any reason in the past?" 4. "Do you know the complications and risks of a transfusion?"

1 rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous his- toryofshockandknowledgeofcomplicationsandrisksoftrans- fusion is not helpful because it may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

Aclient involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be pre- scribed for this client? 1. 5% dextrose in lactated Ringer's solution 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.45% sodium chloride (1/2 normal saline) 4. 0.225% sodium chloride (1/4 normal saline)

1 rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as possible. In this situation, the cli- ent will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. There- fore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in lactated Ringer's (hypertonic) solution would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure.

Once a nurse teaches a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? 1:i will avoid crossing my legs 2:pillows placed under my knees will help avoid clots 3:staying on bed rest as long as possible is best for me 4:three times everyday I will massage my lower legs to get blood moving

1 rationale: avoiding crossing your legs helps prevent the constriction of blood flow in the lower legs

Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure? 1:weighing the client 2:monitoring input and output 3:assessing the extent of pitting edema 4:asking the client about subjective symptoms

1 rationale: because 1 liter of fluid weighs 2.2 pounds, daily weights are the best way to monitor fluid volume status.

Which action will the urgent care clinic nurse anticipate taking for a 24 year old client who is dehydrated after a long run and has a pulse rate of 103 and blood pressure 102/56 mm hg? 1:offer oral fluids at frequent intervals 2:give fluid boluses through a NG tube 3:administer IV antiemetic medications 4:insert a peripheral IV line for fluid infusion

1 rationale: replacement of fluids in dehydrated clients is best done through the oral route, when possible. In this healthy young adult whose VS indicate mild hypovolemia, the nurse would offer oral fluids to correct hypovolemia

Which feature is associated with the maturation phase of normal wound healing? 1:the scar is firm and inelastic on palpation 2: fibrin strands from a scaffold or framework 3:WBC migrates into the wound 4:epithelial cells are grown over the granulation tissue bed

1 rationale: the maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. -proliferative phase: fibrin strands form a scaffold or framework, and epithelial cells are grown over the granulation tissue bed -inflammatory phase: WBCs migrate into the wound

A client is diagnosed with parathyroid dysfunction. Which serum calcium concentration supports the diagnosis? 1:7.8 mg/dl 2:8.9 mg/dl 3:9.7 mg/dl 4:10.2 mg/dl

1 rationale: the normal serum calcium concentration ranges from 8.6 to 10.2 mg/dl. A serum calcium concentration below 8.6 indicates hypocalcemia, and a serum calcium concentration above 10.2 indicates hypercalcemia. -parathyroid hormone maintains calcium balance in the body.

Which key feature is associated with a stage 2 pressure ulcer? 1: presence of nonintact skin 2: development of sinus tracts 3:damage to the subcutaneous tissues 4: the appearance of a reddened area over a bony prominence

1 rationale: the skin is nonintact in stage 2 of pressure ulcers. -stage 4: Sinus tracts may develop -stage 3: the subcutaneous tissue becomes damaged or necrotic -stage 1: a reddened area over a bony surface

A client is hospitalized with pressure injuries. Which tasks can be delegated to a UAP? (select all that apply) 1:empty wound drainage containers 2:report changes in wound appearance 3:apply prescribed dressings and medications 4:assess and record data about wound appearance 5:choose dressings and therapies for wound treatment

1,2

Which finding in a client helps support a diagnosis of an arterial ulcer? (select all that apply) 1: lack of hair 2:thickened toenails 3:copious ulcer drainage 4:diminished pedal pulse 5:brown skin discoloration

1,2,4

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1. Peas 2. Nuts 3. Cheese' 4. Cauliflower 5. Processed oat cereals

1,2,4 rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? (select all that apply) 1:decreased urine 2:hypotension 3:dyspnea 4:dry mucous membranes 5:lung crackles 6:poor skin turgor

1,2,4,6 rationale: -signs of dehydration: decreased urine, hypotension, dry mucous, and poor skin turgor -signs of fluid overload: crackles in the lungs and dyspnea

Which action would be included in an organization's policy for hand hygiene? (select all that apply) 1:wash hands before applying sterile gloves 2:wash hands before touching any of the client's personal items 3:wash with either soap and water or alcohol-based hand rub before client contact 4:wash with soap and water when hands are visibly soiled 5:wash with ABHR if hands are not visibly soiled 6: wash hands, between fingers, and under nails for 60 seconds

1,3,4,5 -wash hands for a minimum of 20 seconds -the hands should be washed after contact with inanimate objects

Which statement made by the client about sleeping positions to follow to prevent ulcers indicates effective learning? (select all that apply) 1:i should use pressure-relieving pads 2: I should place a rubber ring under the sacral area 3:I should place pillows between two bony surfaces 4:I should keep the HOB elevated above 30 degrees 5:I should keep my heels off the bed surface using a bed pillow under the ankles

1,3,5

Which factor contributes to a client's slow rate of healing? (select all that apply) 1:diabetes 2:cataract 3:smoking 4:dermatitis 5:alcohol abuse

1,3,5 rationale: -diabetes: causes the narrowing of blood vessels, causing diminished blood supply to the affected organ or tissues -alcohol abuse: reduces the amount of nutrients and vitamins required for muscle growth which affects the musculoskeletal system -smoking: reduces the blood supply to the affected area which slows down the healing process

Which statement describes negative pressure wound therapy? (select all that apply) 1:A suction pump is used 2:necrotizing infections are treated 3:o2 is administered under high pressure 4:a low voltage current is applied to a wound area 5: chronic ulcers are reduced by removing fluids from the wound

1,5 rationale: in negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound.

Which nursing assessment would be performed by a nurse before administering IV infusion of potassium chloride 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? (select all that apply) 1:urinary output 2:deep tendon reflexes 3:last bowel movement 4:arterial blood gas results 5:last serum potassium level 6:patency of the IV access

1,5,6 rationale: before administering iv potassium, the urinary output must be normal. If the urine is

Which physiological activity is associated with the proliferative phase of normal wound healing? 1:WBC migrate into the wound 2:epithelial cells grow over the granulation tissue 3:scar tissue gradually becomes thinner and pale 4:vasodilation occurs with increased capillary permeability

2 rationale: during the proliferative phase, the epithelial cells grow over the granulation tissue bed. -inflammatory: wbcs migrate into wound, vasodilation, increased capillary permeability -maturation: scar tissues become thinner and pale

Which IV solution would a nurse anticipate administering when caring for a client with a history of severe diarrhea for the past 3 days who is admitted for dehydration? 1:3% sodium chloride 2:0.9% sodium chloride 3:5% dextrose and 0.9% sodium chloride 5:5% dextrose and lactated Ringer solution

2 rationale: An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client because it is an isotonic solution that will act as a volume expander to quickly replace volume losses an promote physiological stabilization.

Which action would the nurse take when a client with chronic venous insufficiency has ankle edema? 1:restrict fluids 2:elevate the legs 3:apply a Unna boot 4:discuss sclerotherapy

2 rationale: elevation of extremities promotes venous and lymphatic drainage by gravity. -unna boots are used to treat venous stasis ulcers

When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse plans to monitor the patient routinely because an increase in these hormones will cause a decrease in which of the following? 1. Blood pressure 2. Urinary output 3. Body temperature 4. Sweat gland secretions

2 rationale: Both hormones are involved with water reabsorption, which conserves fluid and results in a decreased urinary output. With decreased kidney perfusion, the juxtaglomerular cells of the kidneys release angiotensin II, which stimulates the release of aldosterone from the adrenal cortex. Aldosterone promotes the excretion of potassium and reabsorption of sodium, which results in the passive reabsorption of water. As the concentration of the blood (osmolality) increases, the anterior pituitary releases antidiuretic hormone (ADH). ADH causes the collecting ducts in the kidneys to become more permeable to water, thus promoting its reabsorption into the blood.

Hydrochlorothiazide (HCTZ) , a diuretic, is prescribed for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients that contain which electrolyte? 1. Magnesium 2. Potassium 3. Calcium 4. Sodium

2 rationale: Most diuretics affect the renal mechanisms for tubular secretion and reabsorption of electrolytes, particularly potassium. Because of potassium's narrow therapeutic window of 3.5 to 5.0 mEq/L and its role in the sodium-potassium pump and muscle contraction, depleted potassium must be supplemented by increasing the dietary intake of foods high in potassium and/or the administration of potassium drug therapy.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated. 2. Place the client in high-Fowler's position. 3. Increase the rate of infusion of intravenous fluids. 4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

2 rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IVfluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (559 μmol/L)

2 rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia.

A nurse identifies that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion? 1. Dry and scaly 2. Taut and shiny 3. Red and irritated 4. Thin and inelastic

2 rationale: With excessive fluid volume, the increased hydrostatic pressure moves fluid from the intravascular compartment into the interstitial compartment. As fluid collects in the interstitial compartment (edema), the skin appears taut and shiny.

Which cation regulates intracellular osmolarity? 1:sodium 2:potassium 3:calcium 4:calcitonin

2 rationale: a decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. -sodium is the most abundant extracellular cation that regulates serum osmolarity as well as nerve impulse transmission and acid base balance

Which statement by the student nurse about the use of a suction pump in negative pressure wound therapy indicates the need for further teaching? 1:the wound site should be monitored at least every 2 hours 2:this treatment is used mostly for areas of skin cancer 3:the foam dressing should be changed every 48 -72 hours 4:a continuous low negative pressure should be maintained

2 rationale: a suction pump is used in negative pressure wound therapy to reduce chronic ulcers by removing the fluids from the wounds and to enhance granulation -pump should not be used in areas of skin cancer because it may cause serious bleeding and may lead to death

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of which? 1:binder 2:ice bag 3:elastic bandage 4:warm compress

2 rationale: application of ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. -bind or elastic bandage on the area of a soft tissue injury may cause compartment syndrome (constriction resulting in decreased circulation and nerve function) -warm compress would result in vasodilation and care increase hemorrhage, edema, and pain

Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? 1:coagulability of the blood 2:velocity of the venous return 3:effectiveness of internal respiration 4:o2 carrying capacity of the blood

2 rationale: because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity.

which adverse effect would a nurse monitor for in a client taking clopidogrel? 1: nausea 2:epistaxis 3:chest pain 4:elevated temp

2 rationale: clopidogrel is a platelet aggregation inhibitor; therefore bleeding can occur as an adverse effect

Which parent education would the nurse provide the parents of a 9-month-old about the cause of diaper dermatitis? 1:use of disposable diapers 2:prolonged contact with an irritant 3:decreased pH of the infant's urine 4: too early introduction of solid foods

2 rationale: diaper dermatitis is caused by prolonged repetitive contact with an irritant. If not changed frequently, both cloth and disposable diapers can cause this

Which intervention would be included in the plan of care for the prevention of a pressure injury? 1:positioning a client directly on the trochanter 2:keeping the client's skin directly off plastic surfaces 3:keeping the head of the bed elevated above 30 degrees 4:placing a rubber ring or donut under the clients sacral area

2 rationale: for the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces -Direct positioning on the trochanter should be avoided. -The HOB should not be kept elevated above 30 degrees; this prevents shearing -A rubber ring or donut under the sacral area should be avoided

Which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia? 1:avoid massaging the client's legs 2:frequently reposition the client on a scheduled basis 3:increase the fiber content in the client's food 4:encourage the client to participate in weight-bearing exercises

2 rationale: frequent repositioning of the client in bed or wheelchair on a scheduled basis will relieve pressure points -avoiding leg massages will decrease the risk of embolism, but DOESN'T prevent pressure ulcers -increased intake of fiber will relieve the immobilized client of constipation -weight-bearing exercises will prevent the client from developing muscular atrophy or loss of calcium from the bone

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse deter- mines that the client needs further instructions if the client made which statement? 1. "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to keep the insertion site protected when in the shower or bath." 4. "I need to check the markings on the catheter each time the dressing is changed."

2 rationale: he client should be taught that only minor activity restrictions apply with this type of catheter. The client should carry or wear a MedicAlert identification and should protect the site during bathing to prevent infection. The client should check the markings on the catheter during each dressing change to assess for catheter migration or dislodgement.

Which age related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1:atrophy of the sweat glands 2:decreased subcutaneous fat 3:stiffening of the collagen fibers 4:degeneration of the elastic fibers

2 rationale: in older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. -atrophy of sweat glands: causes dry skin and decreased body odor -stiff collagen fibers and degeneration of elastic fibers: result in wrinkles

Which medication is unsafe to administer as an IV bolus? 1:saline flush 2:potassium chloride 3:naloxone 4:adenosine

2 rationale: potassium chloride given as an IV bolus can cause cardiac arrest. It must be diluted and infused slowly through and IV infusion pump.

When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease? 1:pulse rate 2:tissue turgor 3:specific gravity 4:body temperature

2 rationale: skin elasticity will decrease because of a decrease in interstitial fluid

A client has been admitted with a diagnosis of intractable vomiting and can tolerate only sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. The client is likely experiencing which condition? 1:hypernatremia 2:hyponathremia 3:hyperkalemia 4:hypokalemia

2 rationale: sodiums normal range is 135-145 -vomiting and use of diuretics, such as furosemide (lasix), deplete the body of sodium. -without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma

Which prescribed action will the nurse take first when a client is admitted to the ER with reports of frequent loose, watery stools and anorexia during the past week with a blood pressure of 90/68 mm Hg and pulse of 124? 1:obtain blood and urine cultures 2:start infusion of normal saline 3:insert retention catheter 4:transfer the client to the ICU

2 rationale: the clients history of watery stools and anorexia suggest hypovolemia as the cause of the hypotension and tachycardia; fluids should be rapidly infused to correct hypovolemia.

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low sodium diet? 1:body weight control 2:decreased fluid retention 3:lowering of BP 4:prevention of hypernatremia

2 rationale: the purpose of a low sodium diet for client with heart failure is to decrease fluid retention. Although sodium restriction may lower blood pressure in clients with hypertension, because of Frank-Starling law, lower sodium intake may lead to improved cardiac output and higher blood pressures in clients with heart failure.

Which mechanism of action would a nurse recall when using wet-to-damp saline-moistened gauze for wound debridement? 1:promoting the dilution of viscous exudate 2:removing the necrotic tissue mechanically 3:causing a breakdown of the denatured protein of the eschar 4:promoting the spontaneous separation of necrotic tissue

2 rationale: wet to damp moistened gauze mechanically removes the necrotic tissue

Which nursing intervention require the nurse to wear gloves? (select all that apply) 1:giving a back rub 2:cleaning a newborn immediately after delivery 3:emptying a portable wound drainage system 4:interviewing a client in the emergency department 5:obtaining the BP of a client who is positive for HIV

2,3 rationale: PPE should be used because is newborn is covered with amniotic fluid and maternal blood PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

2,3,4 rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IVfluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IVsolution will stop, and if an elec- tronic pump is being used, it will alarm.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2,3,4,6 rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mush- rooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

wound healing with intention

2nd: granulation tissue fills in the wound primary: incision fills with blood and forms a clot -tertiary: granulation tissue following contamination occurs

A nurse is monitoring a patient who is receiving intravenous fluid. Which clinical findings indicate that the patient has a fluid overload? 1. Chills, fever, and generalized discomfort 2. Blood in the tubing close to the insertion site 3. Dyspnea, headache, and increased blood pressure 4. Pallor, swelling, and discomfort at the insertion site

3

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1:Weight loss and dry skin 2:Flat neck and hand veins and decreased urinary output 3:An increase in blood pressure and increased respirations 4:Weakness and decreased central venous pressure (CVP)

3 rationale: Afluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4:packed RBC

3 rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. -Platelets are used to treat thrombocytopenia and platelet dysfunction. -Packed red blood cells are a blood product used to replace erythrocytes.

A nurse is caring for a patient who has dependent edema. Which pressure has caused the excess fl uid in the interstitial compartment? 1. Oncotic pressure 2. Diffusion pressure 3. Hydrostatic pressure 4. Intraventricular pressure

3 rationale: Hydrostatic pressure is the pressure exerted by a fl uid within a compartment, such as blood within the vessels. Hydrostatic pressure moves fl uid from an area of greater pressure to an area of lesser pressure. Hydrostatic pressure within vessels of the body moves fl uid from the intravascular compartment into the interstitial compartment. Interstitial fluid is extracellular fluid that surrounds cells.

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 rationale: 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.

In which category of fluids would the nurse classify an IV solution of 0.45% sodium chloride? 1:isotonic 2:isomeric 3:hypotonic 4:hypertonic

3 rationale: Hypotonic solutions are less concentrated (contains less than 0.85 g of sodium chloride in each 100 mL) than body fluids. -Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid -hypertonic solutions: contain more than 0.85 g of solute in each 100mL. -isometric: relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1. Apples 2. Bananas 3. Smoked sausage 4. Steamed vegetables

3 rationale: Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and veg- etables, which are low in sodium.

A patient exhibits an increasing blood pressure and 2-lb weight gain over 2 days. Which additional clinical manifestation can be clustered with these data? 1. Decrease in heart rate 2. Increase in skin turgor 3. Increase in pulse volume 4. Decrease in pulse pressure

3 rationale: With an excess fluid volume the amount of circulating blood volume increases, resulting in full, bounding peripheral pulses. -FVE: heart rate increases, pulse pressure increases

A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. Which electrolyte imbalance does this data support? 1. Hyperkalemia 2. Hypercalcemia 3. Hypernatremia 4. Hypermagnesemia

3 rationale: With profuse diaphoresis, the water loss exceeds the sodium loss, resulting in hypernatremia. Excess serum sodium precipitates changes in the musculoskeletal (weakness), neurological (disorientation and decreased level of consciousness), and integumentary (dry, sticky mucous membranes) systems.

Which condition would the nurse suspect when a client, who underwent a physical examination two days ago, reports itching? 1:eczema 2:hypersensitivity 3:contact dermatitis 4:anaphylactic shock

3 rationale: a client who is allergic to latex may experience an allergy after a physical exam with latex gloves and itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12-48 hours after exposure -eczema: skin condition that can be worsened with excessive drying -hypersensitivity: an immediate allergic reaction that occurs due to chemicals that are used to make gloves -anaphylactic shock: an immediate allergic reaction that occurs due to natural rubber latex

Which symptom would the nurse monitor for when caring for a client who has hyponatremia? 1:increased urine output 2:deep rapid RR 3:change in level of consciousness 4:distended neck veins

3 rationale: a normal sodium level is between 135-145 of sodium. As sodium levels drop below 140, symptoms reflect cellular overhydration, which results from water movement from the relatively hypotonic serum into cells. Symptoms primarily the CNS and musculoskeletal systems -CNS effects range from headache, fatigue, anorexia, to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma.

Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? 1:rapid, thready pulse 2:distended jugular veins 3:elevated hematocrit level 4:increased serum sodium level

3 rationale: because of fluid overload in the intravascular space, the neck veins become visibly distended. -rapid, thready pulse and elevated hematocrit level occur with a fluid deficit

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for which process? 1:bile production 2:blood production 3:blood clotting 4:digestion of fats

3 rationale: calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Its responsible for bones, health, blood clotting, nerve impulses, and muscle contraction

The nurse is caring for a client who had an above-the-knee amputation 1 week ago. Which action would the nurse take to control the edema of the residual limb? 1: administer a diuretic as needed 2:restrict the client's oral fluid intake 3:rewrap the elastic bandage as necessary 4:keep the residual lim elevated on a pillow

3 rationale: elastic bandages compress the residual limb, preventing edema and promoting residual limb shrinkage and molding; the bandage must be rewrapped when it loosens -prolonged elevation of the residual extremity can lead to a flexion contracture of the hip

which condition is a possible cause of pitting edema on the dorsum of the foot? 1:endocrine imbalance 2:excessive collagen production 3:fluid and electrolyte imbalance 4:autonomic nervous system stimulation

3 rationale: fluid and electrolyte imbalance results in pitting edema of the skin -endocrine imbalance: nonpitting edema

Which event occurs in the proliferative phase of wound healing? 1: thinning of scar tissue 2:strengthening of collagen 3:formation of granulation tissue 4:increase in capillary permeability

3 rationale: granulation tissue is formed in the proliferative tissue. -maturation phase: thinning of scar and strengthening of collagen fibers -Inflammatory phase: increase in capillary permeability

Which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? 1:greenish blue pus 2:creamy yellow exudate 3:blood-tinged amber fluid 4:beige pus with a fishy odor

3 rationale: greenish blue pus, creamy yellow exudate, and beige pus with a fishy odor are characteristics of purulent wound exudate

When performing a clients skin assessment, the nurse identified a thickening of the skin with accentuated normal skin markings over the axillary regions. Which etiology would the nurse associate this clients skin? 1:dehydration 2:parasitic infection 3:pruritus causing irritation 4:interruption of venous return

3 rationale: lichenification is a thickening of the skin with accentuated normal skin markings. This condition appears from repeated scratching, rubbing, and irritation, usually a result of pruritus or neurosis

Which disease increases the risk of hyperkalemia? 1:Crohn disease 2:cushing disease 3:end stage renal disease 4:gastroesophageal reflux disease

3 rationale: one of the kidneys functions is to eliminate potassium from the body -diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis -crohn disease: diarrhea results in potassium loss -cushing disease: retain sodium and excrete potassium

An older client is admitted to the hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? 1:calcium 2:chlorides 3:potassium 4:phosphates

3 rationale: potassium, sodium, and bicarbonate are the electrolytes most often lost with diarrhea. With diarrhea, these electrolytes are excreted via the GI tract before they can be absorbed. -hypokalemia can cause cardiac dysrhythmias

Which education would the nurse provide the parent of a preschool child with atopic dermatitis? 1:scratching causes lesions to become more contagious 2:scratching spreads dermatitis to other areas of the body 3:scratching results in skin breaks that can lead to infection 4:scratching produces changes that are precursors to skin cancer

3 rationale: scratching can compromise the integrity of the skin, leaving it vulnerable to infection -dermatitis is a response to an allergen; it is not contagious

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? 1:answer the clients call light immediately to prevent incontinence 2:place a waterproof pad under them to prevent soiling linens 3:check the clients buttocks at least every 2 hours and clean after incontinence 4:offer toileting to the client every 2 hours to prevent incontinence

3 rationale: since the client is confused this is the best option

An RN is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? 1:edema results in the separation of skin from pigmented and vascular tissue 2: pitting edema leaves an indentation on the site of application of pressure 3:trauma or impaired venous return should be suspected in clients with edema 4:if the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given

4 rationale: It would be a depth of 4mm instead of 2mm

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums

4 rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes.

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 1. The catheter advances easily. 2. The vein is distended under the needle. 3. The client does not complain of discomfort. 4. Blood return shows in the backflash chamber of the catheter.

4 rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated, and if further distention occurs after venipuncture, this could mean the needle went through the vein and into the tissue; therefore, the catheter should not be advanced. Client discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return.

A client is receiving a continuous intravenous infu- sion of heparin sodium to treat deep vein thrombo- sis. The client's activated partial thromboplastin time (aPTT) is 65 seconds (65 seconds). The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4 rationale: The normal aPTTvaries between 28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42 to 52.5) and 2.5 (70 to 87.5) times normal. This means that the client's value should not be less than 42 seconds or greater than 87.5seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged. Test-Taking Strategy: Focus on the subject, the expected aPTT for a client receiving a heparin sodium infusion. Remember that the normal range is 28 to 35 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 28 and 35 will yield a range of 42 to 87.5 seconds). This client's value is 65 seconds

With which complication of the administration of intravenous fluids should the nurse slow the rate of fl ow of the infusion rather than stop the infusion and remove the catheter? 1. Infiltration 2. Extravasation 3. Inflamed vein 4. Fluid overload

4 rationale: When intravenous fluids are infused too rapidly or an excess amount of fluid is infused, the patient can experience an overload of fluid in the intravascular compartment. The nurse should slow the rate of infusion to keep the venous access viable and notify the primary health-care provider for directions.

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? 1:urticaria 2:a medication reaction 3:atopic dermatitis 4:contact dermatitis

4 rationale: allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2-7 days after contact with allergens

Which nursing action has the highest priority when a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 pounds? 1:check for lower leg swelling 2:notify HCP 3:take the clients pulse rate 4:listen to the clients breath sounds

4 rationale: because weight gain may indicate fluid retention in this client, the nurse needs to further assess for fluid overload. Lung congestion associated with fluid overload would affect o2, and the initial action of the nurse should be an assessment of lung sounds

Which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics? 1:hemoglobin levels 2:occurrence of nausea 3:presence of constipation 4:intake and output measurement

4 rationale: diuretics are administered to increase urine output, so the measure of intake and output are very important to diuretic use.

Which predisposing condition would the nurse anticipate in the client observed to have edema at the dorsum of the foot and ankle? 1:neurotrauma 2:hypothyroidism 3:hyperthyroidism 4:congestive heart failure

4 rationale: edema at the dorsum of foot and ankle may be due to congestive heart failure

Which documentation would the nurse utilize to report that a client's degree of edema has a depth of 8 mm? 1: 1 + 2: 2+ 3: 3+ 4: 4+

4 rationale: edema of 8 mm is documented as 4+ (multiply the 4 by 2)

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1:serum sodium of 139 mEq/L 2:serum chloride of 100 mEq/L 3:serum calcium of 10.2 mg/dL 4:serum potassium of 7.2 mEq/L

4 rationale: hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5-5.0. A concentration of 7.2 indicates hyperkalemia.

A client with an above the knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. Which rationale for the treatment would the nurse provide? 1:to limit the formation of blood clots 2:to decrease the phantom limb sensation 3:to prevent hemorrhage and cover the incision 4:to support the soft tissue and minimize swelling

4 rationale: pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb

A pregnant client tells the nurse, "I am sticking to my diet, and I dont watn anything containing salt" how would the nurse response? 1:youre doing fine, just keep up the good work 2:a low salt diet will protect your from getting swollen feet 3:we now encourage pregnant women to increase their salt intake because of changes in the circulation 4:salt is necessary in your diet. Use a little when youre cooking, but avoid processed meats and canned foods with salts

4 rationale: sodium is important in the diet of a pregnant woman. Blood volume increases during pregnancy; sodium is required to maintain physiological edema in interstitial spaces so blood volume is not depleted.

Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons? 1:stage 1 2:stage 11 3: stage 111 4:stage IV

4 rationale: stage IV involves full-thickness tissue loss and the tendons, bones, or muscles are exposed. -in stage 1, the skin is intact and there is a nonblanchable redness at a localized area, usually over a bony prominence -in stage 11, there is a partial thickness loss of the dermis manifesting as a shallow open ulcer with a red pink wound bed, without slough -in stage 111, full thickness tissue is lost

A 9-year-old child who has cerebral palsy, scoliosis, contractures of elbows and wrists, and is also incontinent. Which nursing action will best achieve the goal of skin integrity? 1:padding the child's lower extremities 2:repositioning the child every 4 hours 3:replacing the bed linens with sterile linens 4:changing disposable diapers every 2-3 hours

4 rationale: the buttocks are at greatest risk for excoriation because the child sits in a wheelchair most of the day. For skin integrity to be maintained, the diaper area must be kept dry; disposable diapers keep moisture away from the skin -repositioned every 1-2 hours

Which serum hormone level elevates in response to a clients total calcium concentration of 7.9mg/dl? 1:estrogen 2:thyroxine 3:growth hormone 4:parathyroid hormone (PTH)

4 rationale: the normal range of serum calcium lies between 9-10.5. When total serum calcium concentration levels lower, secretions of PTH increases and stimulates bones to promote osteoclastic activity, which increases serum calcium levels

Which reason would an IV infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a NG tube set to low intermittent suction? 1:prevent constipation 2:prevent dehydration 3:prevent vomiting 4:prevent electrolyte imbalance

4 rationale: when clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern.