reduction of risk potential

A nurse is teaching a client how to do fecal occult blood testing. Which statement by the client indicates a need for further teaching? "I will continue taking aspirin 81 mg daily." "I will refrain from eating raw fruits and vegetables." "I will avoid steak and other red meats." "I will avoid taking ferrous sulfate 24 hours before the test."

"I will avoid taking ferrous sulfate 24 hours before the test." Rationale: The fecal occult blood test is done to detect the presence of blood in the stools. The nurse should teach the client to avoid foods and medications that could alter the results. Clients should avoid red meat, raw fruits and vegetables, aspirin doses greater than 325 mg, and ferrous sulfate for three days prior to the test.

The nurse has provided preoperative teaching to a client who is scheduled for surgery in 1 week. Which of the following statements by the client indicates a correct understanding of the teaching? "I will need to refrain from drinking any clear liquids for 1 hour before my surgery." "I should arrive on the day of surgery with the site of surgery marked with a pen to avoid surgical errors." "I will be able to drive myself home following the procedure and can resume normal activities that evening." "I will need to cleanse my skin using an antiseptic solution 1 day before my procedure."

"I will need to cleanse my skin using an antiseptic solution 1 day before my procedure." Rationale: It indicates a correct understanding of the teaching if the client states that they will need to cleanse the skin the day prior to the procedure to reduce risk of surgical site infection. Clear liquids must be held at least 2 hours prior to surgery and often much longer to reduce the risk of aspiration while under anesthesia. The surgeon must mark the site of the surgical procedure to reduce the risk of wrong-site surgical errors. Clients who receive sedation or anesthesia must have a ride home and should not undergo regular activities for at least 24 hours, and sometimes longer, depending on the procedure performed.

The nurse is teaching a client about the purpose of complete blood count (CBC) testing. Which statement by the client indicates the need for further teaching? "This test will determine the microorganism that is causing my bacteremia." "This test will determine if I have anemia." "This test will measure if I have issues with blood clotting." "This test will measure if I have an acute infection.

"This test will determine the microorganism that is causing my bacteremia." Rationale: Complete blood counts measure white blood cell counts, hemoglobin and hematocrit levels, red blood cell counts, and platelets. This can aid in determining if there is a presence of an active infection, clotting issues, or anemias. The test cannot determine specific organisms within the blood; a blood culture is required to determine this.

The nurse is preparing to apply newly prescribed knee-length anti-embolism stockings for a client. Which of the following nursing actions requires follow-up? A Measuring the length of both legs from the heel to the popliteal space B Assessing the client for presence of pain in the calf with dorsiflexion of the foot C Measuring the circumference of the calf at the narrowest point Correct Answer (Blank) D Assessing the client's skin temperature, color, and skin condition prior to application of the stockings

Rationale: It requires follow-up if the nurse is observed measuring the client's calf at the narrowest point. The correct technique for selecting the appropriate size anti-embolism stocking is to measure from the heel to the popliteal space and the circumference of the calf at the widest point. Clients should be assessed for skin color, temperature, and skin condition as well as the presence of pain upon dorsiflexion of the foot (Homans sign), which could indicate venous thromboembolism.

The nurse has attended a staff education conference about maintenance of percutaneous feeding tubes. Which of the following statements indicates a need for further teaching? A "Tube sites should be cleansed with soap and warm water." B "Clients will experience mild leakage around the insertion site after feedings." Correct Answer (Blank) C "Sites should be assessed for skin breakdown, warmth, and redness." D "Reports of pain during or after feeding should be reported immediately."

Rationale: It requires further teaching if the nurse states that leakage around the insertion site is to be expected. Any leakage around the site indicates possible tube malfunction and should be reported immediately. It is the correct technique for tubes to be cleansed with soap and water, for sites to be assessed for skin breakdown, warmth, and redness, and for pain with feeding or medication administration to be reported immediately.

The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? A Glucose and potassium B Blood urea nitrogen and magnesium C Osmolality and sodium D Calcium and phosphorus Correct Answer (Blank)

Rationale: The parathyroid gland regulates calcium and phosphorous levels. Clients with hyperparathyroidism often present with an elevation in both calcium and phosphorous levels. In clients with hypoparathyroidism, calcium and phosphorous serum levels may be low.

The nurse is caring for a client with a venous insufficiency (stasis) ulcer on one leg. Which intervention performed by the nurse would be most effective to promote healing? A Initiate whirlpool bath therapy B Apply dressings with the use of sterile technique C Begin proteolytic debridement within 24 hours D Improve the client's nutritional status Correct Answer (Blank)

Rationale: Venous insufficiency ulcers are caused due to malfunctioning venous valves resulting in a pooling of blood and edema in the lower extremities. Venous ulcers are slow to heal. To promote healing, good nutrition is essential. The other interventions are appropriate but of little value if the client has poor nutrition.

The nurse is caring for a client with uncontrolled diabetes. Which of the following laboratory values is consistent with this diagnosis? Serum blood glucose level of 108 mg/dl Glycosylated hemoglobin (Hgb A1C) of 5% Serum blood glucose level of 134 mg/dl Glycosylated hemoglobin (Hgb A1C) of 9%

Glycosylated hemoglobin (Hgb A1C) of 9% Rationale: The best indicator of long-term glycemic control is a glycosylated hemoglobin (Hgb A1C) level. A level greater than 6% is indicative of poor glycemic control; therefore, an Hgb A1C value of 9% is consistent with uncontrolled diabetes.

The nurse is preparing to administer prescribed oral medication to a client with aortic valve stenosis who had a transesophageal echocardiogram (TEE) 4 hours ago. Which action should the nurse take before administering the medication to this client? A Encourage the client to use a drinking straw B Have the client cough several times C Assess gag reflex Correct Answer (Blank) D Hold all oral medications for 24 hours

Rationale: A TEE is a diagnostic test that uses a flexible endoscope inserted through the esophagus which is used to visualize the heart and heart structures. Following a TEE, the nurse should assess the client's gag reflex has returned before administering any oral medication.

The nurse is caring for a newborn with hyperbilirubinemia who is being treated with a biliblanket for phototherapy. Which intervention is most appropriate during this type of therapy? A Provide frequent feedings of breast milk or formula Correct Answer (Blank) B Restrict holding the newborn during treatment C Rotate the neonate to treat all of his/her skin D Discontinue breastfeeding during treatment

Rationale: A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment. Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in turn, will increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt the establishment of milk production. It is not necessary to rotate the baby during treatment.

The nurse is planning to ambulate a client with a history of falls. Which of the following actions is most important to perform prior to getting the client out of bed? A Assess for clear lung sounds B Determine if the client has eaten today C Review recently administered medications Correct Answer (Blank) D Ask the client if they need to void

Rationale: A client with a history of falls is at risk of falling again. Medications that are psychoactive or vasoactive, for instance, may increase the risk. Therefore, the nurse should assess for this first. Clients who have adventitious lung sounds may benefit from ambulation. Assessing for intake and output is important but not the priority.

The nurse in the ambulatory care center is assisting in the discharge of a client following a colonoscopy. Which statement by the client requires additional teaching? A "I expect to pass gas over the next few hours." B "I should rest at home for the remainder of today." C "I know fullness and mild abdominal cramping are expected." D "I will be careful when I drive myself home." Correct Answer (Blank)

Rationale: A colonoscopy is an endoscopic examination of the entire large bowel. The procedure is performed under sedation. Due to the anesthetics used during the procedure, the client should not drive themselves home. Other teaching that should be given to the client includes reminding the client that fullness, mild abdominal cramping, and passage of flatus are expected. Since air is instilled in the bowel during the procedure, it is normal and encouraged for a client to pass flatus after the procedure. The client should rest for the remainder of the day since they have received a sedative medication.

A nurse is reviewing laboratory results of a client with chronic kidney disease. Which finding does the nurse expect to see on the report? A BUN level of 19 mg/dl B Potassium level of 3.1 mEq/l C Hematocrit level of 39% D Creatinine level of 4.5 mg/dl

Rationale: A creatinine level of 4.5 mg/dl is indicative of chronic kidney disease (CKD). The normal creatinine level ranges from 0.5 to 1.3 mg/dl. Creatinine levels evaluate renal function. A blood, urea, nitrogen (BUN) level of 19 mg/dl is a normal finding. BUN levels are expected to be elevated in clients with CKD. A potassium level of 3.1 mEq/l is not consistent with chronic kidney disease. Potassium levels are expected to be elevated with CKD. The normal potassium level is 3.5 to 5.0 mEq/l. A hematocrit level of 39% is a normal finding. Hematocrit levels are expected to be decreased in clients with CKD.

A nurse is providing care to a client with a cuffed tracheostomy. Which action does the nurse perform to minimize the risk of aspiration? A Ensure the cuff is inflated properly Correct Answer (Blank) B Clean the inner cannula as prescribed C Secure the ties around the tracheostomy holder D Instruct the client to verbalize any shortness of breath

Rationale: A cuffed tube ensures secretions from the upper airway do not enter the lower airways. A properly inflated balloon prevents aspiration. Cleaning the inner cannula, as prescribed, prevents infection, not aspiration. Securing the tracheostomy holder prevents dislodgement of the tube but does not prevent aspiration. Clients with a cuffed tracheostomy are unable to speak. The client will not be able to alert the nurse if respiratory issues are occurring.

The nurse is preparing a client for a scheduled myelogram. For which statement by the client should the nurse notify the radiologist immediately? A "I suffer from claustrophobia and hate loud noises." B "I think I may be allergic to shellfish." C "I had a severe headache after a spinal tap last year." D "I took my regular dose of warfarin last night." Correct Answer (Blank)

Rationale: A myelogram is a spinal X-ray used to determine the cause of pain, numbness, or weakness in the back, arms or legs. During the exam, contrast material is injected into the spinal canal to provide an outline of the spinal cord. Relative contraindications to myelography include a history of an adverse reaction to the iodine-based contrast media. A history of an allergy to shellfish is no longer considered a contraindication. Clients who are on anticoagulant therapy such as warfarin, are supposed to discontinue these medications prior to undergoing myelography for about 48 hours before and 24 hours after the myelogram. Therefore, since the client took warfarin last night, there is a high risk for bleeding into the spinal column and the radiologist should be notified immediately. Claustrophobia and an aversion to loud noises would be an issue for someone undergoing an magnetic resonance imaging (MRI), not a myelogram.

A client's arterial blood gas shows a pH of 7.30, pCO2 of 53, and HCO3 of 24. The nurse recognizes which acid-base imbalance? A Metabolic alkalosis B Metabolic acidosis C Respiratory alkalosis D Respiratory acidosis Correct Answer (Blank)

Rationale: A normal pH ranges from 7.35 to 7.45. A pH of 7.30 is low and indicates acidosis. Next, the nurse should look at the partial pressure of carbon dioxide (PCO2) level. Normally, carbon dioxide (CO2) levels range between 35 to 45 mm Hg. A level of 53 is high, and since CO2 is an acid, it is causing respiratory acidosis. The kidneys manage the balance of hydrogen and bicarbonate ions and will attempt to balance the CO2 imbalance by producing more bicarbonate, a base. This renal compensatory response takes time. A normal bicarbonate (HCO3) level ranges from 21 to 28 mmol or mEq/L. Since the HCO3 level for this client is still normal, compensation has not yet occurred. Therefore, the client has uncompensated respiratory acidosis.

A client with dyspnea due to exacerbation of COPD is becoming very anxious. An arterial blood gas shows a PaO2 of 93 mm Hg. What action by the nurse is best? A Assist the client with relaxation techniques Correct Answer (Blank) B Administer an antianxiety medication C Administer a bronchodilator D Increase the oxygen flow rate

Rationale: A normal partial pressure of arterial oxygen (PaO2) level ranges from 80 to 100 mmHg. A level of 93 is normal, and therefore it is not necessary to increase the oxygen or administer a bronchodilator. However, both of these interventions would be appropriate if the client were hypoxic. A client with respiratory problems should not take an antianxiety medication as a first-line intervention because this may decrease their respiratory rate and/or alertness. The best intervention at this time is to assist the client with relaxation techniques.

The nurse is caring for a client after a cerebrovascular accident who has altered mental status and weakness. When performing oral care, which of the following positions will the patient be placed in to reduce the risk of aspiration? A Side-lying Correct Answer (Blank) B Semi Fowler's C High Fowler's D Reverse Trendelenburg

Rationale: A side-lying position will allow liquids to drain out of the mouth, preferably onto a towel or into a basin. A semi Fowler's or high Fowler's position will not protect the airway nor would reverse Trendelenburg.

A child and the family were exposed to mycobacterium tuberculosis about two months ago. For confirmation of the presence or absence of an infection in their system, it is important for all family members to have which test? A TB skin test or blood test Correct Answer (Blank) B Blood culture and sensitivity C Sputum culture and sensitivity D Chest X-ray without contrast

Rationale: After exposure to Mycobacterium tuberculosis, it is important to determine that no infection has occurred. The client can have a TB skin test given intradermally or a TB spot blood test to determine if exposure has occurred. A chest x-ray will be done if this test is positive. It is not necessary for the client to have a sputum culture or blood culture.

A nurse is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported to the primary health care provider immediately? A Hemoglobin of 9.3 g/dL B Venous blood pH of 7.30 C Serum potassium of 6 mEq/L Correct Answer (Blank) D Blood urea nitrogen of 50 mg/dL

Rationale: Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (approximate hemoglobin less than 13 g/dL in men or less than 12 mg/dL in women) is common with kidney disease. Blood urea nitrogen (BUN) is expected to be increased in acute renal failure (7 to 30 mg/dL is considered normal).

The nurse is monitoring a client who is 30 minutes post endoscopic retrograde cholangiopancreatography (ERCP). Which assessment finding would require immediate follow-up by the nurse? A Absent gag reflex B Rigid abdomen Correct Answer (Blank) C Drowsiness D Diminished breath sounds

Rationale: An ERCP is an endoscopic procedure to remove a gallstone from the common bile duct. When monitoring a client post ERCP, the nurse should assess for complications, including perforation, pancreatitis, infection, and bleeding. A rigid abdomen is a manifestation of perforation which is a medical emergency. An absent gag reflex, drowsiness, and diminished breath sounds are normal findings following an endoscopic procedure.

A nurse is performing an initial assessment on a newly admitted client. Which finding increases the client's risk for aspiration? A The client's Glasgow Coma Scale is 14. B Crepitus is present at the temporomandibular joint. C The tonsils are a 1+. D The client has an absent gag reflex. Correct Answer (Blank)

Rationale: An absent gag reflex can impair the ability to swallow and increases the risk for aspiration. A Glasgow Coma Scale (GCS) score of 14 is not indicative of a risk for aspiration. The normal GCS is 15 based on eye, motor, and verbal responses. Crepitus at the temporomandibular joint (TMJ) is not associated with a risk for aspiration. Crepitus is not an indication of the inability to swallow. Tonsils with a grade of +1 is a normal finding. A grade of +1 indicates the tonsils obstruct 0 to 25% to midline. This is not indicative of a risk for aspiration.

The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy. Which finding requires immediate notification of the health care provider? A Elevated blood urea nitrogen (BUN) and creatinine B Activated partial thromboplastin time (aPTT) of 50 seconds Correct Answer (Blank) C Increased serum ammonia D Hemoglobin of 11 g/dL (110 g/L)

Rationale: Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the other labs would not increase the client's risk of complications following a liver biopsy.

The nurse is caring for a client who was admitted for melena. The client has had severe abdominal pain 2-3 hours after eating that has been occurring for several months. Which of the following problems would be suspected? A Duodenal ulcer Correct Answer (Blank) B Acute gastritis C Esophageal varices D Reflux disease

Rationale: Bleeding from duodenal ulcers is four times more common than from gastric ulcers. Posterior duodenal ulcers are the most likely to bleed based on proximity to branches of the gastroduodenal artery. Duodenal ulcers tend to differ from gastric ulcers in that abdominal pain occurs 2-3 hours after eating vs immediately after eating. Because the duodenum is below the pyloric sphincter, it is more likely to cause melena than upper GI bleeding. Esophageal varices may cause hematemesis but do not cause pain associated with meals or melena. Gastritis and reflux disease rarely lead to bleeding and would not cause melena.

The nurse is screening clients for factors that impact skin integrity. The nurse should identify which client has an increased risk of skin breakdown? A A client who is malnourished Correct Answer (Blank) B A client who has anemia C A client with visual impairments D A client who is pregnant

Rationale: Clients who are malnourished have an increased risk of skin breakdown because of the lack of subcutaneous tissue surrounding bony prominences. Anemia, visual impairments, and pregnancy do not increase the likelihood of skin breakdown.

The nurse is caring for a client with respiratory acidosis. Which of the following arterial blood gas values is consistent with this diagnosis? A pH of 7.37 B PCO2 of 50 mm Hg Correct Answer (Blank) C PaO2 of 90 mmHg D HCO3 of 25 mEq/l

Rationale: Clients with respiratory acidosis often have elevated partial pressure carbon dioxide levels. Levels of PCO2 greater than 45 mm Hg indicate possible respiratory acidosis. Normal pH is 7.35 to 7.45, normal PaO2 is above 75 mmHg, and normal HCO3 is 22-26 mEq/l.

The nurse is caring for a client who had a full leg cast applied during surgery. What is the purpose for elevating the client's casted leg postoperatively? A Reduce the cast drying time B Improve venous return Correct Answer (Blank) C Promote the client's comfort D Help with fracture healing

Rationale: Elevating the leg on one or two pillows will improve venous return, which will reduce the amount of swelling in the extremity. Elevating the leg will have little effect on cast drying time, fracture healing, or pain.

The nurse is assessing a nasogastric tube for a client with a bowel obstruction. The nurse aspirates the stomach content and notes a gastric pH of 3.0. Which action would be appropriate for the nurse to take? A Document the placement and gastric pH Correct Answer (Blank) B Discard the gastric contents and flush the tube with water C Notify the healthcare provider and request a prescription for CXR D Inject air into the tube and auscultate epigastric sounds

Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Correct placement is confirmed when gastric contents have a pH that is 3.5 or lower. A CXR would be indicated if the pH is higher than 3.5 or an indication that the tube is no longer in the stomach. Any stomach contents that are aspirated should be injected back into the stomach to prevent electrolyte imbalance. Injecting air into the tube and auscultating epigastric sounds is no longer evidenced-based practice to assess NG tube placement.

A nurse working on the orthopedic unit has just received change-of-shift report. Which client should the nurse evaluate first? A The client with osteomyelitis and a temperature of 100.5°F. B The client who has not voided 10 hours after a laminectomy. Correct Answer (Blank) C The client with low back pain rated 8 out of 10. D The client who is anxious about discharge to a rehabilitation facility.

Rationale: Inability to void may indicate damage to the spinal nerves from the laminectomy that is affecting the bladder and causing urinary retention. This presents a medical emergency, which should be evaluated and reported to the surgeon immediately. The nurse should then evaluate the other clients, but the information about them does not indicate a need to be evaluated first.

The nurse is caring for a client with a tibia fracture who has a casted right lower extremity. Which of the following client findings is a priority to follow up? A Client reports pain rated 6 out of 10 in the right lower extremity. B The right extremity skin is pallor in color. Correct Answer (Blank) C Small amounts of serous drainage are on the cast. D Client has an oral temperature of 100.4°F.

Rationale: It is a priority for the nurse to follow up if the client has numbness, tingling, and pallor of the affected extremity, which is a sign of the limb-threatening complication of compartment syndrome. The client's pain, low-grade temperature, and drainage can be addressed after the priority findings of compartment syndrome.

The nurse is caring for a client with a femur fracture who has a cast placed on the left lower extremity. Which of the following client findings is a priority to follow up? A Client reports mild pain B Affected extremity is pink in color and warm to touch C Moderate amounts of serous drainage are on the cast D Petechiae is on the client's chest Correct Answer

Rationale: It is a priority for the nurse to follow up if the client has petechiae on the chest and hypoxemia, which are signs of the life-threatening complication of fat embolism syndrome. After addressing the possible complication, the nurse can then address the drainage and pain. A warm and pink affected extremity indicates adequate circulation and does not require follow-up.

The nurse is implementing measures to reduce complications for a client with increased intracranial pressure (ICP). Which of the following actions requires intervention? A Flexing the client's neck forward to reduce risk of aspiration Correct Answer (Blank) B Raising the head of the bed to maintain a semi-Fowler's position C Repositioning the client with slow, gentle movements D Dimming the lights and reducing environmental noise

Rationale: It requires follow-up if the nurse is observed flexing the client's neck, which can further increase intracranial pressure. The head should be maintained upright and in the midline position. It is the correct management of increased ICP to reduce environmental stimuli, elevate the head of the client's bed, and move the client slowly and gently.

The nurse is caring for a client with a chest tube in place. Which of the following findings requires intervention? A Continuous bubbling in the water seal chamber Correct Answer (Blank) B Tidaling in the water seal chamber during inhalation and exhalation C Moderate amount of serosanguinous drainage in the drainage collection chamber D Continuous bubbling in the suction control chamber

Rationale: It requires follow-up if there is continuous bubbling in the water seal chamber, as this indicates a possible air leak which can lead to a tension pneumothorax. Tidaling in the water seal chamber, continuous bubbling in the suction control chamber, and drainage in the drainage collection chamber all indicate effective functioning of the chest tube.

A woman who is 26-weeks pregnant is admitted for painless vaginal bleeding. The nurse should prepare the client for which procedure or test? A Serum hCG level B Leopold maneuvers C Transvaginal ultrasound Correct Answer (Blank) D Non-stress test

Rationale: The most common cause of painless vaginal bleeding involves a problem with the placenta, such as placenta previa. A transvaginal ultrasound (an ultrasound device inserted into the vagina) is the test of choice to confirm placenta previa. Serum hCG is used to screen for pregnancy. A fetal non-stress test is used in pregnancies over 28 weeks to measure fetal heart rate and contractions. Leopold maneuvers are a stepwise method of abdominal palpation used after about 34 weeks gestation to determine fetal lie and presentation.

The nurse is assessing a postoperative client following femoral popliteal bypass surgery for peripheral arterial disease. The surgical dressing is saturated with bright red blood. Which action should the nurse take first? A Stop the heparin sodium infusion Correct Answer (Blank) B Obtain a set of vital signs C Apply a pressure dressing over the surgical dressing D Increase the rate of the normal saline IV infusion

Rationale: The presence of bright red blood indicates the possibility of arterial bleeding from the surgery site. The nurse should first stop the heparin, an anticoagulant, infusion. Next, the nurse should attempt to slow the bleeding by applying either manual pressure or a pressure dressing directly over the surgical dressing.

A nurse is performing a neurological assessment on a client who is reporting dysphagia. Which cranial nerve should the nurse assess? A Vagus Correct Answer (Blank) B Accessory C Trochlear D Abducens

Rationale: The sensory component of the vagus nerve is evaluated by testing the gag reflex. An absent gag reflex increases the risk for aspiration. The spinal accessory nerve does not evaluate the ability to swallow. The spinal accessory nerve is responsible for shoulder movement. The trochlear and abducens nerves are responsible for eye movement. A deficiency in these cranial nerves does not increase the risk for aspiration.

The nurse is assessing a client with peripheral vascular disease. The nurse is unable to palpate the posterior tibial pulse. Which pulse site should the nurse assess next? A Dorsalis pedis B Femoral C Popliteal Correct Answer (Blank) D Radial

Rationale: When assessing pulse sites, the nurse should begin at the distal pulse site. In the lower extremity, it would be the dorsalis pedis. The nurse moves up the extremity assessing the next proximal site. If the nurse is unable to assess the posterior tibial pulse, the nurse should then assess the popliteal site.

A nurse is removing an IV catheter from a client who has an order to discontinue infusion of IV fluids. Which is an appropriate action for the nurse to take? A Apply firm pressure over the vein B Leave the roller clamp slightly open C Lift the hub upward away from skin. D Pull the catheter straight from insertion site Correct Answer (Blank)

Rationale: When removing an IV catheter, the nurse should pull the catheter straight from the insertion site. This will ensure that the catheter remains intact and prevents trauma to the vein. The nurse should keep the hub flush with the skin as lifting the hub will cause the catheter to irritate the vein. Firm pressure over the vein can cause discomfort. The roller clamp should be closed to prevent the backflow of blood.

The nurse is assessing the neurological status of a client after recovery from a cerebrovascular accident. Which of the following actions by the nurse is appropriate? A Removing the client's glasses while assessing cranial nerves B Utilizing a walker while assessing the client's gait Correct Answer (Blank) C Assessing strength of only the affected side D Placing the client in a supine position for a swallow screen

Rationale: While assessing the gait of a client who may have weakness, the use of assistive devices is recommended until a steady gait is achieved. The client should keep glasses on for testing, strength should be assessed on both sides and compared, and swallow screens should be performed while the client is in a high-Fowler's position.

While inserting an indwelling urinary catheter into a male client, the nurse is met with resistance. Which action should the nurse take? A Press two fingers above the pubic bone B Attempt to rotate the catheter Correct Answer (Blank) C Obtain a smaller size catheter D Advise the client to hold their breath

Rationale: With male clients, the indwelling urinary catheter is inserted into the urinary meatus and guided through the urethra. Resistance with insertion often occurs when guiding the catheter through the urethra where the prostate lies. The prostate, which is the gland that surrounds the urethra, can be enlarged. If resistance is met, the nurse should gently rotate the catheter and instruct the client to take slow, deep breaths. If the catheter does not advance, then the nurse should remove the catheter and contact the healthcare provider. For clients with a retracted penis, the nurse will press two fingers above the pubic bone. A smaller catheter size may be needed if there is urine leaking.

A nurse is preparing to obtain a blood glucose sample from a client with diabetes mellitus type 2. The client informs the nurse that obtaining a blood sample from the right fingertips is usually difficult. What action should the nurse perform to improve blood flow to the collection site? A Elevate the client's right hand B Wrap the client's right hand in a warm towel Correct Answer (Blank) C Clean the right fingertips with an alcohol swab D Apply a tourniquet to the right wrist

Rationale: Wrapping the client's hand in a warm towel will improve blood flow to the extremity by promoting vasodilation. Elevating the client's right hand will not improve blood flow to the fingertips. The extremity should be held in a dependent position before puncturing to improve the blood flow. Cleaning the site with an alcohol swab will not improve blood flow to the extremity. Alcohol swabs are not recommended because they can interfere with the results of the blood sample. Applying a tourniquet to the right wrist will impair circulation to the right hand and may cause skin integrity issues in a client with diabetes. Tourniquets are indicated for venipunctures.

The nurse is caring for a client who has just undergone a cardiac catheterization. Which of the following actions by the nurse is appropriate to assess peripheral circulation after the procedure? A Auscultating heart sounds B Comparing the pulses in all extremities Correct Answer (Blank) C Assessing for bruits in the carotid arteries D Obtaining an echocardiogram

Rationale: A cardiac catheterization involves the use of major vessels in an extremity. Palpating pulses in all extremities to ensure that they are symmetrical is important to determine if there is any circulatory impairment to the affected extremity. All other responses do not assess peripheral circulation.

The nurse is assessing a client with left-sided heart failure. Which of the following findings indicates that the client is experiencing a complication of this condition? A Oliguria B Pitting edema C Peripheral neuropathy D Orthopnea Correct Answer (Blank)

Rationale: A complication of left-sided heart failure is pulmonary congestion that can cause the client to have dyspnea, orthopnea, crackles in the lungs, and low oxygen saturation. Pitting edema is a complication of right-sided heart failure and neuropathy, and oliguria is not directly affected by heart failure.

The nurse is caring for a client who sustained a traumatic brain injury (TBI) and received intravenous mannitol 15 minutes ago. Which of the following client findings indicates that the treatment has been effective? A Blood pressure has increased from 150/86 to 166/74 mmHg. B Intracranial pressure (ICP) has decreased from 25 to 18 mmHg. Correct Answer (Blank) C Brain tissue oxygenation (PbtO2) has decreased from 30 to 15 mmHg. D Cerebral perfusion pressure (CPP) has decreased from 60 to 50 mmHg.

Rationale: A decrease in ICP from 25 to 18 mmHg indicates effective treatment of intracranial hypertension with mannitol. The goal ICP should be less than 20 mmHg, the CPP should be greater than 60, and the brain tissue oxygen should be greater than 20. These values are not within goal range and indicate further management is needed to control intracranial pressure and brain oxygenation. The blood pressure change indicates a widening pulse pressure, which does not indicate effective reduction in intracranial pressure.

The nurse is assessing a client who is postoperative 8 hours from a left pneumonectomy for lung cancer. Which finding should the nurse expect to observe? A Diminished breath sounds bilaterally with auscultation B Sternal incision with dressing C Pleural chest tubes to suction Correct Answer (Blank) D Positioned on the unaffected side

Rationale: A pneumectomy is the removal of an entire lung. The client postoperatively will have absent breath sounds on the affected side, chest tubes to suction, and a posterior incision. The nurse should position the client on the operative side to facilitate lung expansion.

The nurse is completing a follow-up assessment on a client who was admitted for appendicitis. Which of the following assessment findings indicates that the client's condition has worsened? A Constipation B Anorexia C Tenderness at McBurney's point D Abdominal rigidity Correct Answer (Blank)

Rationale: A rigid, distended abdomen indicates that the client's condition has worsened because this finding indicates that the appendix may have ruptured. Anorexia and McBurney's point tenderness are expected findings. Constipation does not indicate worsening of appendicitis.

The nurse is assessing a client who has amyotrophic lateral sclerosis. Which of the following would be an abnormal neurological finding? A Dilated pupils Correct Answer (Blank) B Weakness of the hands C Brisk deep tendon reflexes D Lack of coordinated movements

Rationale: Amyotrophic lateral sclerosis is a progressive condition that causes deterioration of motor neurons. Expected findings include muscle weakness, loss of coordinated movements, hyperactive reflexes, etc. Dilated pupils would be an abnormal finding and require further assessment.

The nurse is educating a client about a newly placed implanted port. Which of the following should the nurse include in the teaching? A "You will have the sutures removed in one week." B "Clean the site once a day." C "Keep the external catheter secured to the chest wall." D "An x-ray will be needed before each use." Correct Answer (

Rationale: An implanted port is a type of long-term central venous access device, which is a subcutaneous injection port attached to a catheter that sits in the superior vena cava. An implanted port requires minimal care with the insertion site and equipment not visible. There are no sutures or site care required by the client to maintain. The client should be instructed that an x-ray will be needed before the use of the port.

The client, who is 12-hours post gastric bypass surgery, is restless and reports increasing back and shoulder pain unrelieved by pain medication. Which action should the nurse take first? A Roll the client to side-lying position to ensure the epidural analgesia catheter is still in place B Report the complaint to the surgeon immediately Correct Answer (Blank) C Place the client in Trendelenburg position D Check the nasogastric (NG) tube for patency and reposition the tube

Rationale: Anastomotic leak is the most serious complication after bariatric surgery and the most common cause of death. Clients should be monitored for increased back, shoulder, or abdominal pain, restlessness, unexplained tachycardia, and oliguria; these findings should be immediately reported to the surgeon. A nasogastric tube should not be manipulated postoperatively because it could damage the surgical site. In order to reduce intra-abdominal pressure on the diaphragm and improve tidal volumes, the head of the bed should be elevated 30 to 45 degrees, preferably in reverse Trendelenburg position. Patient-controlled analgesia is used for pain management; epidural analgesia is not often used because of the difficulty of locating exact spinal segments for the proper insertion of a catheter.

The nurse is caring for a client who has a prescription to use an incentive spirometer to prevent postoperative atelectasis. Which of the following assessment findings indicates that the therapy is effective? A Oxygen saturation of 91% on room air Correct Answer (Blank) B Clear breath sounds in all lobes C Orthopnea D Pulses 2+ in all extremities

Rationale: Atelectasis is manifested by dyspnea (especially while in the supine position), low oxygen saturation, cough, crackles upon auscultation, and sputum production. The absence of these findings indicates that the incentive spirometer is effective at preventing this postoperative complication. Pulse strength is not directly affected by atelectasis.

The nurse explains an autograft to a client scheduled for excision of a skin tumor. Which statement indicates that the client understands the nurse's teaching? A "I will receive tissue from a pig." B "I will receive tissue from a tissue bank." C "I will receive tissue from my thigh." Correct Answer (Blank) D "I will receive tissue from synthetic skin."

Rationale: Autografts are done with tissue transplanted from the client's own skin. Tissue from a pig is called a xenograft or heterograft, which means it is transplanted from an organism of one species to that of a different species. Cadaveric grafts are termed allografts, or homografts because they are transplanted from one individual to another within the same species.

A nurse is providing care to a client with a spinal cord injury at the level of T4. The client suddenly verbalizes a severe headache, blurred vision, and nausea. The nurse suspects autonomic dysreflexia. Which action should the nurse perform? A Inspect the client for a distended bladder Correct Answer (Blank) B Lower the client to a supine position C Prepare to administer prescribed vasopressors D Place an abdominal binder on the client

Rationale: Autonomic dysreflexia occurs in clients with spinal cord injuries above the level of T6. Autonomic dysreflexia is stimulation of the sympathetic nervous system without a compensatory response by the parasympathetic nervous system. The most common cause is a distended bladder that causes pressure in the lower part of the body. The client should be placed in an upright position to decrease hypertension associated with autonomic dysreflexia. Vasopressors increase blood pressure. Autonomic dysreflexia causes hypertension, not hypotension. Tight garments can trigger a sympathetic response. Placing an abdominal binder will worsen the condition.

The nurse is assessing a client after cardiac catheterization. Which of the following findings would indicate that the client is experiencing a complication of the procedure? A Pulses 2+ B Blood pressure 134/91 mmHg C Bradycardia Correct Answer (Blank) D Bruising of the access site

Rationale: Bradycardia, hypotension, and nausea indicate that the client is experiencing a vasovagal reaction after cardiac catheterization. Pulses 2+ and bruising of the insertion site are normal findings after the procedure. Blood pressure of 134/91 is slightly elevated but is not a complication of cardiac catheterization.

A nurse is assessing a client who has end-stage kidney disease. Which findings would indicate that the client requires hemodialysis treatment? A A 5 lb weight gain in two days Correct Answer (Blank) B Neck veins are flattened C Oxygen saturation is 93% D Return of skin to previous position when palpated

Rationale: Clients with end-stage kidney disease are at risk for fluid volume overload due to the kidney's inability to balance the body's volume. A client with a 5 lb weight gain in two days indicates increased fluid volume overload, which is an indication to receive hemodialysis treatment. Flatten neck veins, oxygen saturation of 93%, and normal skin turgor indicate the client is not experiencing fluid volume overload.

The nurse is assessing a client who has been taking prednisone for an exacerbation of inflammatory bowel disease. Which of the following statements by the client requires immediate follow-up? A "I'm having difficulty sleeping at night." B "I feel like I am urinating more frequently." Correct Answer (Blank) C "I've been more irritable than usual." D "I think I have gained some weight over the past month."

Rationale: Corticosteroids are administered to control the symptoms of many different disorders but have many side effects including difficulty sleeping, irritability, and weight gain. However, a more concerning side effect of prednisone use is hyperglycemia. Hyperglycemia symptoms include polyuria (frequent urination), polyphagia (hunger), and polydipsia (thirst). This needs to be managed immediately to avoid adverse client outcomes.

The nurse has an order to insert an indwelling urinary catheter for a male client. What is the best reason for lubricating the tip of the catheter prior to insertion? A Diminish the leakage of urine around the catheter B Prevent bladder distention C Reduce the friction within the urethra Correct Answer (Blank) D Minimize risk for infection

Rationale: Due to the somewhat long length of the male urethra, lubrication reduces potential discomfort and localized tissue irritation as the catheter is passed.

The nurse is caring for a 4-year-old child two hours after a tonsillectomy and adenoidectomy. Which finding must be reported to the health care provider immediately? A Apical heart rate of 110 B Increased restlessness Correct Answer (Blank) C Complaints of throat pain D Vomiting of dark emesis

Rationale: Increased restlessness with increased respiratory and heart rates are often early signs of active bleeding. The other options are expected findings at this time in the postop period for this surgery. The dark emesis indicates old blood that most likely was swallowed during surgery.

The nurse is caring for a client who had a transurethral resection of the prostate (TRUP) 1 day ago and has continuous bladder irrigation (CBI) in place. Which of the following findings requires intervention? A Pink-tinged urine is in the urinary drainage bag. B The client reports dizziness and a headache. Correct Answer (Blank) C The client reports occasional bladder spasms and the urge to urinate. D The amount of drainage output in the urinary drainage bag is greater than the irrigant input.

Rationale: It requires intervention if the client reports dizziness and headache, which are signs of TURP syndrome, which is a serious complication of CBI caused by reabsorption of irrigant fluid into the body. Pink-tinged urine, occasional bladder spasms, the urge to urinate, and output greater than input are all normal findings with CBI.

The charge nurse is observing a newly hired nurse care for a client whose temperature has increased from 99.9 to 102°F during the shift. Which of the following actions by the newly hired nurse requires intervention? A Administering prescribed antipyretics B Requesting to discontinue intravenous fluids Correct Answer (Blank) C Removing excess blankets and clothing D Providing a tepid sponge bath to the client

Rationale: It requires intervention if the nurse is observed requesting to discontinue intravenous fluids in a febrile client. Clients should have adequate fluid and nutrition replacement to meet increased metabolic demands while in febrile states. It is correct to administer prescribed antipyretics, remove excess blankets and clothing, and provide tepid sponge baths during febrile states.

The nurse is caring for a client who underwent a cardiac catheterization 2 hours ago. Which finding would indicate that the client is experiencing a potential complication from the procedure? A Increased blood pressure B Increased heart rate C Absent pedal pulse in the affected extremity Correct Answer (Blank) D Decreased urine output

Rationale: Loss of the pulse in the extremity where the catheterization was performed would indicate a potential severe spasm of the artery or clot formation/occlusion below the site of insertion. It is common for the pulse to be intermittently weaker from the baseline. However, a total loss of the pulse is a medical emergency. The primary health care provider (HCP) should be notified immediately.

The nurse is caring for a client with left ventricular heart failure. The client's ejection fraction is 40%. Which assessment finding is an early indication of inadequate tissue perfusion? A Distended jugular veins B Use of accessory muscles C Confusion and restlessness Correct Answer (Blank) D Crackles in the lungs

Rationale: Neurological changes, including impaired mental status, are early signs of inadequate tissue perfusion due to decreased oxygenation of brain tissues. Other signs of low ejection fraction (EF) include shortness of breath, dependent edema, and arrhythmias. The low EF indicates that this client has severe damage to the left ventricle. Normal EF is about 55-70%.

A nurse is caring for a 7-year-old child who is being discharged following a tonsillectomy. Which instruction is appropriate for the nurse to include during discharge teaching with the parents? A The child can return to school after being home for four days B Report a persistent cough to the health care provider within 24 hours Correct Answer (Blank) C Administer chewable aspirin for pain around the clock every six hours D The child may gargle with saline as necessary for discomfort

Rationale: Persistent coughing should be reported to the health care provider as this may indicate bleeding by a trickling of blood into the back of the throat. The other items are incorrect information especially the aspirin, which is not to be given to children. The saline may irritate the wound where the tonsils were removed.

The nurse is assessing the peripheral venous access for a client who reports pain at the site. The nurse notes the presence of erythema at the site. Which action should the nurse take next? A Remove the catheter at that site Correct Answer (Blank) B Apply warm moist packs to the site C Document the findings in the chart D Start a new peripheral line at a different site

Rationale: Removing the catheter is the first thing that needs to happen to prevent further inflammation. After the removal, warm moist compresses can be applied to help with the inflammatory response. A new site will need to be found if the client needs to continue to have IV access. The documentation of the site condition, what was done for the client, and how the client tolerated would happen last.

The emergency department nurse is caring for a client after a fall with a head injury. Which neurological assessment would the nurse complete first? A Deep tendon reflexes B Muscle strength C Level of consciousness Correct Answer (Blank) D Cranial nerve assessments

Rationale: The client's level of consciousness should be assessed prior to completing any other neurological assessments. If the client is comatose, for example, the neurological assessment will be different from someone who is alert.

The nurse is caring for a client who received 2 units of packed red blood cells after an episode of gastrointestinal bleeding. Which laboratory value should the nurse monitor closely? A White blood cells B Bleeding time C Platelets D Hematocrit Correct Answer (Blank)

Rationale: The hematocrit is an indirect measurement of red blood cells (RBCs) number and volume. It is used as a rapid measurement of RBC count. It is used to determine the degree of anemia in a client and evaluate effectiveness of treatment such as a blood transfusion. It is performed in combination with a hemoglobin level, commonly referred to as an 'H&H'. A follow-up hemoglobin and hematocrit should be checked around 4 to 6 hours after the transfusion is completed.

The nurse is caring for a client who is unconscious and receiving gastric tube feedings. Which assessment finding requires immediate action from the nurse? A Formula residual volume of 100 mL B Decreased breath sounds in the right lower lobe Correct Answer (Blank) C Urine output of 250 mL in the past eight hours D Decreased bowel sounds in all quadrants

Rationale: The most common problem associated with enteral feedings is aspiration with resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimum of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should verify tube placement prior to each feeding or every four to eight hours if the client receives a continuous feeding.

The nurse is providing education for a client who has asthma. Which factor is a priority for the client to monitor daily? A Pulse oximetry B Respiratory rate C Respiratory effort D Peak air flow volumes Correct Answer (Blank)

Rationale: The peak airflow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma. Note that the question asks for a priority, so all of the options would be monitored. However, peak airflow is the priority.

A client has returned to the unit after having a renal biopsy. Which of these nursing interventions is appropriate? A Change the dressing every eight hours B Ambulate the client four hours after procedure C Maintain client on NPO status for 24 hours D Monitor vital signs more frequently Correct Answer (Blank)

Rationale: The potential complication after this procedure is active bleeding from the site of the biopsy. Monitoring vital signs is critical to detect early indications of active bleeding. The other options are incorrect. There is no reason to ambulate every four hours or withhold food and fluids for a day.

The nurse is caring for a client with thrombocytopenia. Which of the following platelet laboratory values is consistent with this diagnosis? A 157,000 cells/mm3 B 90,000 cells/mm3 Correct Answer (Blank) C 350,000 cells/mm3 D 450,000 cells/mm3

Rationale: Thrombocytopenia is a state of low serum platelet levels, which can be caused by various anemias, chemotherapy, and HIV infection. A normal value for platelets is 150,000 - 400,000 cells/mm3. A platelet count of 90,000 cells/mm3 indicates thrombocytopenia.

The critical care nurse is planning care for a client who had a cardiac catheterization with femoral artery access. The nurse should place the client in which position? A Left lateral Sims' B Supine in low-Fowler's Correct Answer (Blank) C Right lateral recumbent D Reverse Trendelenburg

Rationale: When caring for a client who is post heart catheterization with femoral access, the nurse will need to position the client supine in low-Fowler's. This position keeps the lower extremities in a neutral position and avoids flexion at the hips, which will prevent the development of bleeding at the access site. Reverse Trendelenburg is used to increase blood flow to the heart. Right lateral recumbent is the recovery position after a client has had respiratory or cardiac failure following CPR. Left lateral Sims' position is used when medication or enemas are to be administered.

The nurse is providing care to a client with an indwelling urinary catheter. The nurse notes the presence of sediment in the tubing leading to the catheter bag. What action should the nurse take? A Irrigate the tubing with sterile normal saline Correct Answer (Blank) B Place the drainage bag at the foot of the bed C Strip the tubing D Replace the drainage bag

Rationale: When caring for a client with an indwelling urinary catheter, the nurse will assess the patency of the catheter. The presence of sediment is common, however, a buildup of sediment could cause a blockage in the tubing. A blockage in the tubing will prevent the drainage of the tubing. The nurse can irrigate the tubing to remove the sediment. Stripping the tubing is done to remove any clots from the tubing. Placing the drainage bag at the foot of the bed will promote drainage from the tube but will not remove sediment. The drainage bag is replaced when it is damaged.

The nurse is caring for a client who is using pneumatic compression devices to promote venous stasis after a surgical procedure. Which of the following statements by the client indicates an effective response to this therapy? "These sleeves make my legs warm." "I will take the device off when it becomes uncomfortable." "I don't have any pain in my legs." "My toes get numb when I wear these for a long time."

"I don't have any pain in my legs." Rationale: Pneumatic compression devices are designed to promote venous return and prevent deep vein thrombosis. The client should not have pain with the use of this device. The devices should be kept on for the majority of the day and only removed for assessments and ambulation. Numbness of the toes and temperature changes of the extremities indicate that the devices may not be working effectively.

The nurse has attended a staff education conference about electroconvulsive therapy (ECT). Which of the following statements indicates a need for further teaching? "Clients will have 4 electrodes placed on their scalp, which deliver an electrical current and monitor brain activity." "General anesthesia is given during the procedure; therefore, cardiac and airway monitoring is required." "The procedure is performed in order to resolve seizure activity in clients with epilepsy." "Clients may experience memory loss following the procedure, which may resolve over time."

"The procedure is performed in order to resolve seizure activity in clients with epilepsy." Rationale: It requires further teaching if the nurse states that the purpose of the procedure is to resolve seizure activity in clients with epilepsy. The goal of ECT is to induce seizure activity in the brain that may improve depression and bipolar disorder by affecting chemicals and neurons in the brain. Clients will have 4 electrodes placed on their scalp: 2 for monitoring brain activity and 2 for delivering an electrical current. General anesthesia is provided during the procedure, and clients should be monitored closely for airway or cardiovascular compromise. Memory loss is a common and temporary side effect of ECT.

The nurse is caring for a client who had a myocardial infarction 1 day ago and has a cardiac output of 2 L/min. The nurse should monitor the client for which complication? Acute kidney injury Pulmonary embolism Deep vein thrombosis Bradycardia

Acute kidney injury Rationale: A cardiac output of 2 l/min indicates possible heart failure or cardiogenic shock secondary to myocardial damage. The client is at high risk for end-organ damage, such as kidney injury, and it is a priority for the client to be closely monitored for signs of acute kidney injury such as oliguria and anuria.

A nurse is reviewing the laboratory results of a client admitted with orthopnea, fatigue, and frothy sputum. Which finding indicates a diagnosis of heart failure? PaO2 level of 75 mmHg INR level of 1.2 BNP of 300 pg/ml WBC count of 12,000/mm³

BNP of 300 pg/ml Rationale: A brain natriuretic factor (BNP) of 300 pg/ml indicates heart failure. The normal value is less than 100 pg/ml. BNP is a hormone produced by the ventricles of the heart and is increased in response to ventricular pressure overload. A partial pressure of oxygen level (PaO2) of 75 mmHg is not specific to heart failure. Low PaO2 levels may indicate a respiratory disorder. An international normalized ratio (INR) level of 1.2 is not associated with a heart failure diagnosis. INR levels are used to evaluate anticoagulation therapy. A white blood cell (WBC) count of 12,000/mm³ is not indicative of heart failure. Elevated WBCs indicate an infectious process.

The nurse is caring for an older adult client who has a urinary tract infection (UTI). Which trend in vital signs should be a priority for the nurse? A Temperature has increased from 99.9 to 100.2°F B Heart rate has increased from 97 to 105 beats per minute C Respiratory rate has decreased from 20 to 16 breaths per minute D Blood pressure has decreased from 112/76 mmHg to 90/52 mmHg

Blood pressure has decreased from 112/76 mmHg to 90/52 mmHg Rationale: The client with a UTI is at risk for developing complications such as sepsis. The greatest concern is the 20-point reduction in systolic blood pressure, which may indicate sepsis and require prompt intervention to reduce potential damage to body organs from hypoperfusion. The client's respiratory rate is within normal limits. While the heart rate and temperature are slightly elevated, these findings do not warrant immediate intervention over the reduced blood pressure.

The night shift nurse is caring for a client diagnosed with a hemorrhagic cerebrovascular accident. The client has new onset confusion and is agitated. Which action would be a priority for the nurse? Call the healthcare provider and suggest a CT scan Stay with the client and reorient them to the situation Administer the prescribed PRN anxiolytic Lower the lighting to promote relaxation.

Call the healthcare provider and suggest a CT scan Rationale: The priority intervention here is to obtain a CT scan to assess for further bleeding. The client with new onset confusion may have increased ICP from blood in the brain. Administering an anxiolytic may mask the signs of neurologic changes. Encouraging the client to sleep may also delay identification and treatment of a medical emergency.

The nurse is caring for a client who is one day postoperative Roux-en-Y gastric bypass surgery. Which finding would be a concern to the nurse? A Diminished breath sounds B Hypoactive bowel sounds C Oral temperature of 100.1°F (38.4°C) Correct Answer (Blank) D Bedside glucose level 180 mg/dL

Clients who had a Roux-en-Y are at risk for developing a leak at the anastomosis site. A leak of GI contents into the abdomen can cause an infection, which the nurse should monitor for signs of fever. A bedside glucose level of 180 is elevated but normal in a gastric bypass client. Hypoactive bowel sounds and diminished breath sounds are normal findings postop one day.

The nurse is caring for a client who has just been admitted to the acute care facility. Which of the following findings indicate that the client is at risk for skin breakdown? Hematuria Abdominal pain Hypertension Diaphoresis

Diaphoresis Rationale: Diaphoresis causes a client to be at risk for breakdown due to the excessive moisture that the skin is exposed to. Hematuria does not indicate that the client is incontinent, just that there is blood in the urine. Abdominal pain and hypertension are not directly related to skin breakdown.

The nurse is caring for a client receiving total parenteral nutrition (TPN) who has a new prescription to discontinue the infusion. The infusion is tapered off slowly to prevent which of the following complications? Fluid volume deficit Electrolyte imbalance Hypoglycemia Protein calorie malnutrition

Hypoglycemia Rationale: TPN is a hypertonic solution containing protein, carbohydrates, and fats. Immediate discontinuation may result in hypoglycemia, as the client's insulin supply may become higher than the glucose demand. Therefore, the infusion is tapered off slowly. Tapering off the infusion will not prevent a fluid deficit, malnutrition, or electrolyte imbalance.

A nurse is preparing to begin a 24-hour urine collection for a client. Which action will the nurse perform to ensure accurate urine collection? Ask the client to void and include the urine in the collection Place a sign outside the client's room indicating not to discard urine specimens Inform the client to empty their bladder and document the time in the medical record Instruct the client to discard the last urine before the collection time ends

Inform the client to empty their bladder and document the time in the medical record Rationale: Recording the time the urine collection begins is a crucial step to obtaining an accurate sample. The time should be easily accessible to other healthcare providers for continuity of care. The first urine should be discarded. The urine collection begins after the first urine is discarded. Placing a sign outside of the client's room does not provide the client privacy. The sign should be placed on the client's bathroom door to remind the client not to discard their urine. The last urine before the collection time ends should be included with the specimen for analysis.

A nurse is assessing a client with a hemoglobin A1C level of 9.0%. The client reports feeling "pins and needles" in their feet throughout the day. The nurse counsels the client on which intervention to prevent neurological complications? Applying warm compresses to the feet Keeping glucose levels within normal range Inspecting the feet daily for any injuries Taking pain medication as prescribed

Keeping glucose levels within normal range Rationale: The client's symptoms and laboratory value are indicative of peripheral neuropathy caused by diabetes mellitus. Controlling blood sugar levels can prevent peripheral neuropathy from worsening. Applying warm compresses to the feet is not indicated for a client with peripheral neuropathy. The client may sustain burns if unable to detect temperature changes. Inspecting the feet daily for any injuries helps prevent delay in treatment; however, this alone does not prevent peripheral neuropathy from worsening. Taking pain medication as prescribed will help decrease the pain associated with peripheral neuropathy; however, it will not prevent the condition from worsening.

The nurse has inserted an orogastric tube (OGT) into the client being mechanically ventilated via an oral endotracheal tube. Which of the following interventions should be used to confirm the initial placement of the OGT? Instill 30-ml of air into the tube while listening for the air over the epigastric region Aspirate 30-ml of gastric contents and use litmus paper to determine the pH Attach a colorimetric capnometer and assess for end-tidal CO2 Obtain a chest radiograph to identify the end of the tube below the level of the diaphragm

Obtain a chest radiograph to identify the end of the tube below the level of the diaphragm Rationale: The old technique of auscultation of air injected into a gastric tube has proven unreliable. With the exception of the chest x-ray, other methods should not be used for the initial placement of gastric tubes but can be used thereafter. A radiograph is the gold standard for identifying correct tube placement.

The nurse is caring for a client who is immobile. Which of the following locations is most appropriate for the nurse to assess for peripheral edema? On the sternum Over the tibia Above the elbow Behind the knee

Over the tibia Rationale: Peripheral edema should be assessed over a bony area of an extremity, such as the pretibial area. The sternum is not considered a peripheral site, and the areas above the elbow and behind the knee often have adipose tissue that may make the assessment less accurate.

The nurse is caring for a client who is in a second-degree heart block and reports dizziness and shortness of breath. The nurse notes the client's blood pressure is 90/40 mmHg. Which action should the nurse take? Administer prescribed atropine Prepare for transcutaneous pacing Perform synchronized cardioversion Administer prescribed vasopressin

Prepare for transcutaneous pacing Rationale: A second-degree block occurs when the electrical conduction is interrupted, usually at the AV node, and does conduct through the Purkinje fibers. This results in the failure of the ventricles to contract, which decreases cardiac output. To treat a second-degree block, the nurse should prepare the client for transcutaneous pacing, which will increase cardiac output. Synchronized cardioversion is used to treat tachycardia dysrhythmias, such as SVT or atrial fibrillation. Atropine contraindicating in treating a second-degree block. Vasopressin causes vasoconstriction which increases blood pressure but will not treat second-degree block.

A nurse is reviewing documentation for an assigned client. Which finding indicates a high risk for skin breakdown? A Braden scale score of 13 Correct Answer (Blank) B GCS score of 14 C Norton scale score of 15 D FLACC score of 2

Rationale: A Braden score of 13 is considered high risk for skin breakdown. The Braden scale identifies the risk of developing pressure ulcers based on six categories including sensory perception, activity, mobility, nutrition, friction, and moisture. A Glasgow coma scale (GCS) score of 14 is not a high risk for skin breakdown. The GCS measures the level of consciousness. The Norton scale assesses the risk for skin breakdown. Scores less than 14 are considered high risk for pressure ulcer development. The face, legs, activity, crying, and consolability (FLACC) scale is used to assess pain. A score of 2 indicates mild discomfort.

The nurse is caring for a client who had a coronary artery bypass graft (CABG) 1 day ago and has a pulmonary capillary wedge pressure (PCWP) of 20 mmHg. The nurse should monitor the client for which complication? A Pulmonary edema Correct Answer (Blank) B Hemorrhage C Hypovolemia D Tachycardia

Rationale: A PCWP value of 20 mmHg is elevated and indicates left ventricular failure. Clients with acute left ventricular failure are at risk for developing acute pulmonary edema and subsequent respiratory compromise; therefore, it is a priority to monitor this complication based on the PCWP values.

The nurse is administering medication to a client through a percutaneous endoscopic gastrostomy (PEG) tube. Which action by the nurse will maintain the patency of the tube? A Crush medication to a fine powder before pouring into the tube B Flush the tube with water between each medication Correct Answer (Blank) C Push medication through the tube with water D Keep the tube unclamped for an hour

Rationale: A PEG tube, which is a feeding tube that is surgically placed through the client's abdomen into the stomach, is used to administer prescribed medication. To maintain tube patency, the nurse should dilute all medication with water, administer one medication at a time, and flush the tube with 15 to 30 ml of water between each medication. The medication should instill through the tube by gravity, and pushing it through the tube with the syringe and water would cause the tube to clog. After a medication is administered, the nurse should clamp the tube for at least 20-30 minutes before resuming tube feeding.

The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? A "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." B "I will not eat or drink anything after midnight before the procedure." C "I will use the prescribed laxative before the procedure." D "A barium enema is used to examine the upper and lower GI tracts." Correct Answer (Blank)

Rationale: A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while X-ray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body.

The nurse is observing an unlicensed assistive person (UAP) perform a manual blood pressure reading on a client's right arm. As the UAP inflates the cuff, the cuff begins to unwrap from the client's arm. Which action should the nurse take? A Gently hold the cuff in place to help the UAP continue obtaining the blood pressure. B Deflate the cuff completely, then re-inflate the cuff for a new blood pressure reading. C Remove the cuff and check to see if it properly fits the client's arm size. Correct Answer (Blank) D Remove the cuff and take a new blood pressure from the client's other arm.

Rationale: A blood pressure (BP) measurement will be inaccurate if the cuff does not fit properly. A sign of this can be if the cuff tends to come loose during inflation. A cuff that is too tight or too small will cause a falsely high BP reading. The nurse should remove a poorly fitting BP cuff and obtain a cuff that is properly fitted for the client's extremity. To ensure accurate BP measurement, the nurse should ensure the BP cuff is the proper size for the client's extremity. The cuff can be selected using the guides marked on the inside of the cuff. Once selected, the deflated cuff should be applied evenly and snugly around the extremity.

A nurse is assessing a client post-bronchoscopy for tracheobronchial foreign body removal. Which finding indicates the treatment was successful? A Hyperresonance upon percussion B Intercostal retractions upon inspiration C Wheezing noted upon expiration D Vesicular breath sounds upon auscultation Correct Answer

Rationale: A bronchoscopy is a procedure performed to remove foreign bodies from the airways with the use of a scope. Vesicular breath sounds are a normal finding after a bronchoscopy. Vesicular sounds indicate the airways are open and air is flowing adequately into the lungs. Hyperresonance upon percussion is not a normal finding. Hyperresonance indicates air trapped in the lower airways. Intercostal retractions are not a normal finding. Retractions are indicative of a blocked airway. Wheezing upon expiration is not a normal finding. Wheezing indicates a narrowing of the airways.

A nurse is assessing a client post-peripheral bypass graft to the left lower extremity. Which finding indicates the procedure was effective? A Capillary refill time to left foot is 2 seconds Correct Answer (Blank) B Strength of left dorsalis pedis pulse is +1 C Left foot is cold to the touch D Skin to the left lower extremity appears taut

Rationale: A capillary refill time of 2 seconds indicates adequate blood flow and perfusion. The normal capillary refill time is less than 3 seconds. A +1 dorsalis pedis pulse strength is not a normal finding. A +1 strength is indicative of weak circulation. The normal strength is +2. A cold extremity is not a normal finding. Cold extremities are indicative of poor circulation. The nurse should inform the healthcare provider of the finding. Taut or tense skin is not a normal finding. Taut skin is indicative of compartment syndrome and should be reported immediately.

The nurse is caring for a client who underwent an open cholecystectomy 72 hours ago. Which assessment finding requires the nurse's immediate action? A Client complains of right shoulder pain B Spots of blood found on gauze dressings C Client complains of nausea D Temperature of 101.8°F (38.8°C) Correct Answer (Blank)

Rationale: A cholecystectomy is the removal of a client's gallbladder. 'Open' means that the gallbladder was removed through an abdominal incision vs. using laparoscopy. A temperature of 101.8°F three days after surgery may indicate a post-op or surgical-site infection. The temperature should be reported to the health care provider immediately. Nausea after surgery may be common secondary to anesthesia and pain medications. Spots of blood can be expected and shoulder pain from the use of CO2 gas is generally only seen with a laparoscopic cholecystectomy.

The nurse is caring for a client who is postoperative a right mastectomy. Which intervention should the nurse implement to prevent the development of lymphedema? A Place a cool compress on the affected arm B Elevated the affected arm on a pillow above the level of the heart Correct Answer (Blank) C Maintain a peripheral intravenous site below the antecubital area of the affected arm D Encourage the client to avoid excessive movements of the affected arm

Rationale: A client who had a mastectomy is at risk for lymphedema. Lymphedema occurs when lymph nodes are removed or impaired lymph fluid drainage occurs in the extremity on the side of the mastectomy. The lymph fluid collects in the tissues of the affected extremity. To prevent lymphedema, the nurse should encourage the client to perform range of motion exercises and elevate the extremity above the level of the heart. The nurse will advise the student to avoid any IVs or blood pressure measurements in the affected arm to prevent fluid collection or increased pressure. The client should be taught to avoid applying cold compresses, which cause vasoconstriction.

The nurse is caring for a client who is postoperative 48 hours coronary artery bypass graft. The nurse notes the client's telemetry monitor indicates the client is in atrial fibrillation. Which laboratory test should the nurse obtain for this client? A D-dimer B Serum potassium Correct Answer (Blank) C Troponin I D Arterial blood gas

Rationale: A client who is postoperative CABG is at risk for electrolyte imbalance, such as hypokalemia. Clients with hypokalemia are at increased risk for dysrhythmias, such as atrial fibrillation. D-dimer is used to evaluate the presence of clotting. Troponin I is used to evaluate a myocardial infarction. ABG is used to evaluate acid-base balance.

The nurse is preparing to reposition a client who is postoperative day one from right hip arthroplasty. Which actions should the nurse take? A Keep the client's hip in abduction at all times Correct Answer (Blank) B Flex the client's hip at a 90-degree angle C Move the client towards the unaffected side D Place the client's legs together

Rationale: A client who is postoperative hip arthroplasty should be positioned with the hips abducted at all times, which prevents dislocation of the hip. The client should be moved towards the affected side to prevent dislocation. Placing the client's legs together and flexing the hip could cause hip dislocation.

The nurse is assessing a client with glaucoma. To assess the client's peripheral vision, which technique should the nurse perform? A Confrontation Correct Answer (Blank) B Gaze positions C Corneal reflex D Jaeger

Rationale: A client with glaucoma will have a decrease in peripheral vision, which can be tested with the confrontation test. The nurse will have the client cover an eye while the nurse covers the opposite eye. The nurse will then bring an object or their fingers slowly into the field of vision midway between the client and the nurse. The corneal reflex is used to test pupillary response and assess cranial nerve II. The Jaeger test is used to test visual acuity. The gaze positions are used to test oculomotor function and cranial nerves III, IV, and VI.

The nurse is educating a client who has heart failure about disease management. Which statement by the client indicates to the nurse that the teaching was effective? A "I will take my diuretic before sleep and drink fluids during the day." B "I will weigh myself on the same scale three times a week." C "I know that my exercise routine is working when I am breathing hard." D "I will read food labels and limit my sodium to 2 grams per day." Correct Answer

Rationale: A client with heart failure should be taught how to manage their disease, which should include how to prevent fluid volume overload and decrease impaired activity tolerance. The client should be taught to weigh themselves daily using the same scale and limit sodium intake to 2 grams daily. The client should be advised to avoid taking diuretics right before bed and limit fluid intake during the day. The client should be instructed to stop activity before they become short of breath.

A client has just returned from the post anesthesia care unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8°F (34.8°C). Which action should the nurse implement first? A Ask the PACU nurse more details of what happened in PACU B Call the health care provider and obtain further orders for warming C Apply a warm blanket and check the temperature in 10 minutes Correct Answer (Blank) D Continue to monitor the vital signs as indicated

Rationale: A client's postoperative temperature should be at least 95° F (35° C). Post-surgical hypothermia can lead to cardiovascular complications, transfusion requirements, and risks of infection. The first action of the nurse should be to apply a warm blanket and recheck the temperature in 10 minutes. If the temperature does not increase after this time, the next step would be to call the health care provider for further actions, such as an electric warming blanket. Postoperative hypothermia may be due to an effect of surgery due to anesthetic drugs or if the client's skin was exposed for a long period of time.

The nurse is reviewing laboratory results for a client who had a left-heart cardiac catheterization 1 hour ago. Which of the following findings is of greatest concern to the nurse? A Creatinine level of 2.2 mg/dl Correct Answer (Blank) B Hemoglobin level of 14 g/dl C Glucose level of 120 mg/dl D Potassium level of 4.9 mEq/l

Rationale: A creatinine level of 2.2 mg/dl indicates possible contrast-induced acute kidney injury following cardiac catheterization and requires follow-up and immediate treatment to prevent further kidney damage. The other laboratory values are not of concern over the elevated creatinine.

The nurse is assessing a client who has just had a cast placed for an upper extremity fracture. Which of the following findings indicates that the client is experiencing a decrease of peripheral circulation to the casted extremity? A Unequal pulses are present in the upper extremities. Correct Answer (Blank) B Fingers are warm to the touch. C Capillary refill is less than two seconds. D Turgor is brisk.

Rationale: A decrease in the pulse strength of the affected extremity indicates that there is circulatory impairment to the affected extremity. Warm fingers and quick capillary refill indicate appropriate circulation. Turgor assesses hydration status rather than circulation.

A client who is scheduled for a diagnostic mammography asks the nurse about the cancer risk from radiation exposure. Which response is most appropriate by the nurse? A "You have nothing to worry about; it is less than tanning in the nude." B "The radiation from mammography is equivalent to one hour of sun exposure." Correct Answer (Blank) C "A chest X-ray gives you more radiation exposure." D "This exam does not use radiation, and it is not dangerous."

Rationale: A diagnostic mammogram is used when the clinical findings of a breast examination or on a screening mammogram are suspicious. The additional views of a diagnostic digital mammogram provide an adequate assessment by the health care provider and are the current method of diagnosing breast lesions. A client would need to have several mammograms in a year to be at risk for cancer. The radiation exposure from one mammogram session is thought to be equivalent to being out in natural sunlight for one hour. This answer is concise and gives the client a point of reference. Comparing the radiation exposure between diagnostic tests is not therapeutic and may cause greater concern by the client. Additionally, mammograms do pose a (very small) risk due to some radiation exposure.

The nurse is reviewing the medical record of an inpatient client and notes a positive stool occult blood test. The nurse recognizes which factors may have contributed to this positive result? Select all that apply. Current naproxen sodium use Correct Answer (Blank) Recent invasive dental procedure Correct Answer (Blank) Amblyopia Daily consumption of red meat Correct Answer (Blank) Hemiparesis Current corticosteroid use Correct Answer (Blank)

Rationale: A fecal occult blood test is used to detect occult (i.e. hidden) blood from causes such as colorectal cancer, gastric or duodenal ulcers, diverticulosis, or gastrointestinal (GI) bleeding. Drugs that can cause GI bleeding include non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. naproxen sodium) and corticosteroids. Factors that may contribute to a false-positive result include bleeding gums following a dental procedure (due to swallowed blood), and the ingestion of red meat within three days before testing because red meat contains animal hemoglobin. Amblyopia (i.e. poor vision in one eye) and hemiparesis (i.e. unilateral weakness) would not directly contribute to a positive fecal occult blood test.

The nurse instructs a client on how to collect a stool specimen at home using the guaiac test. The nurse also instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? Select all that apply. Sirloin steak Correct Answer (Blank) Broiled salmon Marinated cauliflower Correct Answer (Blank) Oranges Correct Answer (Blank) Pork chops Acetaminophen

Rationale: A guiac specimen checks to see if there is microscopic blood in the stool. There are various factors and substances that can create a false positive or negative result. Clients should limit their intake of vitamin C because too much can lead to a false negative result. Fruits and vegetables with high peroxidase activity, such as broccoli and cauliflower should be avoided several days prior to obtaining the specimen. Food like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test is performed. Chicken, pork and seafood can be consumed. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test. Acetaminophen does not affect the results of the fecal occult blood test.

A nurse is providing care to a client admitted for gastrointestinal bleeding. Which laboratory finding will the nurse immediately report to the healthcare provider? A PT of 12 seconds B Albumin level of 3.8 g/dl C INR of 1.6 D Hemoglobin level of 6.1 g/dl Correct Answer

Rationale: A hemoglobin level of 6.1 mg/dl should immediately be reported. Gastrointestinal bleeding can lead to hemorrhage and shock. The normal hemoglobin level ranges from 12 to 18 g/dl A prothrombin time (PT) of 12 seconds and an international normalized ratio (INR) of 1.6 are slightly above normal and are expected findings in a client with gastrointestinal bleeding. The normal PT time is 9.5 to 11.8 seconds, and the normal INR level is between 0.8 and 1.2. An albumin level of 3.8 g/dl is slightly below normal and expected in a client with gastrointestinal bleeding. The normal albumin level is between 4 and 6 g/dl.

The nurse is caring for a client with anemia of chronic disease. The client's latest hemoglobin level is 7.6 g/dL. Which clinical manifestations would the nurse expect to find? Select all that apply. Pallor Correct Answer (Blank) Hypertension Tachypnea Correct Answer (Blank) Bradycardia Fatigue Correct Answer (Blank)

Rationale: A hemoglobin level of 7.6 is very low. Normal levels range from 12 to 16 g/dL for females and 14 to 18 g/dL for males. Due to the low level of hemoglobin in the blood, the client will exhibit signs of low tissue oxygenation or hypoxia, such as fatigue, activity intolerance, shortness of breath, tachycardia, tachypnea and skin pallor (i.e., the skin is pale and cool to the touch). The client would not have bradycardia or hypertension with such severe anemia. The opposite is more likely, such as tachycardia.

The nurse is preparing a client for a kidney, ureter, bladder (KUB) radiograph test. Prior to the test, which action should the nurse plan to take for this client? A Keep the client NPO for eight hours before the examination B Plan to have a fleets enema given prior to the examination C Medicate the client with a PRN antihistamine prior to the examination D Take no special actions before this examination Correct Answer (Blank)

Rationale: A kidney, ureter, bladder X-ray is a simple X-ray requiring no special preparation. Antihistamines are generally administered if there is an expectation of allergic reaction to contrast; there is no contrast given for a KUB. Fleets enemas are sometimes given prior to barium enemas. It is not necessary to keep the client NPO.

A nurse is reviewing the results of an amniocentesis performed on a client who is 36-weeks pregnant. Which finding indicates fetal lung maturity? A Absence of PG B hCG level of 5,400 mIU/ml C L/S ratio of 2:1 Correct Answer (Blank) D High AFP levels

Rationale: A lecithin/sphingomyelin (L/S) ratio of 2:1 indicates fetal lung maturity. L/S are pulmonary surfactants found in amniotic fluid. An absence of phosphatidylglycerol (PG) is indicative of respiratory distress. PG is a lipid found in pulmonary surfactants that helps prevent alveolar collapse. A human chorionic gonadotropin (hCG) level of 5,400 mIU/ml is an expected finding at 36 weeks gestation. Levels of hCG are not indicative of fetal lung maturity and are determined by a blood test. High alpha-fetoprotein (AFP) levels are associated with fetal neural tube defects.

The nurse is completing an initial assessment on a client. Which of the following findings should the nurse identify as a risk factor for insufficient vascular perfusion? A A fiberglass cast on the lower extremity Correct Answer (Blank) B Use of a supplemental oxygen device C History of skin cancer D Generalized weakness

Rationale: A limb that is immobilized (especially those that are casted, splinted, or braced) is at an increased risk of circulation impairment. Supplemental oxygen devices do not affect peripheral vascular circulation. A history of skin cancer and generalized weakness do not directly affect vascular perfusion.

The nurse is caring for a client who had a thoracotomy with a right upper lobectomy. The nurse should focus on pain management for which reason postoperatively? A Deep breathing and coughing Correct Answer (Blank) B Maintain full range of motion C Internal incisional healing D Relaxation and sleep

Rationale: A lobectomy is often performed to treat tuberculosis, bronchiectasis, and cancer. Postoperatively, the focus of care is to prevent respiratory complications, such as atelectasis and pneumonia. Without proper pain management, clients will be reluctant to cough and deep breathe, which will predispose them to these and other complications.

A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first? A Obtain the client's heart rate and oxygen saturation Correct Answer (Blank) B Assess the client's deep tendon reflexes C Place the client on fall risk and seizure precautions D Order the client a meal with foods high in magnesium

Rationale: A normal serum magnesium level ranges from 1.5 to 2.5 mEq/L. Causes of hypomagnesemia include alcohol abuse, medication use (i.e., diuretics), and lack of intake of magnesium-containing foods. Clients with hypomagnesemia can present with tremors, tetany, hyperactive reflexes, arrhythmias, and confusion. Although it is important to check the client's reflexes, hyperreflexia is to be expected. The most appropriate action to take first is to evaluate the client's heart rate, rhythm, and oxygen saturation. The client should be placed on continuous cardiac monitoring until the magnesium level returns to normal. The other interventions should also be implemented but not until after evaluating the client's cardiac and respiratory status first.

A nurse is assessing a client post small bowel resection with ileostomy placement. Which clinical finding indicates a surgical complication? A The client verbalizes abdominal pain upon palpation. B The collection bag is empty. C The stoma is pale pink and dry. Correct Answer (Blank) D The client reports nausea after a meal.

Rationale: A pale pink, dry stoma is indicative of ischemia. Decreased circulation to the area can lead to necrosis. The nurse should report this finding promptly. Pain around the area of the stoma is an expected finding after a surgical procedure. The nurse should administer prescribed analgesics. An empty collection bag is not an abnormal finding after a small bowel resection. An ileostomy drains 24 to 48 hours after surgical placement. Nausea after a surgical procedure is a common finding. The nurse should monitor for vomiting and other gastrointestinal issues.

The nurse is preparing a client for a paracentesis. Which action would be a priority for the nurse to take before the procedure? A Auscultate lung sounds B Palpate bladder for distention Correct Answer (Blank) C Verify last bowel movement D Administer prescribed analgesia

Rationale: A paracentesis is a procedure where the healthcare provider uses an ultrasound-guided needle to drain fluid from the peritoneal cavity. The nurse should assess for bladder distension to prevent puncture of the bladder during the procedure. Verifying the last bowel movement, auscultating the lungs, and administering prescribed analgesia are important actions but not the priority before the procedure.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What information would be essential for the nurse to know about this procedure when teaching the client? A The procedure involves surgical repair with an incision of a diseased coronary artery to improve blood flow. B The procedure involves placement of an automatic implanted cardiac defibrillator. C The procedure is a noninvasive radiographic examination of the coronary arteries. D The procedure compresses plaque against the wall of the diseased coronary artery to improve blood flow. Correct Answer (Blank)

Rationale: A percutaneous transluminal coronary angioplasty (PTCA) is an invasive procedure performed to open blocked coronary arteries caused by coronary artery disease (CAD). The procedure is performed during a cardiac catheterization and does not involve implanting a cardiac defibrillator. A balloon is inflated once the catheter is in place in the diseased artery and compresses fatty tissue resulting in improved blood flow. A coronary artery bypass graft (CABG) is a surgical procedure that requires incisions to repair diseased coronary arteries.

A nurse is reviewing the laboratory date for a client with disseminated intravascular coagulation. Which results should the nurse expect for this client? A Hemoglobin level of 19 g/dL B Platelet count of 100,000 mm³ Correct Answer (Blank) C PT level of 10 seconds D D-dimer of 0.2 mcg/mL

Rationale: A platelet count of 100,000 mm³ is expected in a client with disseminated intravascular coagulation (DIC). The normal platelet count is 150,000 to 400,000 mm³. A hemoglobin level of 19 g/dL is above normal. The hemoglobin level in a client with DIC is expected to be below normal. The normal hemoglobin range is 12 to 18 g/dL. A prothrombin level of 10 seconds is below the normal range. The prothrombin time in a client with DIC is expected to be above normal. The normal clotting time is 11 to 12.5 seconds. A D-dimer of 0.2 mcg/mL is normal. The D-dimer level of a client with DIC is expected to be increased above 0.4 mcg/dL.

The nurse is assessing a client who had a thoracotomy and has a pleural chest tube connected to a dry suction drainage system. Which finding would require the nurse to take immediate action? A Drainage system is secured to the end of the bed. B Tubing is looped next to the client. C The client reports feeling the chest tube move. D Bubbling is noted in the water seal chamber. Correct Answer

Rationale: A pleural chest tube is placed after a thoracotomy to promote drainage from the pleural space and promote re-expansion of the lung. A dry suction drainage system uses an internal vacuum that, when connected to wall suction, will create the suction pressure. Bubbling in the water seal chamber can indicate that there is an air leak in the system requiring immediate action by the nurse. An air leak could indicate the client has a pneumothorax. To prevent tipping over, the drainage system can be secured to the end of the bed. Looping the tubing next to the client will prevent drainage from settling in the tube. It is normal for clients to report that the tube feels like it is moving.

The nurse is caring for a client admitted with a diagnosis of bacterial meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse should expect to see which result? A Elevated sedimentation rate B Increased glucose levels C Clear cerebrospinal fluid D High protein levels Correct Answer (Blank)

Rationale: A positive CSF for bacterial meningitis would include the presence of protein, a positive blood culture, decreased glucose, cloudy color with increased opening pressure, and an elevated white blood cell count. If it was viral meningitis, the difference would be that the CSF glucose would be within normal parameters.

The nurse is reviewing laboratory results for a client with hepatic cirrhosis. Which of the following findings is of greatest concern to the nurse? A Elevated alkaline phosphatase (ALT) level B Prothrombin time of 25 seconds Correct Answer (Blank) C Elevated serum bilirubin level D Hemoglobin (Hgb) of 14 g/dl

Rationale: A prothrombin time of 25 seconds is elevated and indicates an increased risk of bleeding due to hepatic cirrhosis. The client should be closely monitored for signs and symptoms of hemorrhage. The ALT and bilirubin levels are elevated in hepatic cirrhosis, and this is an expected finding. The Hgb level is within normal limits and indicates no active bleeding at this time.

A client is scheduled to have a pulmonary artery catheter inserted (PAC). Prior to the procedure, what information would be essential for the nurse to teach the client about a PAC? A "The catheter is inserted through the groin into the left side of the heart. B "You will be under general anesthesia for this procedure by an anesthesiologist." C "The catheter will measure different pressures in the heart and lungs." Correct Answer (Blank) D "You will be unable to eat or drink anything for several hours after the procedure."

Rationale: A pulmonary artery catheter, also known as a Swan-Ganz catheter or right heart catheterization, is inserted into the right side of the heart and into the arteries that lead to the lungs. It is inserted either through the groin or neck, using conscious sedation and local anesthetic, at the bedside (usually in an intensive care unit.) PAC can measure right atrial pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure; these measurements can be used to assess oxygenation of the blood in the right heart and overall cardiac output. Clients can eat or drink after the procedure.

The nurse is planning care for a group of assigned clients on a medical unit. Which client should the nurse identify as requiring immediate risk reduction interventions? A The client with a history of a fall in the last three months Correct Answer (Blank) B The client who uses a cane at home C The client who frequently calls for assistance to the bathroom D The client who reports mild dizziness when sitting up in the morning

Rationale: A recent fall is the biggest indicator that a client will fall again. Falling once doubles the chance that an older adult will fall again. While all the other clients are at risk and require some form of intervention, the client with a history of falls is the priority for the nurse. One out of five falls causes a serious injury, such as a traumatic brain injury (TBI), or fractures, such as hip fractures.

A nurse is performing a bladder scan on a postoperative client. The scan reveals a bladder volume of 100 milliliters. Which intervention does the nurse expect to perform next? A Insert an intermittent urinary catheter B Keep the client on NPO status C Administer a prescribed intravenous fluid bolus Correct Answer (Blank) D Request a prescription for a diuretic

Rationale: A result of 100 milliliters indicates a low volume of urine in the bladder. Urine production is altered in postoperative clients. The nurse should expect to administer intravenous fluids to increase urine production. Inserting an intermittent urinary catheter is not indicated for a urine volume of 100 mL. There is no indication of urinary retention. Keeping the client on NPO status will further decrease urine production. Requesting a prescription for a diuretic is not indicated. A diuretic is administered in clients with fluid volume overload.

A nurse is assessing a newborn after receiving phototherapy. Which clinical finding indicates the therapy was successful? A Bilateral PERRLA B Serum bilirubin level of 7 mg/dl Correct Answer (Blank) C Axillary temperature of 36.7°C (98.0°F) D Intact skin turgor

Rationale: A serum bilirubin level of 7 mg/dl is an expected finding after phototherapy. Phototherapy is initiated when serum bilirubin levels are above 10 to 12 mg/dl in a newborn. Pupils that are equal, round, and reactive to light and accommodation (PERRLA) are a normal finding but unrelated to the intended effects of phototherapy. An axillary temperature of 36.7°C (98.0°F) is a normal finding; however, phototherapy is not intended for this purpose. Intact skin turgor is a normal finding and indicative of adequate hydration; however, this finding does not evaluate the intended effects of phototherapy.

The nurse is reviewing laboratory results for a client with end-stage renal disease (ESRD). Which of the following findings is of greatest concern to the nurse? A Serum creatinine level of 3.5 mg/dl B Serum potassium level of 6.2 mEq/l Correct Answer (Blank) C Blood urea nitrogen (BUN) level of 25 mg/dl D Hemoglobin (Hgb) level of 11 g/dl

Rationale: A serum creatinine level of 6.2 mEq/l indicates severe hyperkalemia due to renal failure and requires follow-up as the client with ESRD will need hemodialysis to prevent cardiac arrhythmias related to hyperkalemia. A serum creatinine level of 3.5 mg/dl and a BUN level of 23 mg/dl are elevated and are expected findings in ESRD. A Hgb level of 11 g/dl is slightly decreased and indicates anemia due to ESRD, which is also an expected finding.

During a routine clinic visit, the nurse reviews the laboratory results of an adult client. Which laboratory result is most important to notify the health care provider about? A Red blood cell level of 3.7 x 106/µL B Low-density lipoprotein level of 160 mg/dL C Serum potassium level of 2.5 mEq/L Correct Answer (Blank) D Fasting glucose level of 132 mg/dL

Rationale: A serum potassium level less than 3.5 mEq/L indicates hypokalemia. The low serum potassium level is the most important abnormal lab value because hypokalemia can lead to serious cardiac complications, including life-threatening dysrhythmias. The nurse should notify the health care provider about the abnormal potassium level. The other lab values are also outside of the normal ranges but do not pose as immediate of a threat as the low potassium level.

A nurse is evaluating the results of a stress test performed on a client. Which finding indicates an expected response to the procedure? A Blood pressure drops from 125/82 mmHg to 91/50 mmHg during the stress test B A prolonged episode of dyspnea with accessory muscle use occurs after the stress test C P waves have no relationship to QRS complexes on an ECG after the stress test D Heart rate increases from 80 beats/min to 120 beats/min during the stress test Correct Answer

Rationale: A stress test evaluates the heart's ability to adapt to physical activity. An elevation in heart rate is an expected finding when exercising. Hypotension is not expected when exercising. A significant decrease in blood pressure may indicate heart disease. A prolonged episode of dyspnea with accessory muscle use after the stress test is not an expected finding. Shortness of breath should improve gradually after the physical activity has stopped. P waves that have no relationship to QRS complexes on an electrocardiogram are indicative of cardiac arrhythmia. The client may require further treatment.

A client who underwent surgery 12 hours ago becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment should the nurse complete first? A Peripheral glucose stick B Pupillary response C Pulse oximetry Correct Answer (Blank) D Cardiac rhythm strip

Rationale: A sudden change in mental status in any postop client should trigger a nursing intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange, which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these findings, which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations and loss of consciousness. While there may be other factors influencing the client's behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant changes in glucose would be evaluated.

The nurse is assessing a client in the postoperative area following a thyroidectomy. Which assessment finding should the nurse report immediately to the health care provider? A Mild sore throat and hoarseness B Headache and nausea C Tetany and paresthesia Correct Answer (Blank) D Irritability and insomnia

Rationale: A thyroidectomy is the removal of the thyroid gland. Complications of a thyroidectomy include bleeding, infection, airway obstruction, hypoparathyroidism and hypocalcemia. Manifestations of hypocalcemia include tetany and paresthesia. Tetany (involuntary muscle contractions) and paresthesia (numbness and tingling) are indicative of a dangerously low serum calcium level; therefore, the nurse should notify the health care provider immediately of those findings.

The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which assessment finding would the nurse immediately report to the health care provider? Select all that apply. Nonpalpable pedal pulse on the affected limb Correct Answer (Blank) Capillary refill 6 seconds on the affected toes Correct Answer (Blank) Bruising or lump at the insertion site Pale color of the affected limb Correct Answer (Blank) Trace amount of serosanguineous drainage on the groin dressing

Rationale: A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds.

A nurse is reviewing the transvaginal ultrasound results for a client with a suspected ectopic pregnancy. Which finding does the nurse expect to observe on the ultrasound? A Fetal biparietal diameter of 8.5 cm B Grade II placenta C Tubal gestational sac Correct Answer (Blank) D Fetal weight of 2,500 g

Rationale: A tubal gestational sac indicates an ectopic pregnancy. Gestational sacs should be located inside the uterus in a normal pregnancy. A fetal biparietal diameter of 8.5 cm indicates an advanced gestational age. This finding is not consistent with an ectopic pregnancy. A fetal weight of 2,500 grams is consistent with advanced gestational age, not an ectopic pregnancy. An ultrasound provides only an estimate of the fetal weight based on other anatomical measurements. Grade II placenta indicates a mature placenta consistent with advanced gestational age. This finding is not observed in an ectopic pregnancy.

The nurse has taught a client about the purpose of urinalysis testing. Which of the following statements by the client indicates the need for further teaching? A "This test can measure if I potentially have issues with my kidney function." B "This test can determine which type of bacteria may be causing my urinary tract infections." Correct Answer (Blank) C "This test can measure if my high blood sugar from diabetes is causing metabolic issues." D "This test can determine if I potentially have kidney stones."

Rationale: A urinalysis can determine a wide variety of potential systemic issues by measuring pH, glucose, ketones, protein, red and white blood cells, and bacterial counts. The presence of protein may indicate glomerular disorders and warrants further kidney function work-up. A urinalysis can measure the presence of bacteria; however, a urine culture is needed to identify the specific organism to determine specific antimicrobial therapy. The presence of ketones in the urine may indicate diabetic ketoacidosis and requires further monitoring. The presence of red blood cells in the urine may indicate kidney stones and requires further work-up.

A nurse is preparing to obtain a urine culture from a client with an indwelling catheter. Which action will the nurse take to collect the sample? A Empty urine from the collection bag into a clean specimen container B Detach the collection bag from the catheter and allow the urine to drain into the specimen container C Discontinue the indwelling catheter and obtain the sample when the client urinates D Attach a syringe to the catheter access port and aspirate urine Correct Answer

Rationale: A urine sample from an indwelling catheter should be obtained from the access port to ensure fresh urine. A syringe is required to aspirate the urine from the access port. A urine sample should not be collected from the collection bag. The drainage bag is not considered sterile and may alter the results of the urine culture. Detaching the collection bag from the catheter is not required to obtain a urine sample. Detaching the bag may introduce bacteria into the urethra. The indwelling catheter does not need to be discontinued to obtain a urine sample.

A nurse is working in the emergency department caring for clients with intoxication. Which lab value is important before treatment can begin for the intoxicated client? A Ethanol/alcohol Correct Answer (Blank) B Hemoglobin C Glucose D Albumin

Rationale: A verbal report of alcohol consumption by the client is notoriously inaccurate (usually on the lower side of ingestion), so blood alcohol levels are initially obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. The other lab values are important but are not the priority.

A nurse is providing care to a client with esophageal varices and a history of cirrhosis. The client suddenly vomits 750 milliliters of frank, red blood. Which action should the nurse perform first? A Call a rapid response Correct Answer (Blank) B Insert an additional intravenous line C Prepare to infuse packed red blood cells D Request a prescription for a type and crossmatch

Rationale: A volume of 750 milliliters of hematemesis is indicative of rapid blood loss. The nurse should first call a rapid response to prevent hypotensive shock. Inserting an additional intravenous line is necessary for pharmacological treatment; however, the nurse should first call a rapid response, so the client can be evaluated. Packed red blood cells will help replace the blood loss; however, the nurse should first call a rapid response before preparing blood transfusion equipment. A prescription for a type and crossmatch is necessary for a blood transfusion; however, this action is not the priority.

The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that the prescribed treatment is working? A The periwound texture is moist and soft B The edge of the wound appears rolled or curled under C The size of the wound is decreasing Correct Answer (Blank) D Soft yellow tissue seen in wound bed

Rationale: A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound, preventing the wound from healing.

The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV). Which lab finding should the nurse anticipate to be elevated? A Albumin B WBC (white blood cells) C BUN (blood urea nitrogen) D ALT (alanine aminotransferase) Correct Answer (B

Rationale: ALT and AST (aspartate aminotransferase) are enzymes located in liver cells that can leak out into the bloodstream when liver cells are injured. Elevated ALT (and AST) indicate liver damage. One of the liver's jobs is to make albumin; low albumin can be a sign of liver disease. Leukopenia (a decrease in the number of WBCs) is a common finding associated with HBV. BUN and creatinine are used to evaluate kidney function.

The nurse is caring for a 17-month-old child diagnosed with acetaminophen poisoning. Which of these lab reports should the nurse review first? A Red blood cell and white blood cell counts B Blood urea nitrogen (BUN) and creatinine clearance C Aspartate aminotransferase (AST) and Alanine transaminase (ALT) Correct Answer (Blank) D Prothrombin Time (PT) and partial thromboplastin time (PTT)

Rationale: Acetaminophen is toxic to the liver and causes hepatic cellular necrosis. This causes the liver enzymes AST and ALT to be released into the blood stream, which elevates serum levels. The next lab values to review are those associated with coagulation, then the blood counts and lastly the renal-associated labs, including BUN and creatinine.

A nurse witnesses a child lose consciousness from choking on a hotdog in a public park. What should the nurse do first? A Attempt a single finger sweep to remove the food. B Start 100 to 120 chest compressions per minute. C Open the airway and give two rescue breaths. D Activate the emergency response system. Correct Answer (Blank

Rationale: Activating the emergency response system should be done first, so that emergency medical services (EMS) personnel can arrive quickly and support the nurse's resuscitation efforts.

The nurse is caring for a 7-year-old child hospitalized for acute glomerulonephritis. Which is the priority intervention to include in the client's plan of care? A Encourage rest periods B Monitor for increased urinary output C Monitor for increased blood pressure Correct Answer (Blank) D Assess for generalized edema

Rationale: Acute glomerulonephritis (AGN) is the inflammation of the glomeruli and nephrons caused by an immune response secondary to a previous infection. Clients with AGN lose protein and red blood cells in their urine. Clients with AGN will have a decrease in urine output, not an increase in urine output, due to the decrease in glomerular filtration rate (GFR). This decreased in GFR is related to the inflammation of the glomeruli. The priority is the evaluation of hypertension because clients with AGN are at risk for hypertension due to the decrease in urine output and sodium retention. Although rest periods are important for a client with AGN, focusing on the client's blood pressure is the highest priority. Clients with AGN will have edema that is mild. However, assessing for edema is not as high of a priority as hypertension.

The nurse is comparing arterial blood gas results obtained at 1000 for a client with chronic obstructive pulmonary disease (COPD) with results obtained at 0800. Which of the following findings is of greatest concern to the nurse? A PaO2 has decreased from a baseline of 82 mmHg to 78 mmHg B Oxygen saturation has decreased from a baseline of 94% to 90% C PCO2 has increased from a a baseline of 55 mmHg to 65 mm Hg Correct Answer (Blank) D HCO3 has increased from a baseline of 28 mEq/l to 32 mEq/l

Rationale: Acute hypercapnia with rapid rises above the client's baseline represents a serious decline in the client's condition and can lead to respiratory failure. Normal PCO2 values are 35-45 mm Hg. Clients with COPD often have chronic elevation in PCO2 levels; however, an increase of 10 mmHg indicates a rapid decline in respiratory status. Clients with COPD often have chronic hypoxemia and the values for the PaO2 and oxygen saturation have decreased slightly but are still within the expected range for a client with COPD. The HCO3 indicates metabolic compensation for acidosis related to COPD.

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. Which value should the nurse expect to be elevated? A Calcium B Magnesium C Creatinine D Amylase Correct Answer (Blank)

Rationale: Acute pancreatitis is inflammation of the pancreas due to autodigestion from pancreatic enzymes of amylase and lipase. Amylase, which is required to convert starchy foods into simple sugar, will be elevated in acute pancreatitis. Calcium levels will be decreased with acute pancreatitis. Creatinine and magnesium levels are not affected with acute pancreatitis.

The nurse is educating a client who is newly diagnosed with Addison's disease about preventing complications. Which statement should the nurse include in the teaching? A "Keep your legs elevated when you are sitting." Correct Answer (Blank) B "Increase your physical activity by 10 minutes every day." C "Reduce the amount of sodium in your diet." D "Decrease your fluid intake to about 1.5 liters a day."

Rationale: Addison's disease is hypofunction of the adrenal cortex with results in a decrease in secretion of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). The client will have hyponatremia, so the client should increase their sodium intake. Addison's disease increases the risk of hypotension, due to hypovolemia, so the nurse should instruct the client to keep legs elevated when sitting and increase fluid intake. The client with Addison's is at risk for decreased glucose levels and activity intolerance and should be instructed to avoid excessive activity.

The nurse is educating a client who is newly diagnosed with Addison's disease about preventing complications. Which statement should the nurse include in the teaching? A "Increase your physical activity by 10 minutes every day." B "Reduce the amount of sodium in your diet." C "Keep your legs elevated when you are sitting." Correct Answer (Blank) D "Decrease your fluid intake to about 1.5 liters a day."

Rationale: Addison's disease is hypofunction of the adrenal cortex with results in a decrease in the secretion of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). The client will have hyponatremia, so the client should increase their sodium intake. Addison's disease increases the risk of hypotension due to hypovolemia, so the nurse should instruct the client to keep their legs elevated when sitting and increase fluid intake. The client with Addison's is at risk for decreased glucose levels and activity intolerance and should be instructed to avoid excessive activity.

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. When should the nurse suction a client's ET tube to maintain patency? A When peripheral wheezes are heard in all lobes B After the client completes deep breathing exercises C When adventitious sounds are auscultated over the central airways Correct Answer (Blank) D After the ventilator alarms go off

Rationale: Adventitious sounds over the central airways indicate accumulation of secretions, which need to be removed to maintain the airway. Wheezing in the lobes will not cause airway obstruction. Ventilators alarm for many reasons, and the cause needs to be determined before suctioning. Deep breathing exercises should help open and clear the airway, so suctioning is not needed.

A client who had a wrist cast applied three days ago calls from home, reporting that the cast is loose enough to slide off. How should the nurse respond? A "You need a new cast now that the swelling is decreased." Correct Answer (Blank) B "Use an arm sling to keep the casted arm immobile." C "Place several gauze bandages inside the cast to prevent it from sliding off." D "As your muscles atrophy, the cast is expected to loosen."

Rationale: After a new fracture, the surrounding soft tissue may be significantly swollen when the cast is initially applied. After the swelling has resolved, the cast may become loose. If the cast is loose enough to permit more than one finger between the cast and the skin, the cast probably needs to be replaced. The client should never place anything inside the cast. The client's muscles should not have atrophied while in a cast for just three days. Keeping the arm immobile does not solve the problem and therefore would not be appropriate. On the contrary, immobilizing the arm above the casted fracture is not necessary and can cause contractures of the upper extremity proximal to the fracture.

The respiratory therapist arrives to draw blood from a client for an arterial blood gas analysis. What should the nurse understand about the collection procedure? A The femoral artery is the preferred sample site. B Supplemental oxygen should be turned off 30 minutes prior to collecting the sample. C The blood sample must be kept at room temperature and delivered to the lab as soon as possible. D Firm pressure should be applied over the puncture site for at least 5 minutes after the sample is drawn. Correct Answer (Blank)

Rationale: After drawing the sample, it is very important to press a gauze pad firmly over the puncture site until bleeding stops or for at least 5 minutes. The client should not be asked to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. The sample of arterial blood must be kept cold, preferably on ice, to minimize chemical reactions in the blood.

The nurse has inserted an indwelling urinary catheter into a male client who is uncircumcised. Which action should the nurse do next? A Gently pull the catheter back into place B Attach catheter to securing device C Replace foreskin over the catheter D Inflate the catheter tip balloon Correct Answer

Rationale: After inserting an indwelling urinary catheter into a male client who is uncircumcised, the priority action by the nurse is to inflate the catheter tip balloon. Inflating the catheter tip balloon ensures that the catheter will not dislodge from the bladder. Once the catheter tip is inflated, then the nurse will gently pull the catheter back into place, replace the foreskin over the catheter, and attach the catheter to a securing device.

An older adult client is admitted to the hospital with a diagnosis of protein-energy malnutrition. The nurse understands that which blood test reflects the client's overall protein status? A Albumin level Correct Answer (Blank) B Myoglobin level C Haptoglobin level D Bilirubin level

Rationale: Albumin is a serum protein that is formed in the liver. A serum albumin level reflects a client's overall protein status, and is used to diagnose, evaluate and monitor the disease course in clients with impaired nutrition. Malnourished clients have decreased serum albumin levels. The approximate normal range for serum albumin is 3.5 to 5.0 g/dL. A serum haptoglobin measurement is primarily used to identify the presence of intravascular hemolysis. A serum bilirubin test evaluates a client's liver function, and a serum myoglobin test is used to evaluate muscle damage.

The nurse is caring for a client admitted with a diagnosis of myocardial infarction (MI). Which lab finding is most consistent with the client's diagnosis? A Elevated proBNP B Elevated troponin Correct Answer (Blank) C Elevated myoglobin D Elevated creatine kinase

Rationale: All of these lab tests may be elevated during an MI. Although CK-MB (along with total CK) is a very good test, it has been replaced by troponin. Elevation of troponin is the most reliable because it is more specific to heart damage; it elevates within a few hours and remains elevated for about 10 days. CK-MB is one of three separate forms (isoenzymes) of the enzyme creatine kinase (CK); it is found mostly in heart muscle and rises when there is damage to the heart. An elevated C-reactive protein is associated with a risk of cardiovascular disease.

A client who had a vasectomy is in the post-anesthesia care unit (PACU) at an outpatient clinic. Which point is most important for the nurse to reinforce? A "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception." Correct Answer (Blank) B "This procedure doesn't impede the production of male hormones or the production of sperm in the testicles." C "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours." D "The health care provider recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort."

Rationale: All of these options are correct information. The most important point to reinforce is the continued need to take additional action for birth control until it is determined that no risk is present for a possible pregnancy outcome.

The home health nurse is performing a daily dressing change on a client who has a diabetic ulcer. Which intervention is most important for the nurse to implement to meet the goal of wound healing? A Arrange for a referral to a diabetic educator. B Involve the client in making heath care decisions. Correct Answer (Blank) C Evaluate the client's understanding of appropriate foot care. D Schedule regular visits to monitor wound healing.

Rationale: Although all of these interventions may benefit the client, the involvement of the client in making health care decisions is the most important intervention to meet the outcomes. The client will be more motivated to adhere to the nurse's recommendations if they are involved in the process of setting priorities and making decisions. Regular assessments, evaluating the client's understanding of foot care and referring the client to a diabetic educator may be follow-up interventions. However, client involvement in treatment decisions and care is essential for providing client-centered nursing care.

The nurse is monitoring a client following an esophagogastroduodenoscopy (EGD). Which finding should the nurse immediately report to the healthcare provider? A The client's voice is hoarse when speaking. B The client has hypoactive bowel sounds. C The client reports difficulty with swallowing. Correct Answer (Blank) D The client reports nausea.

Rationale: An EGD is a procedure that uses a flexible, fiberoptic scope to visualize the esophagus, stomach, and upper duodenum. Following the EGD, the nurse should monitor the client for signs of perforation, such as pain, difficulty swallowing, and vomiting blood. The client should be instructed to expect a hoarse voice and sore throat for several days following the procedure. Nausea is common after an EGD.

A nurse is providing care to a client with liver cirrhosis. Which finding should the nurse expect to see on a laboratory report? A Ammonia level of 100 mcg/dl Correct Answer (Blank) B Prothrombin time of 12 seconds C Albumin level of 5.5 g/dl D Total bilirubin level of 0.9 mg/dl

Rationale: An ammonia level of 100 mcg/dl is expected in a client with liver cirrhosis. The liver is unable to convert ammonia to urea causing increased levels in the blood. The normal ammonia level is 10 to 80 mcg/dl. A prothrombin time (PT) of 12 seconds is a normal finding. PT is expected to be prolonged in clients with liver cirrhosis. An albumin level of 5.5 g/dl is above the normal range. Albumin levels are expected to be decreased in clients with liver cirrhosis due to a lack of hepatic synthesis. The normal albumin level is 3.5 to 5.0 g/dl. A total bilirubin level of 0.9 mg/dl is a normal finding. Total bilirubin levels are expected to be elevated in a client with liver cirrhosis due to the inability of the liver to excrete it.

The health care provider (HCP) of a client with opioid-induced constipation prescribed the administration of a bisphosphate enema. After reviewing the client's medical record, the nurse recognizes which contraindications for giving the enema? Select all that apply. The client has a history of syncopal episodes. Correct Answer (Blank) The client has a history of thrombocytopenia purpura. Correct Answer (Blank) The client has a history of hyperkalemia. The client has a history of substance use disorder (SUD). The client has a history of hepatitis A. The client has a history of hemorrhoidectomy. Correct Answer (Blank)

Rationale: An enema can cause a vasovagal response and a temporary decrease in heart rate and blood pressure, causing syncope. Because the client already has a history of syncopal episodes, the nurse should clarify the order with the HCP first. The client's history of hemorrhoidectomy implies that hemorrhoids could be present, even if none are externally visible. If internal hemorrhoids are present, inserting the enema may cause bleeding and discomfort. Therefore, the nurse should clarify the order with the HCP first. Clients with thrombocytopenia (low platelet count) may begin bleeding from the rectum due to the mechanical trauma of the enema and should be given stool softeners and laxatives instead. The other conditions do not represent contraindications for receiving an enema.

The nurse is caring for a client who is scheduled for an exercise stress test. Which statement made by the client should indicate to the nurse that the client requires further teaching? A "I'll take my heart medications the morning of my test." Correct Answer (Blank) B "I will not smoke prior to my test." C "I will avoid eating for at least 8 hours." D "I'll skip my coffee the morning of my test."

Rationale: An exercise stress test is performed to assess the oxygen demand on the heart during activity. A client with coronary artery disease, or blockages in the coronary arteries, will increase the oxygen demand on the heart during exercise. The client should be instructed to avoid any caffeine and smoking, which could cause vasoconstriction altering the results of the stress test. The client should be NPO for at least 8 hours before the test. The client should be advised to hold any medications that can cause vasodilation, which could alter the results of the test.

The nurse is caring for a client who had an extracorporeal shockwave lithotripsy procedure for kidney stones. Which statement by the nurse demonstrates appropriate client teaching? A "Limit your intake of sodium to no more than 2 grams a day." B "Avoid the intake of citrus fruits for the next 2 months." C "Drink at least 3000 to 4000 mL of fluids each day." Correct Answer (Blank) D "Increase your intake of milk and dairy products."

Rationale: An extracorporeal shockwave lithotripsy (ESWL) procedure is a non-invasive method for treating stones in the kidney or ureter. It utilizes an energy source which generates a shock wave that is directed at the stone, breaking it up and allowing it to be flushed out of the kidney or ureter. After an ESWL, the client should drink 3 to 4 quarts (3,000 to 4,000 mL) of fluids each day. This extra hydration will aid in the passage of fragments of the broken up renal calculi and help prevent formation of new calculi. The other instructions are not appropriate or required after an ESWL.

The nurse is caring for a client who has been diagnosed with acute kidney injury. Which of the following changes in urinary output would indicate that the client condition is improving? A Increase in urine output Correct Answer (Blank) B Urinary hesitancy C Elevated urine concentration D Occasional hematuria

Rationale: An increase in urinary output indicates that the client's glomerular filtration rate is recovering from the initial injury. In the oliguria stage of acute kidney injury, the urine is very concentrated; once diuresis begins, the urine will be less concentrated. Hesitancy and hematuria do not indicate improvement of acute kidney injury.

After surgery, a client who has nasogastric tube placed reports feeling nauseous. What action should the nurse take? A Call the health care provider to troubleshoot the problem B Check the patency of the nasogastric tube Correct Answer (Blank) C Administer an antiemetic that is ordered PRN D Put the head of the bed in a higher position

Rationale: An initial indication that the nasogastric tube is obstructed is a client's report of nausea. Nasogastric tubes may become obstructed by being kinked or with mucus or sediment.

A nurse is reviewing laboratory results of a client taking warfarin for atrial fibrillation. Which finding should immediately be reported to the healthcare provider? A PTT of 45 seconds B INR of 3.9 Correct Answer (Blank) C Platelet count of 145,000/mm³ D D-dimer of 1.25 nmol/l

Rationale: An international normalized ratio (INR) of 3.9 should be reported to the healthcare provider immediately. The target INR for a client taking warfarin for atrial fibrillation is between 2.0 to 3.0. An increased INR can lead to bleeding. A partial thromboplastin time (PTT) of 45 seconds is a normal finding. PTT is not a value used to assess the effectiveness of warfarin therapy. A platelet count of 145,000/mm³ is not consistent with warfarin therapy. Thrombocytopenia is a possible complication of heparin. A D-dimer of 1.25 nmol/l is a normal finding. D-dimer is an indicator of fibrinolysis and is not used to evaluate warfarin therapy.

The nurse is reviewing the medical record of a client who is scheduled to have an intravenous pyelogram tomorrow. Which item in the client's health history should the nurse report to the health care provider? A Iodine allergy Correct Answer (Blank) B Pacemaker C Claustrophobia D Obesity

Rationale: An intravenous pyelogram (IVP) is a radiologic study in which intravenous radiopaque contrast material is used to visualize the kidneys, renal pelvis, ureters and bladder. Clients who are allergic to iodine or iodinated contrast dyes may need to be premedicated with prednisone and diphenhydramine to prevent an allergic reaction. Therefore, the nurse should notify the health care provider of the client's iodine allergy. Claustrophobia, the presence of a pacemaker and obesity are not contraindications for this test.

The nurse is caring for a client with anemia. Which of the following laboratory values is consistent with this diagnosis? A Hemoglobin (Hgb) level of 10 g/dl Correct Answer (Blank) B Hematocrit (HCT) of 45% C Hemoglobin (Hgb) of 20 g/dl D Hematocrit (HCT) of 55%

Rationale: Anemia is indicated by low hemoglobin and hematocrit levels. Normal hemoglobin levels are 14-18 g/dl for males and 12-16 g/dl for females. A hemoglobin level of 10 g/dl indicates anemia. Normal hematocrit levels are 42-54% for males and 37-47% for females. A hematocrit level of 45% is within normal limits and 55% is elevated, which can be seen in conditions such as dehydration.

The nurse is monitoring a client with a history of heart failure who is receiving a transfusion of packed red blood cells (PRBCS). The client reports the sudden onset of shortness of breath, and crackles are auscultated in the bases of the lungs. What is the priority assessment? A Mental status assessment and metabolic panel Correct Answer (Blank) B Skin turgor and intake and output (I&O) C Heart sounds and beta natriuretic peptide (BNP) D Capillary refill and presence of edema

Rationale: Any fluid that increases intravascular volume can place the patient at risk of acute circulatory overload. Increases in the extracellular fluid (ECF) can lead to swelling of cells in the central nervous system initially causing confusion, which may progress to coma or seizures. These findings can be best identified through laboratory tests and an assessment of mental status. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate of an impact on patient outcomes as cerebral edema.

The nurse is reviewing the plan of care for a client with a sacral, stage III pressure ulcer who is prescribed continuous negative-pressure wound therapy (NPWT). For which finding should the nurse notify the health care provider (HCP) immediately? A The client is incontinent of stool. B The client is receiving enteral nutrition. C The wound has extensive tunneling. D The client is receiving apixaban. Correct Answer (Blank)

Rationale: Apixaban is an anticoagulant (a direct factor Xa inhibitor) used to reduce the risk of stroke and systemic embolism in clients with atrial fibrillation. Anticoagulant therapy is a contraindication for NPWT due to the increased risk of bleeding in the wound. The other findings do not contraindicate the use of NPWT.

A nurse is providing care to a client with a nasogastric tube receiving continuous feedings. The nurse is informed by the healthcare provider that the client's chest x-ray reveals areas of consolidation in the lungs. Which action does the nurse expect to perform? A Discontinue the nasogastric tube B Switch to bolus feedings C Irrigate the nasogastric tube D Stop the continuous feedings Correct Answer (Blank)

Rationale: Areas of consolidation on a chest x-ray indicate fluid or solid contents within the lungs. A client receiving feedings via a nasogastric (NG) tube is at risk for aspiration. The nurse should expect to stop the feedings. Discontinuing the NG tube is not indicated. An NG tube can be repositioned if necessary. Switching to bolus feeds will not correct the problem of aspiration. Irrigating the NG tube is contraindicated. Irrigation may cause further accumulation of fluid in the lungs.

The nurse is caring for a client who is taking antibiotics for a urinary tract infection. Which of the following findings would indicate that the client's condition is improving? A Increase in urine output B Decrease in urinary frequency Correct Answer (Blank) C Increase in client's body temperature D Decrease in client's blood pressure

Rationale: As a urinary tract infection improves, the nurse should expect to see a decrease in urinary frequency and a decrease in dysuria. A decrease in blood pressure and an increase in urine output do not necessarily indicate that the client is improving. An increase in body temperature may indicate a worsening of the infection.

The recovery room nurse is assessing a client who is one-hour post-operative from a total knee arthroplasty with spinal anesthesia. Which of the following findings would indicate that the client is experiencing a complication? A Pulse oximetry reading fluctuates between 96% and 98% B Client reports knee pain increased from 3/10 to 5/10 C Systolic blood pressure decreased from 140 mmHg to 110 mmHg Correct Answer (Blank) D Temperature has increased from 99.0°F to 99.3°F

Rationale: As the client's anesthesia wears off and their pain increases, an expected finding would be that the blood pressure would rise. A decrease in systolic BP would indicate that the client may be bleeding and needs to be reported to the healthcare provider. Fluctuating O2 saturations are expected, as well as a small increase in temperature, due to the inflammatory process.

The nurse is assessing a client who is seeking care for abdominal pain and diarrhea. Which of the following questions by the nurse is appropriate to establish a baseline of the client's bowel movements? A "Where exactly is the pain in your abdomen?" B "Can you describe what your stool normally looks like?" Correct Answer (Blank) C "Has anyone around you been sick in the last week?" D "Do certain foods make your diarrhea better or worse?"

Rationale: Asking the client to describe their normal bowel movements will allow the nurse to establish the baseline for any further stool changes. The nurse could ask about the location of pain, exposure to someone sick, and triggering foods, but these do not gather data about the client's normal bowel movements.

A client had an open reduction and internal fixation (ORIF) of a femur fracture. During a routine assessment 36 hours after surgery, the nurse finds the client disoriented, short of breath, and warm to the touch. The client's temperature is 102.4°F (39°C). What assessment should the nurse perform next? A Measure oxygen saturation using a pulse oximeter Correct Answer (Blank) B Perform a neurologic check of bilateral distal extremities C Remove the splint and inspect the incision D Assess orientation to time, person and place

Rationale: Based on the client's history and assessment findings, the nurse should suspect fat embolism syndrome (FES). Neurologic changes and respiratory distress are two of the classic findings of FES (the third finding is a characteristic petechial rash.) The nurse should activate the rapid response team. While waiting for the team, the nurse will measure the client's SpO2, as well as pulse and blood pressure, and auscultate the lungs. The nurse will also administer supplemental oxygen and ensure venous access.

The nurse is preparing to administer a 250 ml bolus tube feed to a client with a percutaneous endoscopic gastrostomy (PEG) tube. The nurse aspirates the gastric contents and measures 95 ml of residual. Which action should the nurse take? A Hold scheduled feeding B Wait one hour before administering feeding C Continue with the scheduled feeding as prescribed Correct Answer (Blank) D Administer half of the prescribed feeding

Rationale: Before administering a bolus tube feed, the nurse will aspirate the stomach contents and measure residual. Residual is the amount of fluid left in the stomach from the previous feeding. A residual amount of 200 ml or more could indicate that the client has not digested the previous feeding. If the residual is 200 ml or more, the nurse should hold the scheduled feeding. Any residual less than 200 ml means the nurse would administer the feeding as scheduled. A nurse may need to reduce the amount of feeding or adjust the tube feeding time if the residual amount continues to be above 200 ml.

The nurse is observing unlicensed assistive personnel (UAP) obtain blood pressure measurements on assigned clients. Which of the following actions by UAP requires the nurse to intervene? A Obtaining a blood pressure on the left arm of a client with an arteriovenous fistula graft in the left upper extremity Correct Answer (Blank) B Measuring the blood pressure on the right upper arm of a client who had a left-sided mastectomy C Obtaining a blood pressure on the right lower extremity of a client with burns to bilateral upper extremities D Measuring the blood pressure on the left upper arm of a client who has a blood transfusion infusing through a right hand peripheral intravenous catheter

Rationale: Blood pressure measurements should not be performed on a particular client's limb in the following situations: the presence of casts or bulky bandages, burns or trauma to the extremity, surgical removal of lymph nodes such as mastectomy, an intravenous infusion in that limb or an arteriovenous fistula for dialysis is present. It requires intervention if the UAP is observed obtaining a blood pressure measurement in the same arm as an arteriovenous fistula. All other actions are a correct technique for obtaining blood pressures in these clients.

The nurse is caring for a client with a chest tube who is one day post-op following a thoracotomy. While performing an assessment, the nurse observes bubbling in the water seal chamber when the client coughs. Which intervention should the nurse do first? A Continue to monitor the client to see if the bubbling increases Correct Answer (Blank) B Clamp one of the chest tubes and ask the client to cough again C Call the surgeon immediately for potential return to surgery D Instruct the client to avoid coughing for the next day

Rationale: Bubbling in the water seal chamber that is associated with coughing after lung surgery is an expected finding within the first 48 hours postop. Small amounts of air escape into the pleural space when pressures inside the chest increases with coughing. Monitoring for increases or decreases in the bubbling with coughing is the only nursing action required at this time. The client should be encouraged to deep breathe and cough every two hours minimally.

The nurse is reviewing lab results for a client admitted with acute exacerbation of chronic obstructive pulmonary disease. Which lab result should be of highest concern? A Serum albumin level of 2.0 mg/dL B Hematocrit level of 50% C PaO2 level of 60 mm Hg Correct Answer (Blank) D PaCO2 level of 52 mm Hg

Rationale: COPD or chronic obstructive pulmonary disease is a chronic disease that causes obstructed airflow in the lungs due to inflammatory processes. Obstructed airflow may cause severe respiratory distress and affect a person's ability to exchange oxygen and carbon dioxide efficiently. The PaO2 level is significantly decreased (normal 80 to 100 mm Hg), indicating severe hypoxemia and should be of highest concern for the nurse. Clients with COPD chronically retain PCO2; thus, an elevated level is to be expected. The hematocrit level is at the upper end of the normal range. Although the albumin level is also significantly decreased, indicating malnutrition, it it of a lower priority than the low PAO2 level.

The nurse is planning care for a client with cystic fibrosis who has a prescription for chest physiotherapy (CPT). Which action should the nurse plan to take? A Administer prescribed bronchodilator before therapy Correct Answer (Blank) B Percuss each lung segment for 15 minutes C Perform therapy 30 minutes after eating D Apply vibration during inspiration

Rationale: CPT is prescribed. Apply vibration during inspiration is for clients who have thick bronchial secretions with difficulty clearing their airways. CPT involves the use of percussion and vibration to mobilize secretions. The nurse should administer the prescribed bronchodilator before therapy, which will open airways and make the removal of secretions easier. The nurse should only percuss lung segments for 2-5 minutes. Vibration should be applied when the client takes a deep breath in.

The nurse is obtaining a client's health history. Which of the following statements by the client indicates that they are at risk for insufficient vascular perfusion? A "My father died of pneumonia when he was sixty years old." B "I am allergic to lots of different antibiotics." C "I have noticed that I am getting weaker as I get older." D "I get pain in my calves when I walk for more than a few minutes." Correct Answer

Rationale: Calf pain with activity is often caused by peripheral arterial disease. This would indicate that the client is at risk for impaired perfusion. Allergies and age-related weakness are not risk factors for peripheral vascular insufficiency. Certain aspects within family history may be risk factors, but in this case, pneumonia does not affect the likelihood of peripheral vascular conditions.

The nurse is screening clients for factors that affect the peripheral vascular system. Which of the following clients is at risk for insufficient vascular perfusion? A A client who has gastroesophageal reflux B A client who has just had a cardiac catheterization Correct Answer (Blank) C A client who uses a walker for ambulation D A client who has dementia

Rationale: Cardiac catheterization requires the insertion of a catheter into a large blood vessel, such as the femoral artery. Circulation may be impaired to the extremity that was used for the insertion site. Gastroesophageal reflux and dementia do not affect peripheral circulation. The use of an assistive device for ambulation does not increase the risk of peripheral vascular impairment.

The nurse has received the laboratory results for a client who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory result will be most important to review? A Low-density lipoprotein level B Creatine kinase-MB level C Troponin T and I levels Correct Answer (Blank) D Myoglobin level

Rationale: Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction and therefore the most important lab value for the nurse to review. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body thus limiting its use in the diagnosis of myocardial infarction. The low-density lipoprotein (LDL) cholesterol level is useful in assessing cardiovascular risk but is not helpful in determining whether a client is having an acute myocardial infarction. The creatine kinase-MB level is also specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels.

The nurse is caring for a client with cardiogenic shock due to an acute myocardial infarction. The client's urine output has decreased from 60 to 70 mL per hour to 20 mL per hour. Which laboratory test is the priority to monitor? A Troponin B Hematocrit C Serum sodium D Serum creatinine Correct Answer (Blank)

Rationale: Cardiogenic shock occurs when either systolic or diastolic dysfunction of the heart's pumping action results in reduced cardiac output, stroke volume and blood pressure, leading to insufficient perfusion of vital organs such as the kidneys. The drop in urine output is indicative of impaired renal tissue perfusion secondary to the low cardiac output. The serum creatinine level is an important clinical indicator of kidney function and, therefore, is the priority to monitor.

The occupational health nurse is teaching a group of employees about prevention of carpal tunnel syndrome. Which interventions should the nurse include? Select all that apply. Perform wrist exercises Correct Answer (Blank) Request workstation modifications such as an ergonomic keyboard Correct Answer (Blank) Regularly rest your hands throughout the workday Correct Answer (Blank) Wear a brace or splint at night Correct Answer (Blank) Request an endoscopic carpal tunnel release

Rationale: Carpal tunnel syndrome (CTS) is a type of repetitive strain injury (RSI) resulting from prolonged force or repetitive movements. CTS is caused by compression of the median nerve, which enters the hand at the wrist through the narrow carpal tunnel. The carpal tunnel is formed by ligaments and bones. CTS is the most common RSI in the upper extremity. It is associated with hobbies or work that require continuous wrist movement (e.g., musicians, carpenters, computer operators). Preventative measures include identification of risk factors, stop aggravating movement, resting the hand, ice, wrist immobilization with a hand splint, nonsteroidal anti-inflammatory drugs, wrist exercises and physical therapy. A carpal tunnel release is a surgical intervention, usually reserved until all noninvasive interventions have been exhausted.

A client with a history of hypertension and hyperlipidemia is being evaluated in the emergency department for chest pain and shortness of breath. Which diagnostic tests should the nurse plan for? Select all that apply. Electrocardiogram Correct Answer (Blank) Complete blood count (CBC) Correct Answer (Blank) Serum calcitonin Helicobacter pylori Cardiac enzyme panel Correct Answer (Blank)

Rationale: Chest pain and shortness of breath are findings that could suggest the client is experiencing an acute myocardial infarction. An electrocardiogram (ECG) should be acquired to check the client's cardiac rhythm as well as any signs of acute myocardial ischemia (e.g., ST segment elevation). Cardiac enzymes, including creatinine kinase, myoglobin and troponin, are indicated to determine if cardiac muscle damage has occurred. A complete blood count (CBC) would check for low hemoglobin (Hgb), which can precipitate shortness of breath and chest pain if there is not enough Hgb to deliver oxygen to the myocardium. Serum calcitonin and Helicobacter pylori are not typically used with chest pain or shortness of breath.

A nurse receives a prescription to obtain a sputum sample from a client with a respiratory infection. Which nursing action is indicated for this procedure? A Obtaining the sample before bedtime B Waiting 15 minutes after meals to obtain the sample C Performing chest physiotherapy prior to obtaining the sample Correct Answer (Blank) D Using a throat swab to obtain the sample

Rationale: Chest physiotherapy (CPT) helps to mobilize secretions within the airways. CPT facilitates obtaining a sputum sample. Sputum samples should be obtained in the morning. Respiratory secretions are more concentrated with organisms earlier in the day. The nurse should wait to obtain the sample 1 to 2 hours after meals to decrease the risk of vomiting or aspiration. A throat swab is not indicated for a sputum sample. A greater amount of sputum is necessary for analysis.

A nurse is caring for a client with chronic kidney disease who is in fluid overload after being given an intravenous fluid bolus. Which assessment finding should the nurse anticipate? A S3 heart sound Correct Answer (Blank) B Flattened neck veins C Hypoventilation D Thready pulse

Rationale: Chronic kidney disease is characterized by a gradual loss of kidney function and decreases the body's ability to excrete wastes and fluids efficiently. When receiving a large about of intravenous fluids, the poorly functioning kidneys are unable to excrete properly, and the fluid builds up in the body. Symptoms the nurse should anticipate are shortness of breath, crackles in the lungs, swelling in the arms or legs (edema), distended neck veins, and bounding pulse. Auscultation of the heart will also reveal an S3 heart sound as this is an early sign of volume overload and heart failure due to the excessive fluid left in the ventricles.

The nurse is teaching a client who has chronic venous insufficiency about self-care. Which information should the nurse include in the teaching? A "Routinely check the tips of your toes for ulcers that can occur in people with this condition." B "Frequently flex and extend your ankles if you must remain standing for a long time at work." Correct Answer (Blank) C "Avoid eating green, leafy vegetables to minimize the risk for blood clots in your calves." D "Apply a topical antibiotic to any areas on your lower legs that have brown discoloration."

Rationale: Chronic venous insufficiency is characterized by the incompetence of the valves in the leg veins, which results in elevated venous pressure in the legs. Sequelae may include pain, edema, venous hemorrhage, venous thrombosis, and stasis ulcer development. Prolonged stationary standing may be detrimental for a client with chronic venous insufficiency because blood is allowed to remain stagnant in the legs, increasing venous pressure. Clients with chronic venous insufficiency may develop brown discoloration in the skin of the lower legs, as the elevated venous pressure causes capillary leakage of red blood cells, which eventually break down and release hemosiderin. This discoloration does not have an infectious etiology and thus is not improved by topical antibiotic application.

A nurse is reviewing the laboratory results of a client who is preoperative knee surgery. The nurse should notify which results to the healthcare provider? A Hematocrit of 40% B WBC count of 20,000/mm3 Correct Answer (Blank) C Creatinine level of 0.9 mg/dl D Potassium level of 3.9 mEq/l

Rationale: Clients having surgery will have laboratory tests done to identify any issues, such as infections, electrolyte imbalances, renal impairment, or bleeding complications. The nurse should report any abnormal labs to the healthcare provider. A WBC of 20,000/mm3 is elevated, indicating the client may have an infection or inflammatory response. A normal hematocrit is 40-50% for men and 36.1-44% for women. Creatinine levels should be between 0.5-1.1 mg/dl, and potassium levels should be between 3.6-5.0 mEq/l.

The nurse is assessing a client with diabetes type 2 who had a CT scan of the abdomen with contrast dye. The nurse identifies that the client received the prescribed dose of metformin after the diagnostic test. Which of the following laboratory findings indicates a complication? A Elevated lactate level Correct Answer (Blank) B Decreased blood urea nitrogen (BUN) level C Increased glomerular filtration rate (GFR) D Low mixed venous oxygen saturation

Rationale: Clients taking metformin are at increased risk for acute kidney injury and lactic acidosis with the use of iodinated contrast material for diagnostic studies; metformin should be stopped 48 hours prior to and 48 hours after the use of contrast agent or until kidney function is evaluated and normal. In kidney failure, BUN would increase and GFR would decrease. Mixed venous oxygen saturation is used in clients with impaired tissue perfusion.

The nurse is caring for a client who is experiencing alcohol withdrawal. The nurse notes the client has tremors in the upper extremities, hyperactive deep tendon reflexes, and a change in mental status. The nurse should assess the client for which electrolyte imbalance? A Hypocalcemia B Hyponatremia C Hypokalemia D Hypomagnesemia Correct Answer (Blank)

Rationale: Clients who are experiencing alcohol withdrawal are at risk of developing hypomagnesemia. The client will exhibit tremors, muscle weakness, changes in mental status, and hyperactive deep tendon reflexes. The nurse should obtain a serum hypomagnesemia level. Clients with inadequate calcium intake can develop hypocalcemia. Clients with vomiting or diarrhea or taking prescribed diuretics can develop hypokalemia. Hyponatremia develops from an excessive gain of water.

The nurse is reinforcing foot care instructions for a client with a history of arterial insufficiency in the legs. Which client statement should indicate to the nurse the need for further teaching? A "I will use Epsom salt to remove any corns and calluses." Correct Answer (Blank) B "I will ask a family member to help inspect my feet." C "I should not walk barefoot around my house." D "I should wear absorbent cotton socks."

Rationale: Clients who have peripheral arterial vascular disease suffer from decreased circulation and sensation to the lower legs and feet. Appropriate and regular foot care is very important to prevent integumentary complications. The client should not use commercial preparations or home remedies such as magnesium sulfate, the active ingredient in Epsom salt, to remove calluses or corns. Whenever possible, the client should have a professional inspect and remove any calluses or corns.

The nurse is planning care for a client who had a stroke earlier today. The client is alert, cooperative and follows commands. The client has left-sided hemiplegia. Which interventions should the nurse include in the client's plan of care? Select all that apply. Anterior hip precautions Contact precautions Seizure precautions Correct Answer (Blank) Swallow precautions Correct Answer (Blank) Fall precautions Correct Answer (Blank)

Rationale: Clients who have suffered a stroke can have neurological deficits. A client with hemiplegia (unilateral weakness) is at risk for impaired swallowing, choking and aspiration. The nurse should include a swallow screening/evaluation in the client's plan of care before allowing the client to eat or drink. This client is also at risk for falls due to hemiplegia. Clients who have suffered a stroke are at risk for seizures and should have seizure precautions in place (e.g., padded side rails, oxygen readily available, suction available). Anterior hip precautions are appropriate for clients who have had a hip arthroplasty, not a stroke. Contact precautions are not indicated for this client.

The preoperative nurse is reviewing the medical record of a client who is scheduled for a surgery with general anesthesia. Which information in the client's medical record should be reported to the health care provider prior to surgery? Select all that apply. Latex allergy Correct Answer (Blank) Anxiety Family history of malignant hyperthermia Correct Answer (Blank) Vitiligo Anticoagulant use Correct Answer (Blank)

Rationale: Clients who will be undergoing general anesthesia should be screened carefully to prevent complications. Malignant hyperthermia is an acute, life-threatening complication of certain drugs used for general anesthesia. A family history of malignant hyperthermia should be reported to the health care provider because it is a genetic condition. A latex allergy should be reported to the health care provider so products containing latex are avoided during the surgery. Recent anticoagulant use increases the risk for bleeding during or after surgery, and should also be reported to the health care provider prior to the surgery. Vitiligo is an autoimmune related skin pigment disorder with no contraindications for general anesthesia. Although anxiety is a pertinent consideration, it would not be a contraindication for general anesthesia.

The nurse is educating a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD) about symptom management. Which statement should the nurse include in the teaching? A "Keep your fluid intake to less than a liter a day." B "Choose foods that are low in protein." C "You can exercise until you feel short of breath." D "Perform pursed-lip breathing to prolong exhalation." Correct Answer

Rationale: Clients with COPD are at risk for malnutrition due to dyspnea and should be taught to eat a high protein diet. Clients with COPD can participate in exercise but should be instructed to rest before they experience shortness of breath, which could be a sign of overworking. Increasing fluid intake will decrease and thin secretions in the airway. Pursed-lip breathing provides positive pressure to allow for the client to prolong exhalation, which will decrease trapped air and reduce airway resistance.

The nurse is providing discharge instructions about symptom management to a client newly diagnosed with multiple sclerosis. Which statement should the nurse include in the instructions? A "Wear an eye patch on the right eye at all times to prevent diplopia." B "Relaxing in a hot tub will help with your muscle spasticity." C "Implement a schedule to include periods of rest." Correct Answer (Blank) D "Make sure you keep your immunizations up to date."

Rationale: Clients with MS should be instructed on how to manage symptoms, which should include implementing periods of rest to prevent muscle fatigue, increasing fiber in the diet, avoiding extremes in temperature, and decreasing stress. Clients do not need to wear an eye patch to prevent diplopia. Clients should be taught to identify triggers of exacerbations, such as immunizations, trauma, and stress.

A client has a new order for an open magnetic resonance imaging (MRI) scan without contrast to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the health care provider (HCP) before scheduling the MRI? A The client wears prescription glasses. B The client has a pacemaker. Correct Answer (Blank) C The client is claustrophobic. D The client is allergic to shellfish.

Rationale: Clients with a pacemaker, an internal device made of metal, cannot have a MRI scan done because of the force exerted by the magnetic field on metal objects. An open MRI scan is unlikely to cause claustrophobia. The client will be instructed to remove the glasses before the MRI scan, but this does not require consultation with the HCP. Because contrast medium will not be used, a shellfish allergy is not a contraindication to the MRI scan.

A client has a new order for an open magnetic resonance imaging (MRI) scan to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? A The client is allergic to shellfish. B The client is claustrophobic. C The client has a pacemaker. Correct Answer (Blank) D The client wears prescription glasses.

Rationale: Clients with permanent pacemakers cannot have an MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The client will need to be instructed to remove the glasses before the MRI, but this does not require consultation with the health care provider. Should contrast medium be used, a shellfish allergy is no longer considered a contraindication.

The nurse is caring for a client with a calcium imbalance related to hypoparathyroidism. The nurse should anticipate which clinical manifestation in this client? A Decreased neuromuscular excitability B Bounding peripheral pulses in the lower extremities C Decreased gastrointestinal activity and constipation D Facial twitching when the region over cranial nerve VII is tapped Correct Answer (Blank)

Rationale: Clinical manifestations of hypoparathyroidism are associated with electrolyte imbalances, such as hypocalcemia. Hypocalcemia is characterized by increased neuromuscular excitability, such as a positive Chvostek's sign when cranial nerve VII is stimulated. Decreased neuromuscular excitability, decreased gastrointestinal activity, and bounding pulses are associated with hypercalcemia, which is a condition related to hyperparathyroidism.

The nurse observes cloudy drainage from an abdominal catheter that was inserted two days ago for peritoneal dialysis. What other data should the nurse assess? A Urine output B Temperature Correct Answer (Blank) C Bowel sounds D Breath sounds

Rationale: Cloudy drainage may indicate a peritoneal infection, so it is essential to evaluate the client's temperature before notifying the health care provider. In a client on dialysis for renal failure little to no urine output would be an expected finding.

The nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings requires additional assessment? A Straw colored urine is in the drain tube. B One hundred ml of urine are in the drainage bag. C Urine in the drain tube is cloudy. Correct Answer (Blank) D Urinary output does not have an odor.

Rationale: Cloudy urine may indicate the presence of infection and requires additional assessment. Odorless, straw-colored urine and an output of 100 ml are normal assessment findings.

A nurse is caring for a client with peripheral arterial disease. The client verbalizes numbness to the lower extremities when lying in bed. Which intervention should the nurse implement to prevent neurological complications? A Apply a heating pad to the extremities B Elevate the lower extremities above the level of the heart C Instruct the client to perform leg raises while in bed Correct Answer (Blank) D Advise the client to switch positions often

Rationale: Collateral circulation increases the availability of blood flow to the extremities and prevents numbness associated with narrowing of blood vessels. A gradual increase in exercise builds up collateral circulation. Direct heat should never be applied to extremities that have decreased sensation. The inability to detect temperature changes may cause burns. The legs should be elevated but not above the level of the heart. Extreme elevation can slow arterial blood flow to the feet. Switching positions often while in bed will prevent skin breakdown; however, this will not prevent neurological complications.

The nurse is planning care for a group of clients who have had surgery. Which client should the nurse understand has the highest risk for delayed wound healing? A The client who had a mastectomy and who is receiving prescribed chemotherapy Correct Answer (Blank) B The client with diabetes type 1 who had a laparoscopic cholecystectomy C The client with renal failure who had an atrioventricular graft placed D The client who had a bowel resection and who is receiving prescribed IV antibiotics

Rationale: Combining other treatment methods, such as radiation and chemotherapy, with surgery contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of venous thromboembolism (VTE). The nurse completes a thorough preoperative assessment for factors that may affect the patient undergoing the surgical procedure. While the other clients may have some immunosuppression, the client receiving chemotherapeutics is at greatest risk for delayed wound healing.

The nurse is caring for a client who received thrombolytic therapy for an acute myocardial infarction (MI). Which information is most important for the nurse to communicate to the health care provider (HCP)? A A large bruise at the client's IV insertion site B An increase in troponin levels from baseline C No change in the client's reported level of chest pain Correct Answer (Blank) D A decrease in ST-segment elevation on the ECG

Rationale: Continued chest pain suggests myocardial ischemia and that the thrombolytic therapy is not effective. Other coronary interventions may be needed, such as a stent. Bruising is a possible side effect of thrombolytic therapy and should be monitored, but it is not more important to report than the unrelieved chest pain. The decrease of the ST-segment elevation indicates that perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the release of cardiac biomarkers into the circulation as the blocked vessel reopens.

A client who has a wet chest drainage system following a thoracotomy develops continuous bubbling in the water seal chamber of the collection device. What action should the nurse take? A Adjust the dial on the wall regulator to decrease suction. B Notify the health care provider of the presence of an air leak. Correct Answer (Blank) C Instruct the client to deep breathe and cough more frequently. D Clamp the chest tube immediately.

Rationale: Continuous bubbling in the water seal chamber is indicative of an air leak. Clamping the chest tube is contraindicated and can cause a pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system. Instructing the client to deep breathe and cough is not an appropriate intervention in this situation.

The nurse is caring for a client who is being treated for hypokalemia. The client has an order to receive an IV infusion of 40 mEq of potassium in 1,000 mL of 0.9% NaCl over 12 hours. Which intervention should the nurse implement during the infusion? A Obtain a set of arterial blood gases. B Initiate continuous pulse oximetry monitoring. C Place the client on bedrest during the infusion. D Place the client on continuous cardiac monitoring. Correct Answer (Blank)

Rationale: Continuous cardiac monitoring and a baseline electrocardiogram (ECG) is recommended for clients with hypokalemia. Hypokalemia causes electrical conduction changes in the heart (e.g., ST-segment depression, flat or inverted T waves, and U waves). Hypokalemia can also cause dangerous and potentially life-threatening cardiac dysrhythmias. This client should have continuous cardiac monitoring before, during and after the potassium replacement infusion. There is no clinical indication for bedrest, arterial blood gases or continuous pulse oximetry monitoring for a client receiving IV potassium replacement.

The nurse is providing discharge teaching for a client who has a spinal cord injury. Which of the following statements by the nurse should be included in the teaching? A "Reduce your fluid intake to prevent episodes of incontinence." B "Complete range of motion exercises to prevent contractures." Correct Answer (Blank) C "Your caregiver should do all of your self-care activities to prevent falls." D "Eat a diet low in protein to strengthen your immune system."

Rationale: Contractures occur due to the lack of use of the musculoskeletal system; therefore, it is important to perform range of motion activities to reduce the risk of developing contractures. Fluid intake should not be decreased, and the client's diet should be high in protein. The client should do as much self-care as they can to maintain independence.

The nurse is reviewing the medical record of a client who is scheduled for a computerized tomography (CT) scan of the brain with contrast. For which information in the client's medical record should the nurse notify the health care provider? Select all that apply. Client has a positive pregnancy test. Correct Answer (Blank) Client has an iodine allergy Correct Answer (Blank) Client takes anticonvulsant medication. Client has a mechanical heart valve Client is on hemodialysis. Correct Answer (Blank) Client has peripheral neuropathy.

Rationale: Contraindications for a CT scan of the brain with intravenous contrast dye include pregnancy, renal failure (clients on hemodialysis) and an iodine allergy (iodinated contrast dye is used). Peripheral neuropathy, anticonvulsant medications and the presence of an artificial, i.e., mechanical, heart valve are not contraindications for a CT scan of the brain with contrast.

The nurse is caring for a client following a coronary angiography procedure. The client's medical history includes type 2 diabetes mellitus and mild renal insufficiency. The nurse should anticipate which post-procedural order from the health care provider? A Place an indwelling urinary catheter. B Monitor serum creatinine levels. Correct Answer (Blank) C Resume metformin 500 mg by mouth daily. D Restrict oral fluid intake for 24 hours.

Rationale: Coronary angiography requires the use of an intravenous contrast dye. Clients with diabetes and/or impaired kidney function are at an increased risk for developing contrast media-induced nephrotoxicity (CIN). Therefore, creatinine levels should be closely monitored before and after the procedure to monitor kidney function and possible development of CIN. After the procedure, increased hydration is appropriate to help maintain renal blood flow and reduce the time the contrast media is in contact with the renal tubules and, therefore, help prevent CIN. Metformin is typically withheld for approximately 48 hours after the test because hypoglycemia or acidosis may occur in clients who have received contrast dye and take metformin. Urine output should be monitored after the procedure, however there is no indication for an indwelling urinary catheter.

The nurse has taught a female client about obtaining a clean catch urinalysis. Which of the following statements by the client indicates the need for further teaching? A "I will cleanse my perineum from back to front prior to obtaining the specimen." Correct Answer (Blank) B "I will urinate a small amount into the toilet before urinating in the specimen cup." C "I will remove the cup from my urine stream before I have finished urinating." D "I will use a new antiseptic swab each time I wipe to cleanse my perineum before the procedure."

Rationale: Correct technique for a female clean catch urine specimen includes cleansing the perineum with a new wipe from front to back (cleanest to dirtiest) prior to urinating. The client should urinate a small amount into the toilet prior to urinating into the cup to flush contaminants from the urethra contaminating the specimen. The client should remove the cup from the urine stream before finishing urinating, which eliminates contamination from skin flora.

The nurse is caring for a client who has a prescription for serum cortisol levels. When should the nurse prepare to obtain the specimen? A In the middle of the night around midnight B Before the client goes to sleep C During the middle of the day after lunch D First thing in morning before the client is out of bed Correct Answer (Blank)

Rationale: Cortisol levels, which evaluate adrenal activity, are the highest in the morning and then slowly begin to drop through the day with the lowest level around midnight. For accurate testing, the nurse should obtain the specimen first thing in the morning before the client engages in activity.

The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which lab finding is the priority? A Hematocrit of 60% Correct Answer (Blank) B PaO2 of 79 mm Hg C pH of 7.34 D Potassium level of 5.0 mEq/L

Rationale: DKA is defined as a blood pH less than 7.30, bicarbonate level less than 18 mEq/L, and blood glucose greater than 250 mg/dL. Hyperglycemia induces osmotic diuresis causing water and electrolyte loss. The elevated hematocrit level (approx. normal range 38% to 55%) confirms severe dehydration and is the priority lab finding for this client. The client will require rehydration with intravenous fluids. The potassium level for this client is on the high end of normal, and the PaO2 level is near the low end of normal (80-100 mm Hg).

The nurse is caring for a postoperative client who had a laparotomy six hours ago. Which nursing intervention is the most effective in preventing atelectasis from developing? A Assist the client to slowly deep breathe and cough Correct Answer (Blank) B Splint the incision with a pillow C Maintain adequate hydration D Ambulate the client within 24 hours postoperative

Rationale: Deep air excursion by slow deep breathing and coughing expands the lungs and stimulates surfactant production. This is the priority to prevent pulmonary complications along with the use of an incentive spirometer. The nurse should instruct the client on how to splint the abdomen when coughing. Maintaining hydration is also an important role in preventing atelectasis. Postoperative patients should be encouraged to ambulate early to promote bowel motility and lung expansion.

The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is most important in the prevention of the formation of deep vein thrombosis (DVT)? A Elevate the foot of the bed B Apply knee high support stockings C Prevent pressure at back of the knees Correct Answer (Blank) D Encourage isometric leg muscle exercises

Rationale: Deep vein thrombosis (DVT) is a blood clot that forms in a vein in the body, typically found in the lower extremities. DVTs can be caused by a variety of reasons. Prolonged bed rest in the hospital setting puts this client at high risk for developing a DVT due to decreased venous stasis or blood flow to the lower extremities. To prevent any obstruction in blood flow, the nurse would want to prevent pressure at the back of the knees. Other actions that may be implemented after this action include elevating the foot of the bed, apply pneumatic stockings and/or applying knee high support stockings, and encouraging the client to perform ankle pumps to promote blood flow back through the body.

When planning care for a client at risk for pulmonary embolism, the nurse shall make which intervention a priority? A Encourage client to cough and deep breathe B Maintain client on bedrest C Instruct client on how to use the incentive spirometer D Apply sequential compression devices to the legs Correct Answer (Blank)

Rationale: Deep vein thrombosis (DVT) is the primary cause of pulmonary embolism (PE). Preventing a DVT with the use of sequential compression devices, early ambulation, and prophylactic use of anticoagulant medications should be priority nursing interventions. Bedrest will increase the risk for a DVT and PE. Pulmonary hygiene interventions do not prevent a DVT or PE from occurring.

The nurse is reviewing the assessment data of a client suspected of having diabetes insipidus. Which of the following findings should the nurse expect after a water deprivation test? A Increased edema and weight gain B Unchanged urine specific gravity Correct Answer (Blank) C Decreased serum potassium D Rapid protein excretion

Rationale: Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve water. Symptoms of DI are excessive thirst and excessive urine output. Even when fluids are restricted, as with the fluid deprivation test, the client continues to excrete large amounts of urine. Normally, urine becomes more concentrated in situations of reduced fluid intake. Clients with DI do not have an increase in edema or weight gain. Due to the excessive urine output, these clients would be more apt to lose weight. Although clients who have DI are at risk for hypokalemia, participating in a water deprivation test would not alter the client's potassium level. If an individual was deprived of water, their specific gravity level should increase. This is a normal response. However, if a client suffers from DI, their specific gravity level would remained unchanged if they were deprived of water. Rapid protein excretion does not occur in a water deprivation test with clients who have DI.

The nurse is caring for a client with a traumatic brain injury (TBI) and a Glasgow Coma Scale score of 8. The client is being monitored for increased intracranial pressure. Which of the following changes in the client's condition requires prompt intervention? A Urine output has increased to 250 mL per hour. Correct Answer (Blank) B The client's ICP has decreased to 15 mmHg. C The pupillary response is sluggish bilaterally. D The systolic blood pressure has decreased to 110 mmHg.

Rationale: Diabetes insipidus (DI) is caused by decreased secretion of antidiuretic hormone (ADH, vasopressin). TBI is commonly associated with abnormalities of the water and sodium balance (SIADH and DI). If unrecognized, they can lead to severe electrolyte disturbances. High volume urine output is the primary sign of DI. Cushing's Triad includes the three primary signs that often indicate an increase in intracranial pressure. They are a rise in systolic BP, decreased pulse, and decreased respiration. The client has decreasing BP, which indicates an improvement in ICP, which corresponds with the normal ICP of 15. The client has a GCS of 8, which corresponds with sluggish pupils.

The nurse is caring for a client with type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing a complication of this condition? A Bounding pulses B Hematuria C Kussmaul respirations Correct Answer (Blank) D Hypertension

Rationale: Diabetic ketoacidosis is a serious complication of diabetes and may be manifested by Kussmaul respirations, fruity-smelling breath, hypotension, and gastrointestinal upset. Pulses will be weak rather than bounding, and hematuria is not directly associated with diabetes mellitus.

The nurse is developing a plan of care for a client with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse include in the plan? Select all that apply. Provide high-protein, high-calorie meals to help maintain adequate nutrition. Correct Answer (Blank) Schedule the client for an annual influenza vaccination. Correct Answer (Blank) Instruct the client on the pursed lip breathing technique to reduce carbon dioxide (CO2) retention. Correct Answer (Blank) Instruct the client to engage in high-intensity aerobic exercise to increase activity tolerance. Educate the client about relaxation techniques to help with their anxiety. Correct Answer (Blank)

Rationale: Diaphragmatic (abdominal) and pursed lip breathing help manage dyspneic episodes that occur with COPD. Breathing through pursed lips creates mild resistance, which prolongs exhalation and increases airway pressure. This technique delays airway compression and reduces air trapping prevalent with COPD. Clients with COPD tend to become anxious during acute dyspneic episodes. The nurse will help the client manage dyspneic episodes and panic attacks through the use of progressive relaxation, hypnosis therapy and biofeedback. For some clients, anxiolytics may be needed. Pneumonia is a common complication of COPD, and the client should receive the yearly influenza vaccine. Clients with COPD tend to feel too full to eat and have poor appetite and meal-related dyspnea. The work of breathing raises the client's calorie and protein needs, which can lead to protein-calorie malnutrition. It is important to urge the client to eat small, frequent meals of high-calorie, high-protein foods. Exercise for conditioning and pulmonary rehabilitation can improve function and activity tolerance in clients with COPD. Each client's exercise program should be personalized to the client's limitations. The simplest plan is to have the client walk daily at a self-paced rate, until symptoms limit further walking. High-intensity aerobic exercise would not be appropriate for the client with COPD.

A nurse is reviewing the medication administration record (MAR) for a 72-year-old client scheduled to have a cardioversion. Prior to the procedure, the nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A Digoxin Correct Answer (Blank) B Nitroglycerin ointment C Diltiazem D Metoprolol

Rationale: Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation during and after cardioversion. The other medications do not increase ventricular irritability.

A nurse is reviewing the results of an amniocentesis performed on a client who is pregnant. The nurse knows that low levels of alpha-fetoprotein may indicate which fetal condition? A Anencephaly B Down syndrome Correct Answer (Blank) C Spina bifida D Omphalocele

Rationale: Down syndrome is a chromosomal disorder associated with low levels of alpha-fetoprotein (AFP). AFP is a fetal serum protein used to assess for neural tube defects or chromosomal disorders. Anencephaly is the incomplete fetal skull and brain development. Spina bifida is the incomplete development of the fetal spinal cord. Omphalocele is an abdominal wall defect that results in the abdominal organs protruding into the umbilical cord. Anencephaly, spina bifida, and omphalocele are neural tube defects associated with high levels of AFP.

The nurse is preparing to obtain an aerobic wound culture from a stage IV pressure ulcer. After removing the wound dressing, the nurse observes a moderate amount of purulent, foul-smelling exudate. Which action should the nurse take to ensure the best specimen? A Using a dry gauze pad, gently pat the wound to remove the exudate. B Using a culture swab, obtain a scraping of tissue from the edges of the wound. C Using soap and water, wash the wound edges and wound bed first. D Using a piston syringe, gently irrigate the wound with sterile normal saline. Correct Answer (Blank)

Rationale: Due to the presence of purulent exudate, the wound should first be irrigated with sterile normal saline to remove surface pathogens and exudate that will alter the wound culture. This is the best approach to obtain a noncontaminated specimen. Using dry gauze to remove the exudate can irritate the wound bed and cause bleeding. The specimen should ideally be taken from the wound bed, not the edges. Washing a stage IV pressure ulcer is not appropriate.

The nurse is caring for a client who is postoperative day four from a coronary artery bypass graft and is scheduled to be discharged home during the shift. Which finding observed by the nurse would require immediate intervention? A The client pushes up with their arms when getting out of bed. Correct Answer (Blank) B The client is sitting in the chair with legs elevated. C The client inhales slow and deep while using the incentive spirometer. D The client is taking a shower with assistance from family.

Rationale: During a CABG, the sternal is surgically cut and then sutured back with wires. Until the sternum has healed completely, the client should be instructed to follow sternal precautions. Sternal precautions include splinting a pillow against the chest when coughing and to avoid lifting or pushing up with arms, which can increase the pressure on the sternum. The client who is postoperative CABG should be taking a shower, sitting up in the chair, and using the incentive spirometer by slowing inhaling.

The nurse is caring for a client with a T-tube following a cholecystectomy on the first postoperative day. The nurse would expect which color of drainage from the client's T-tube at this time? A Yellowish red B Light lime greenish C Yellowish brown Correct Answer (Blank) D Dark chocolate brown

Rationale: During a cholecystectomy, a T-tube may be inserted to collect bile. Bile is yellowish-brown. Gastric contents may be green. Dark brown or a yellowish red color would be an indication of some type of bleeding which would not be expected.

The nurse is caring for a client who had a laparoscopic cholecystectomy. The client reports pain in the shoulder. Which action should the nurse take first? A Administer prescribed analgesia B Instruct the client to use the incentive spirometer C Auscultate bowel sounds D Place client in left lateral Sims' position Correct Answer (Blank)

Rationale: During a laparoscopic cholecystectomy, CO2 is introduced into the abdominal cavity to allow for visualization. CO2 is irritating to the phrenic nerve and diaphragm resulting in the client reporting pain in the shoulder. To help expel the CO2 gas, the nurse should place the client in Sims' position, which will move the gas pocket away from the diaphragm. Then the nurse will administer prescribed analgesia, encourage deep breathing, and auscultate bowel sounds.

The nurse is caring for a client who had a laparoscopic cholecystectomy. The client reports pain in the shoulder. Which action should the nurse take first? A Administer prescribed analgesia B Place client in left lateral Sims' position Correct Answer (Blank) C Instruct the client to use the incentive spirometer D Auscultate bowel sounds

Rationale: During a laparoscopic cholecystectomy, CO2 is introduced into the abdominal cavity to allow for visualization. CO2 is irritating to the phrenic nerve and diaphragm resulting in the client reporting pain in the shoulder. To help expel the CO2 gas, the nurse should place the client in Sims' position, which will move the gas pocket away from the diaphragm. Then the nurse will administer prescribed analgesia, encourage deep breathing, and auscultate bowel sounds.

The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was effective. Which action by the client indicates that additional teaching is required? A The client alternates solids with liquids. B The client is sitting in a chair during meals. C The client tucks in the chin while swallowing. D The client uses a straw to drink. Correct Answer (Blank)

Rationale: Dysphagia means difficulties with swallowing that can cause food and/or liquids to be aspirated into the lungs. Strategies to reduce the risk of aspiration include sitting up in a chair while eating, cutting up food into small, bite-size pieces, chewing food thoroughly, drinking liquids separate from solid food, performing a chin tuck while swallowing, dry swallowing several times, and avoiding the use of a straw. Drinking through a straw tends to propel fluids into the back of the mouth faster increasing the risk for aspiration.

A 5-year-old child is rushed to the emergency department approximately six hours after ingesting an undetermined amount of acetaminophen. Which lab test should receive priority attention from the nurse? A Serum acetaminophen concentration (APAP) Correct Answer (Blank) B Alanine transaminase test (ALT) and aspartate transaminase test (AST) C Electrolytes and blood urea nitrogen (BUN) D Prothrombin time (PT) and INR

Rationale: Emergency treatment of acetaminophen overdose involves checking the client's 4-, 6-, and 8-hour acetaminophen concentration (APAP) levels. These levels will determine N-acetylcysteine (NAC) therapy (the antidote). Clients who ingest an acute overdose and have NAC therapy initiated within 8 hours usually do well and do not develop liver failure. However, because acetaminophen poisoning can lead to liver failure, it is important to evaluate hepatotoxicity; ALT and AST will help determine the degree of liver cell damage. PT (or INR) may also be used to detect impaired liver function. BUN and electrolytes may show renal impairment or acidosis.

The nurse is caring for a client who had an epidural anesthesia during surgery. The nurse should monitor the client for which complication of the epidural? A Hypoglycemia B Hypotension Correct Answer (Blank) C Hypoxia D Tachycardia

Rationale: Epidural anesthesia is a regional block where the anesthetic agent is injected into the epidural space of the lumbar or thoracic spine. The client will have a loss of sensation below the level of injection. Epidural anesthesia has the effect of vasodilation, which can lead to hypotension. The client is awake with epidural anesthesia so will not have respiratory depression. Tachycardia can occur with benzodiazepines, and hypoglycemia can occur with nonbarbiturate hypnotics, which are used in moderate sedation.

The medical-surgical nurse is performing an assessment on a client who is admitted for community-acquired pneumonia. Assessment findings include a respiratory rate of 20 breaths per minute, the skin is pink, and the client is receiving oxygen via nasal cannula at 6 liters per minute. What action should the nurse take? A Call the health care provider (HCP) about the client's condition B Put the client in a more comfortable position C Maintain the current oxygen therapy Correct Answer (Blank) D Lower the oxygen rate to 3 liters per minute

Rationale: Even though this client has a history of asthma, the condition of pneumonia requires oxygenation. If the oxygen was at too high of a concentration, the hypoxic drive would be eliminated, and the client's depth and rate of respiration will decrease. The client's rate is within the higher limits of normal. Thus, there is no need at this time to change the rate of oxygen. The client's condition is stable, and it is not necessary to notify the HCP. There is no evidence the client is uncomfortable at this time.

The nurse is caring for an unconscious client. In order to prevent exposure keratitis, which of the following interventions would be most appropriate for the nurse to implement? A Apply warm compresses to both eyes daily B Initiate the administration of topical antibiotics to both eyes C Tape upper eyelids in both eyes closed D Apply lanolin alcohol (Lacri-lube) to the inside of the eyelids Correct Answer (Blank)

Rationale: Exposure keratitis is the inflammation and dryness of the cornea; which is secondary to air exposure due to incomplete eyelid closure. Clients who are at greatest risk for this condition, are those admitted to a critical care unit. Additional risk factors for exposure keratitis include mechanical ventilation, fluid overload and the administration of sedatives and neuromuscular blockade agents. Although the literature does mention tapping eyelids closed as a method for preventing exposure keratitis, additional evidence suggests that this practice also places the client at risk for developing corneal abrasions. There is no evidence that suggests applying warm compresses to a client's eye, prevents exposure keratitis. In cases where exposure keratitis is identified, topical antibiotics may be initiated if bacterial keratitis is suspected and/or diagnosed. The most appropriate intervention that prevents the development of exposure keratitis, is the use of moisturizing eye drops or ointments to the exposed cornea.

The home health nurse is assessing an older adult client for safety risks. Which of the following findings increases the client's risk of injury from falling? A The client attends a silver sneakers program. B The client is taking prescribed temazepam for sleep. Correct Answer (Blank) C The client has hardwood floors throughout the home. D The client wears glasses for reading.

Rationale: Falls can be prevented if they can be predicted. Fall risk factors can be person-based and environmental-based. Risk factors may include advanced age, previous falls, muscle weakness, poor vision, obstacles and tripping hazards, and psychoactive medications. The client in this case is taking a benzodiazepine, which is known to contribute to falls. Wearing glasses for reading does not increase the risk of falls.

The nurse is performing routine daily cleaning of a client's tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube out of the stoma. The nurse understands that this outcome could have been avoided by which of the following actions? A Apply clean tracheostomy ties before removal of old ties Correct Answer (Blank) B Placement of an obturator at the client's bedside C Have another nurse assist with the procedure D Place the client in a flat, supine position

Rationale: Fastening clean tracheostomy ties before removal of the old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. However, the question asks how to prevent the situation. A second nurse is not needed during the procedure. A change in the position of the client does not prevent a dislodged tracheostomy.

The nurse is caring for a client diagnosed with a fecal impaction. While preparing to manually remove the impaction, what essential information should the nurse remember?The nurse is caring for a client diagnosed with a fecal impaction. While preparing to manually remove the impaction, what essential information should the nurse remember? A Cardiac dysrhythmias can result during the process Correct Answer (Blank) B The procedure will require a mild sedative C Increased dietary fiber can minimize such problems D Family members should be taught the procedure

Rationale: Fecal impaction requires manual disimpaction or removal. While using a lubricated, glove, the nurse inserted the index finger into the rectum and attempts to break up the hardened stool using a circular or scissoring motion. This will allow the stool to be extracted. While performing the procedure, it would be essential for the nurse to remember that cardiac dysrhythmias could occur from vagal nerve stimulation. The other options are appropriate; however, they are not the priority or essential consideration.

The nurse is monitoring a client who received prescribed fentanyl during a bronchoscopy. The nurse notes that the client's respiratory rate is 10 breaths per minute. Which is the priority action for the nurse to take? A Administer IV naloxone B Begin rescue breathing with bag-mask-valve Correct Answer (Blank) C Alert the rapid response team D Raise the head of the bed

Rationale: Fentanyl is an opioid and is used to decrease pain during a procedure, like a bronchoscopy. Opioids can decrease the respiratory drive leading to hypoventilation. The priority action for a client with a low respiratory rate is to increase ventilation through rescue breathing. Raising the head of the bed can assist with opening the airway but does not increase ventilation. Naloxone is the medication that reverses the effect of opioids but breathing is the priority. Once the nurse has provided ventilatory support to the client, the nurse would then alert the rapid response team.

The nurse is interviewing a client in the outpatient clinic who is seeking care for a sudden weight increase. Which of the following questions by the nurse is appropriate to assess for fluid retention? A "Have you noticed any swelling in your legs?" Correct Answer (Blank) B "How many calories do you eat a day?" C "When was your last bowel movement?" D "Do you have a history of any eating disorders?"

Rationale: Fluid retention is often manifested by peripheral edema, so asking the client if they have experienced swelling of the lower extremities will allow the nurse to gather information about the history of the condition. While the other questions might be appropriate to assess for gastrointestinal concerns, they do not assess peripheral circulation.

The nurse is planning care for a client following a stroke. Which approach would be most effective in the prevention of skin breakdown? A Reposition every two hours when in bed Correct Answer (Blank) B Pad the bony prominences C Place client in the wheelchair for four hours daily D Massage reddened bony prominences

Rationale: Following a stroke, clients often experience some degree of immobility, leading to an increased risk for impaired skin integrity. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. Repositioning the client every two hours while in bed would be most effective in preventing skin breakdown, such as a pressure ulcer. If the client is in a wheelchair, a shift of the weight should be done every hour. Massage of reddened bony prominences is no longer recommended to prevent pressure ulcers or injuries.

The nurse is educating a client with diabetes mellitus on prevention of associated complications. Which of the following statements by the nurse is appropriate? A "You should inspect your feet frequently." Correct Answer (Blank) B "Stop taking the medication if your glucose is controlled." C "You should limit your physical activity to prevent injury." D "Visit the ophthalmologist every few years."

Rationale: Foot care for diabetic clients is important to prevent diabetic ulcers. Medications should not be changed or discontinued without consulting with the treating provider. Physical activity should not be limited, and proactive ophthalmologist visits should happen at least once per year.

The nurse is reviewing the medical record of a client who has been hospitalized for a pulmonary embolism 3 times in the past six months. The nurse understands that which potential intervention is appropriate for this client? A Lung resection surgery B Hemodialysis C Prophylactic alteplase infusion D Inferior vena cava filter Correct Answer (Blank)

Rationale: For clients with recurrent deep vein thrombosis (DVT) or pulmonary emboli (PE), an inferior vena cava (IVC) filter may be indicated. The filter is inserted by a surgeon or interventional radiologist through the femoral or jugular vein. The IVC will trap emboli in the inferior vena cava before they progress to the lungs. Holes in the device allow blood to pass through, without interfering with the return of blood to the heart. Several new filter brands are available that are designed for removal if and when DVT and PE risks diminish. The other interventions are not appropriate for this client.

The nurse is preparing to assess a client who is recovering from abdominal surgery with general anesthesia. Which is the priority assessment for the nurse to perform? A Note the presence of any surgical drains B Measure the client's respiratory rate Correct Answer (Blank) C Observe the surgical incision D Check the client's IV site

Rationale: Frequent assessments of the patient's airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care in the postoperative period. While the client may have been in the post-anesthesia care unit, it is still a priority to assess these areas in the surgical unit as some clients may clear anesthetics more slowly than others. Impaired neurological function from anesthesia will affect the client's ability to protect the airway from complications, such as hypopharyngeal obstruction & aspiration, and ventilate adequately. While all other assessments are appropriate, the airway is the priority.

A nurse is assisting a client with their meal. Which observation does the nurse identify as a risk for aspiration? A The client belches several times during the meal. B The client yawns repeatedly after the meal. C The client chews their food for several seconds before swallowing. D The client coughs every time they drink water. Correct Answer (Blank)

Rationale: Frequent coughing while eating or drinking is an indication that the client is unable to tolerate their oral secretions. The inability to handle oral secretions increases the risk for aspiration. A yawn is not indicative of the inability to tolerate oral secretions. Yawning does not increase the risk for aspiration. Belching is not associated with an increased risk for aspiration. Belching is indicative of excess gas in the gastrointestinal tract. Chewing for a prolonged period of time decreases the risk of aspiration. The client should be encouraged to chew their food thoroughly before swallowing.

A nurse is assessing a client with a percutaneous endoscopic gastrostomy (PEG) tube who is receiving intermittent feedings. Which observation increases the client's risk for aspiration? A The client's head of the bed is at 30 degrees. B Bowel sounds are hypoactive upon auscultation. C There are 450 ml of gastric residuals. Correct Answer (Blank) D The client's abdomen appears rounded upon inspection.

Rationale: Gastric residuals above 250 milliliters are associated with an increased risk of aspiration. The nurse should withhold feedings to avoid regurgitation. The head of the bed at 30 degrees is the proper placement for a client with a feeding tube. Hypoactive bowel sounds are not associated with a higher risk of aspiration. The nurse should further assess the client for possible constipation. A rounded abdomen is a normal finding. A distended abdomen is indicative of poor toleration of feeds.

The nurse is caring for a 4-year-old child admitted after being burned over more than 50% of the body. Which of the following laboratory data should be reviewed by the nurse as a priority in the initial 24 hours after the burn? A Blood urea nitrogen Correct Answer (Blank) B Hematocrit C Blood glucose D White blood count

Rationale: Glomerular filtration is decreased in the initial response to severe burns. A fluid shift occurs from the loss of fluid from the burned areas. Kidney function must be monitored closely, or renal failure may follow in a few days from a lack of circulating volume. In the initial 48 hours, fluids are given IV at high rates to maintain circulation. After this, the clients are evaluated for fluid overload and heart failure, as well as infection.

The nurse is reviewing the lab results of a client with diabetes type I. Which of the following results indicates poor glucose control? A Glycosylated hemoglobin level of 9.0% Correct Answer (Blank) B Fasting serum glucose of 100 mg/dl C Oral glucose tolerance test result of 135 mg/dl D Urinalysis glucose level of 0

Rationale: Glycosylated hemoglobin, or HgbA1C, is a measure of glucose control resulting from glucose molecules attaching to hemoglobin for the life of the red blood cell (120 days). The longer the glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the A1C level becomes. Normal values range from 4% to 6%. The target range for people with diabetes is less than 7%. The other values indicate good glucose control.

The nurse is caring for a client with decompensated heart failure. Which of the following changes in the client's condition would require intervention? A Urine output has decreased to 15 mL/hr. B Beta natriuretic peptide has decreased to 400pg/mL. C Ejection fraction has increased to 40%. D Systolic blood pressure has increased to 100 mmHg. Correct Answer

Rationale: Heart failure is a syndrome resulting from structural or functional disorders that impair the ability of the ventricles to fill or eject blood. Decompensated heart failure is characterized by increased symptoms, decreased CO, and low perfusion. Decreased urinary output is a sign of impaired renal perfusion. Ejection fraction is the percentage of blood pumped out of the heart with each beat. An increase indicates improved cardiac output. Beta natriuretic peptide is secreted by the heart to regulate blood pressure and fluid balance. A decrease indicates an improvement in heart function and reduced distension. Increasing systolic BP indicates improved cardiac output and tissue perfusion.

The nurse is conducting teaching with a client who was recently diagnosed with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the hemoglobin A1C test? A "It indicates the level of insulin resistance of the cells in my body." B "It indicates how much insulin I should be administering to myself." C "It is a measurement of how my kidneys are functioning." D "It reflects my average blood glucose level for the past three months." Correct Answer (Blank)

Rationale: Hemoglobin A1C (HbA1c) reflects the average glucose level for approximately 100 to 120 days prior to the blood test. The test is beneficial for evaluating the success of diabetic treatment and client compliance. It can also be used to determine the duration of hyperglycemia in clients who are newly diagnosed with diabetes. By testing the portion of the hemoglobin that combines with glucose (glycosylated hemoglobin) it is possible to determine the average blood glucose over the lifespan of the red blood cell, which is 120 days. The desired HbA1c target value for clients with diabetes is around 7%. The other statements are incorrect.

The nurse is reviewing the laboratory results for a client with diabetes type 1. Which finding would best indicate if treatment has been effective? A Fasting plasma glucose 130 mg/dL B Negative urine ketones C Hemoglobin A1C of 6.0% Correct Answer (Blank) D Positive urine glucose

Rationale: Hemoglobin A1C measures the amount of glucose attached to the total hemoglobin. The amount of glucose that attaches to the hemoglobin is a correlation to the average blood glucose levels over a three-month period, which can provide information on the effectiveness of treatment. The other options are used to diagnose diabetes but not evaluate the effectiveness of the treatment.

The client is having an intravenous pyelogram procedure. After the contrast material is injected, which client reaction should be acted upon by the nurse immediately? A Hives with severe itching all over the body. Correct Answer (Blank) B Face turning a deep ruddy red color. C An excessive salty taste in the mouth. D A feeling of excessive warmth.

Rationale: Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur.

The nurse is teaching a client with a diagnosis of metastatic bone cancer about actions to prevent hypercalcemia. Which statement by the client indicates the client understands the teaching? A "I should exercise by walking for 20 to 30 minutes daily." Correct Answer (Blank) B "I should restrict my fluid intake to less than one liter per day." C "I should increase my servings of dairy each day to five." D "Calcium carbonate is the preferred antacid if I experience indigestion."

Rationale: Hypercalcemia (increased serum calcium level) occurs most often in clients with bone metastasis. Cancer in the bone causes the bone to release calcium into the bloodstream. In clients with cancer in other parts of the body (especially in the lung, head and neck, kidney or lymph nodes), the tumor secretes parathyroid hormone causing the bones to release calcium into the bloodstream. Decreased mobility and dehydration worsen hypercalcemia. Mobility should be encouraged to prevent demineralization and breakdown of bones. Weight-bearing exercise, such as walking, helps to prevent hypercalcemia and keeps the calcium in the bone. Good hydration is important in hypercalcemia prevention as well, so clients should not restrict their oral fluid intake. Dairy products contain high amounts of calcium, so the client should not increase their dairy intake, as this would put them at an increased risk of hypercalcemia. Clients at risk for hypercalcemia should not take calcium carbonate because it can increase their serum calcium levels.

The nurse is working with clients who are diagnosed with eating disorders. Which eating disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels? A Bulimia nervosa Correct Answer (Blank) B Dysthymic disorder C Anorexia nervosa D Binge eating disorder

Rationale: Hypokalemia can be caused by prolonged fasting and starvation, but is more common in those who exhibit binging and purging behaviors. Binging and purging, common in bulimia nervosa, result in dehydration and potassium loss. Hypokalemia can result in weakness, abdominal cramping and arrhythmias.

The nurse is developing the plan of care for a group of assigned clients with drainage tubes. Which of the following clients should the nurse identify as having a risk for hypokalemia? A The client who has a tracheostomy tube connected to humidified oxygen B The client who has an indwelling urinary catheter to gravity drainage C The client who has a pleural chest tube to water seal D The client who has a nasogastric tube to intermittent suction Correct Answer (Blank)

Rationale: Hypokalemia occurs when there is a loss of potassium from the body. GI losses, such as through diarrhea and NG suction, renal losses through the use of diuretics, and skin losses, such as diaphoresis, are the most common causes of hypokalemia. A tracheostomy tube, an indwelling urinary catheter, and a pleural chest tube are not risk factors for potassium loss.

The nursery nurse is caring for a newborn male infant with hypospadias. The infant's parents request for the infant to be circumcised before leaving the hospital. How should the nurse respond? A "Circumcision is delayed so the foreskin can be used to correct the defect." Correct Answer (Blank) B "Circumcision should be performed as soon as the newborn is stable." C "Circumcision is not medically indicated for any child." D "Circumcision is contraindicated because of the permanent defect."

Rationale: Hypospadias is an abnormality of the penis in which the urethral opening is located on the ventral aspect of the penis , roximal to the tip of the glans penis. Hypospadias is a congenital defect that is thought to occur between 8 and 20 weeks' gestation. Hypospadias is generally repaired for functional and cosmetic reasons, typically between 6 and 18 months of age. Boys who are born with hypospadias should not be circumcised immediately after birth. The extra tissue of the foreskin may be needed to repair the hypospadias during surgery. The client can have a circumcision performed at a later age.

The nurse is caring for a client who underwent cardiac catheterization using the femoral artery. The client's BP is 85/40 and they report severe back and lower abdominal pain. Which of the following complications would be suspected? A Arterial obstruction B Pseudoaneurysm C Acute kidney injury D Retroperitoneal hematoma

Rationale: Hypotension, along with back, flank, and abdominal pain, may indicate a retroperitoneal hematoma caused by blood leaking outside of the artery after percutaneous coronary interventions. Weak/absent distal pulses are an indication of occlusion. Pseudoaneurysm is caused by vessel trauma and causes a swelling at the insertion site. Acute kidney injury would lead to decreased urine output and elevated BUN and serum creatinine levels.

The emergency room nurse is caring for the client who is homeless and was admitted during a blizzard. The client has an elevated blood alcohol level, has a core temperature of 33.2°C (91.8ºF), and is unable to feel the lower extremities. What is the priority action at this time? A Apply a forced-air warming blanket Correct Answer (Blank) B Assess the lower extremities for frostbite C Observe for signs of alcohol withdrawal D Obtain a high-calorie meal

Rationale: Hypothermia is a condition in which the core (internal) temperature is 35°C (95°F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures. People who are homeless are particularly susceptible. Alcohol ingestion increases susceptibility because it causes systemic vasodilation. The patient may also have frostbite but hypothermia takes precedence in treatment.

A client has been taking isoniazid and rifampin for several months. Which laboratory test should the nurse monitor with this client? A Liver enzymes Correct Answer (Blank) B Sputum culture C Cardiac enzymes D Creatinine clearance

Rationale: INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury and multilobular necrosis and is believed to result from the production of a toxic isoniazid metabolite. Rifampin is also toxic to the liver posing a risk of jaundice and even hepatitis. Asymptomatic elevation of liver enzymes occurs in about 14% of patients. Hepatotoxicity is most likely in people who abuse alcohol and in clients with pre-existing liver disease. These individuals should be monitored closely for signs of liver dysfunction. Tests of liver function (serum aminotransferase levels) should be made before treatment and every 2 to 4 weeks thereafter. The other lab tests are not specific to the medications the client is taking.

The nurse is preparing the client for a thoracentesis. Which position should the client be placed in to reduce the risk of complications? A Sitting on the edge of the bed with arms and head resting on and over the bed table Correct Answer (Blank) B Lying on the affected side with the head of the bed elevated C Prone with the head on a pillow and arms above the head D Turned on the unaffected side with the head of bed flat

Rationale: If possible, place the patient upright leaning over an over-the-bed table. The upright position facilitates the removal of fluid that usually localizes at the base of the thorax. It expands the ribs and widens the intercostal space to aid needle insertion. A position of comfort helps the patient to relax and prevents patient movement that could contribute to potential complications. The client may also lie on the unaffected side with the head of the bed elevated.

The nurse is caring for a client with a small bowel obstruction. The health care provider orders the nurse to insert a nasogastric tube. The nurse is unable to pass the tube into either of the client's nostrils. Which action should the nurse take next? A Insert the tube via the orogastric route instead. B Stop the procedure and notify the health care provider. Correct Answer (Blank) C Apply oxygen to the client via nasal cannula. D Perform nasotracheal suctioning on the client.

Rationale: If the nurse is unable to insert a nasogastric (NG) tube into either nostril, the nurse should stop the procedure and notify the health care provider. The nurse should not insert the tube orogastrically without first notifying the health care provider and obtaining an order for an orogastric (OG) tube. Nasotracheal suctioning would not be advised as it may cause swelling in the client's nasopharynx, further complicating the NG tube insertion. There is no indication the client needs supplemental oxygen.

The visiting nurse is evaluating a 2-month-old child who had bilateral leg casts applied for the treatment of clubfoot. Which nursing goal is the priority for this child? A Muscle spasms will be relieved B Tissue perfusion will be maintained Correct Answer (Blank) C Minimal pain with cast application D Mobility will be managed as tolerated

Rationale: Immediately following cast application, the priority goal is to maintain circulation and tissue perfusion around the cast. Although most casts do not cause problems, the risk for complications such as compartment syndrome does exist. Compartment syndrome means the pressure in an extremity that can cause so much pressure that blood flow and tissue perfusion is impaired. Permanent tissue damage can occur in the limb within a few hours, if perfusion is not maintained. Therefore, assessment and monitoring of the extremity for the 6 Ps (pain, paresthesia, pallor, paralysis, pulselessness) of poor tissue perfusion/ischemia is the most important during this period.

The nurse is caring for a client who is postoperative below the knee amputation. Which assessment finding would indicate to the nurse that the client is at risk for delayed wound healing? A The client reports a strict vegetarian diet. B Posterior popliteal pulses are 2+ with palpation. C Post prandial blood glucose is 118 mg/dl. D The client has a history of kidney transplant. Correct Answer

Rationale: Immunosuppressive therapy is increasingly being used in clinical practice and has been shown to affect wound healing to varying degrees. It is shown that some agents affect wound healing to such an extent that reduction or avoidance of these drugs until complete wound healing is achieved is advocated. Clients who have had organ transplants are often on immune-suppressing medications; therefore, this finding requires follow-up. While a vegan may be at risk of protein deficit, the vegetarian is at less risk.

The nurse is positioning the client on the left side in Sims' position prior to the administration of an enema. How should the nurse place the right arm to prevent injury? A Flexed on a pillow Correct Answer (Blank) B Extended behind the back C Along the length of the torso D In internal rotation

Rationale: In Sims' position, the client lies on their side with the lower arm behind the back and the upper arm flexed. Both knees are flexed, with the upper leg more so. Careful positioning is required to prevent damage to nerves and blood vessels as well as injury to the shoulder. It is used to assess the rectum or vagina and perform interventions such as enemas and suppositories.

When admitting a client to the ambulatory surgery unit, the nurse notices the client has painted fingernails. The nurse reviews the pre-op orders and notes that pulse oximetry is prescribed. Which statement by the nurse is appropriate? A "I am sorry. All of your nail polish must be removed." B "I will ask your health care provider if we can discontinue the pulse oximetry." C "May I remove the polish from at least two nails?" Correct Answer (Blank) D "We can monitor your oxygen levels with lab work instead of pulse oximetry."

Rationale: In order to effectively measure pulse oximetry, there can be no nail polish on the finger fitted with the reading device. The client should be approached using therapeutic communication skills. The other options are inappropriate.

A nurse is providing care to a client with suspected community-acquired pneumonia. In addition to a white blood cell count of 12,000/mm³, which diagnostic result does the nurse expect to find? A Air volume of 1,500 mm on the incentive spirometer B Increased areas of density on a chest x-ray Correct Answer (Blank) C HCO3 level of 20 mEq/l in an arterial blood gas D Negative sputum culture

Rationale: Increased areas of density on a chest x-ray indicate consolidation of the lungs. Community-acquired pneumonia (CAP) is a respiratory infection characterized by an increased white blood cell count and inflammation of the airways. An incentive spirometer is a device used to assess the volume of air inhaled with each breath. The incentive spirometer is not used to diagnose pneumonia. Bicarbonate (HCO3) levels below normal do not indicate pneumonia. A low level of HCO3 is indicative of metabolic acidosis. A negative finding on a sputum culture is not consistent with an infectious respiratory disease process.

The nurse is caring for a client with suspected infective endocarditis. Which laboratory test is the priority? A Complete blood count B Blood culture Correct Answer (Blank) C C-reactive protein D Sedimentation rate

Rationale: Infective endocarditis (IE) is an infection of the endocardium caused by bacteria, fungi or viruses. The most common cause of IE is Staphylococcus aureus in the blood. The key to making a diagnosis of IE is two blood cultures collected at two different sites with two separate venipunctures. A variety of other baseline blood tests are also ordered, however, these blood tests are not specific or they might not be specific enough to diagnose IE specifically and identify the causative organism. Therefore, blood cultures are the priority lab tests to obtain.

The nurse is reviewing the medical record of a client who is receiving hemodialysis for end-stage renal disease (ESRD). Which lab values are important to monitor for this client? Select all that apply. Hemoglobin level Correct Answer (Blank) Serum calcium Correct Answer (Blank) Troponin level Serum potassium Correct Answer (Blank) Serum creatinine Correct Answer (Blank)

Rationale: Intermittent hemodialysis (HD) is the most common kidney replacement therapy used for ESRD. Dialysis removes excess fluids and waste products and helps restore the body's fluid and electrolyte balance. HD involves passing the client's blood through an artificial semipermeable membrane to perform the kidney's filtering and excretion functions. Clients with ESRD and on HD are often anemic, so it is important to monitor their hemoglobin level. The creatinine level indicates kidney function, and the potassium and calcium levels are affected by ESRD and dialysis and should also be closely monitored. Troponin pertains to the myocardium and is not typically done for clients on dialysis.

The nurse is obtaining a thigh blood pressure on a client. Which of the following actions indicates the correct technique? A Assisting the client to a standing position prior to securing the cuff B Placing the cuff with the compression bladder over the popliteal artery Correct Answer (Blank) C Inflating the cuff until the client's toes are no longer pink D Placing the stethoscope over the client's dorsalis pedis artery

Rationale: It indicates the correct technique for obtaining thigh blood pressure if the compression bladder is placed over the popliteal artery to ensure accurate measurement. Clients should be assisted to a prone or supine position. The cuff should be inflated to 20 to 30 mmHg higher than the brachial artery systolic pressure. The stethoscope should be placed over the popliteal artery.

The nurse is assessing vital signs on a group of assigned clients. Which client should the nurse see first? A The client with dehydration who has a blood pressure that has increased from 90/48 mmHg to 98/52 mmHg B The client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 93% on 2 l oxygen via nasal cannula C The client who had a permanent pacemaker placed 1 day ago and has a pulse that has decreased from 60 to 48 beats per minute Correct Answer (Blank) D The client who has bacterial pneumonia and has a temperature of 101.1°F

Rationale: It is a priority for the nurse to follow up with a client who had a permanent pacemaker placed and has developed bradycardia as this may indicate the pacemaker is failing to capture. The client with dehydration is showing improvement in their condition with increased blood pressure. The client with COPD has an oxygen saturation within the normal range for their condition. The client with a fever from pneumonia is exhibiting expected findings from their condition.

The nurse is caring for a client who is admitted with pneumonia and has orders for a sputum culture. The nurse observes the unlicensed assistive person (UAP) assisting the client in collecting a sputum specimen. Which action by the UAP would require the nurse to intervene? A The UAP lowers the head of the bed to stimulate coughing. B The UAP asks the client to rinse their mouth with water prior to sputum collection. C The UAP asks the client to spit 5 mL of saliva into the cup Correct Answer (Blank) D The UAP asks the client to take several deep breaths then cough.

Rationale: It is important that the proper sputum collection procedure is followed to obtain accurate laboratory and microbiology results. The client should rinse their mouth with water before expectorating the sputum to decrease contamination by particles in the oropharynx. The client should be asked to take several deep breaths then cough. If the client is unable to produce a sputum specimen, coughing can be stimulated by lowering the head of the bed. The client should expectorate a sputum specimen directly into the sterile collection container. The sputum specimen should be representative of pulmonary secretions, not saliva. The client should be reminded not to use antiseptic mouthwash before sputum collection.

The nurse is preparing to assess the blood pressure (BP) of an assigned client. Which action should the nurse take when measuring the BP in the upper extremity? A Placement of the deflated BP cuff approximately 2 inches below the antecubital space B Palpation of the brachial pulse prior to placement of the cuff around the arm Correct Answer (Blank) C Placement of the stethoscope directly over the radial artery D Inflation of the BP cuff to 10 mmHg above the client's stated normal

Rationale: It is the correct technique to palpate the brachial pulse before placement of the cuff to ensure the bladder of the cuff is directly above the artery for an accurate reading. The cuff should be placed approximately 2 inches above the antecubital space. The stethoscope should be placed over the brachial artery. The cuff should be inflated to 30 mmHg above where the brachial pulse disappears when the cuff is inflated.

The nurse is observing unlicensed assistive personnel obtain pulse oximetry readings for assigned clients. Which of the following actions by the UAP requires intervention? A Changing the location of an adhesive finger sensor every 4 hours B Applying the sensor to the forehead of a client who is taking vasoconstrictive medications C Changing the location of a spring-tension oximeter every 2 hours D Applying the sensor to the fingertip of a client with peripheral vascular disease Correct Answer (Blank)

Rationale: It requires follow-up if the UAP is observed applying the oximeter sensor to the fingertip of a client with peripheral vascular disease as the reduced circulation can cause inaccurate measurements of pulse oximetry readings. Applying a sensor to a central location, such as the forehead, for a client on a vasoconstrictive medication indicates the correct technique. Adhesive oximeter probes should be rotated every 4 hours and spring-tension probes every 2 hours in order to prevent skin breakdown.

The nurse is planning interventions to prevent autonomic dysreflexia for a client with spinal cord injury at the level of T4. Which of the following, if included in the nursing plan, requires follow-up? A Monitor the client for fecal impaction and administer stool softeners as prescribed B Apply antiembolism stockings for venous thromboembolism prophylaxis Correct Answer (Blank) C Monitor client for urinary retention and perform urinary catheterization as needed D Apply lidocaine ointment to sacral pressure ulcer as prescribed for comfort

Rationale: It requires follow-up if the nurse implements antiembolism stockings, as one of the precipitating factors for the development of autonomic dysreflexia is constrictive clothing, which should be removed. It is correct to implement measures to reduce bladder distention, fecal impaction, and tactile stimulus on the skin, such as pain from pressure ulcers, which are all known triggers for autonomic dysreflexia.

The nurse is observing a newly hired nurse apply anti-embolism stockings for a client. Which of the following actions requires follow-up? A Turning the upper portion of the stocking inside out so the foot portion is inside the leg B Asking the client to point the toes to place the foot portion over the toes and heels C Grasping the loose portion of the stocking at the ankle and pulling it right side out and over the leg D Bunching the stocking at the top and ankle once applied to reduce client discomfort Correct Answer

Rationale: It requires follow-up if the nurse is observed bunching the stocking at the top and ankle to reduce discomfort. Stockings should have all folds and creases removed and should not be bunched or folded, which can cause skin irritation or impair venous return. The other actions are correct steps for applying anti-embolism stockings on a client.

The nurse is observing a graduate nurse obtain a capillary blood glucose specimen for a client. Which of the following actions by the graduate nurse requires follow-up? A Wiping the finger with an alcohol wipe and allowing the site to dry completely B Placing the lancet perpendicular to the skin prior to piercing the finger C Holding the reagent strip under the puncture site and removing when half of the indicator square is covered with blood Correct Answer (Blank) D Applying pressure to the puncture site with gauze after obtaining the blood specimen

Rationale: It requires follow-up if the nurse is observed covering only half of the indicator square on the reagent strip with blood. The entire square needs to be covered with blood to obtain an accurate reading. It is the correct technique to allow the site to dry completely before piercing the finger, to hold the lancet perpendicular to the skin to ensure accurate depth of the needle, and to apply pressure after obtaining the blood sample to ensure hemostasis.

The nurse observing a graduate nurse access a peripherally inserted central catheter (PICC) for blood specimen collection. Which action by the graduate nurse requires follow-up? A Flushing the catheter with a 5 ml syringe of normal saline prior to accessing the port Correct Answer (Blank) B Donning a mask and gloves prior to accessing the venous access device C Wasting 10 ml of blood prior to collecting the specimen D Cleansing the hub of the venous access port with alcohol prior to accessing the device

Rationale: It requires follow-up if the nurse is observed flushing the line with a 5 ml syringe prior to obtaining blood specimens. PICC lines should always be flushed with a 10 ml syringe or greater. Smaller syringes exert a higher pressure and increase the risk for rupturing the catheter. Aseptic technique using a mask and gloves is required when accessing the device, and the site should be cleansed with alcohol before and after. The nurse should waste 5-10 ml of blood prior to collecting the blood specimen to prevent contamination from fluids and hemolysis of the specimen.

The nurse is observing a newly hired nurse apply anti-embolism stockings for a client. Which of the following nursing actions requires follow-up? A Assisting the client to dangle the legs for several minutes before applying the stockings Correct Answer (Blank) B Applying the stockings in the morning before the client gets out of bed C Assessing the client's skin temperature, color, and skin condition prior to application of the stockings D Drying the client's legs thoroughly prior to applying the antiembolism stockings

Rationale: It requires follow-up if the nurse is observed having the client dangle the legs for several minutes prior to applying the stockings. Stockings should be applied, if possible, first thing in the morning prior to getting out of bed before veins become engorged from walking. If the client has been walking, the client should lie down and elevate the legs for 15-30 minutes before applying the stockings. Skin color, temperature, and integrity should be assessed before and after applying stockings. Legs should be dry prior to the application of stockings to reduce the risk of skin breakdown.

The nurse is observing a newly hired nurse access an implanted port for blood specimen collection. Which of the following actions by the newly hired nurse requires follow-up? A Cleansing the site with chlorhexidine solution 2 inches around the port B Piercing the port with the non-coring (Huber) needle at a 45-degree angle Correct Answer (Blank) C Priming the tubing connected to the non-coring (Huber) needle with saline prior to accessing the port D Discarding the first syringe of aspirated blood sample

Rationale: It requires follow-up if the nurse is observed piercing the port with the Huber needle at 45 degrees. The needle should be inserted perpendicularly at a 90-degree angle. It is correct to cleanse the site with chlorhexidine 2 inches around the port, to prime the tubing connected to the port prior to accessing it, and to discard the first syringe of blood as this sample will be diluted with saline from the tubing and yield inaccurate test results.

The nurse has taught a client about the purpose of collecting stool specimens for testing. Which of the following statements by the client indicates the need for further teaching? A "This test will determine if I have an intolerance to certain foods." Correct Answer (Blank) B "This test can determine if I have certain microorganisms growing in my gastrointestinal system." C "This test will measure if I have any bleeding in my gastrointestinal system." D "This test can determine if the treatment for my gastrointestinal system infection has been effective."

Rationale: It requires further teaching if the client states that a stool specimen sample will test for food intolerances. Food allergies and intolerances require blood sampling and determination via elimination diets, not by stool samples. Stool tests can determine the presence of specific microorganisms, the effectiveness of treatment for infections, and the presence of bleeding within the gastrointestinal system.

The nurse has taught a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client indicates the need for further teaching? A "I should expect to see improvement in my symptoms after this first treatment." Correct Answer (Blank) B "It is common to experience headaches or nausea following a treatment." C "I may feel confused for several hours following a treatment." D "It is possible to experience mild memory loss from events that occurred before my treatment."

Rationale: It requires further teaching if the client states that improvement in symptoms should occur after the first treatment. ECT is often required for four to six treatments before improvement in symptoms is noticed by clients. Clients may experience physical symptoms after a treatment, such as headaches and nausea, or may experience confusion for minutes to hours after a treatment. Some clients may experience memory loss related to events right before an ECT therapy, and in some cases, forget events from weeks to months before treatment.

The nurse has attended a staff education conference about monitoring for complications of percutaneous feeding tubes. Which of the following statements indicates the need for further teaching? A "Insertion sites should be monitored for signs of infection, such as redness, warmth, and drainage." B "Clients should be monitored for dehydration due to common complications, such as diarrhea." C "Clients with enteral feedings should have the head of their bed elevated to reduce the risk of complications, such as aspiration pneumonia." D "Clients with newly inserted percutaneous feeding tubes will report discomfort, such as a board-like abdomen." Correct Answer (Blank)

Rationale: It requires further teaching if the nurse states that clients should experience pain and a rigid, board-like abdomen, which are signs of complications of peritonitis. It is correct to monitor the client for signs and symptoms of infection, to monitor for complications of diarrhea, and to provide interventions to reduce the risk of aspiration pneumonia.

The nurse has attended a staff education conference aboutelectroconvulsive therapy (ECT). Which of the following statements indicates a need for further teaching? A "Clients will have 4 electrodes placed on their scalp, which deliver an electrical current and monitor brain activity." B "General anesthesia is given during the procedure; therefore, cardiac and airway monitoring is required." C "Clients may experience memory loss following the procedure, which may resolve over time." D "It is a medical emergency if the client experiences a seizure during the procedure." Correct Answer

Rationale: It requires further teaching if the nurse states that it is a medical emergency if the client experiences a seizure during the procedure. The goal of ECT is to induce seizure activity in the brain that may improve depression and bipolar disorder by affecting chemicals and neurons in the brain. Clients will have 4 electrodes placed on their scalp: 2 for monitoring brain activity and 2 for delivering an electrical current. General anesthesia is provided during the procedure, and clients should be monitored closely for airway or cardiovascular compromise. Memory loss is a common and temporary side effect of ECT.

The nurse is caring for a client who was admitted 1 hour ago with an acute ischemic stroke and has a left-sided facial droop. Which action by unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? A Providing the client with a pitcher of water Correct Answer (Blank) B Elevating the head of the bed to a semi-Fowler's position C Applying sequential compression devices (SCDs) to bilateral lower extremities D Suctioning secretions from the client's oral cavity using an oropharyngeal suction catheter

Rationale: It requires immediate follow-up if the UAP is observed providing the client with a pitcher of water. Clients who are experiencing an acute stroke are at high risk for aspiration and require a thorough swallowing evaluation. It is appropriate for the UAP to elevate the head of the bed, to apply SCDs, and to suction excess secretions from the client's mouth to prevent aspiration.

The charge nurse is observing unlicensed assistive personnel (UAP) obtain oxygen saturation measurements of a client. Which of the following actions by the UAP requires intervention? A Applying a clip oxygen sensor for a client with an adhesive tape allergy B Placing the sensor on the fingertip of a client with severe peripheral vascular disease Correct Answer (Blank) C Removing the nail polish from a client's nail prior to applying the sensor D Positioning the sensor on the side of the finger for a client with thickened nails

Rationale: It requires intervention if the UAP is observed applying the sensor to the fingertip of a client with peripheral vascular disease. Clients who take vasoconstrictive medications or have circulatory compromise in their extremities should have their oxygen saturation measured from a central location, such as the nose or forehead, to ensure accurate measurements. It is the correct technique to use a clip sensor instead of an adhesive sensor for a client with an adhesive tape allergy. It is the correct technique to remove nail polish to ensure accurate measurement and to position the sensor on the side of the finger on clients with very thick nails that may otherwise cause inaccurate measurements.

The nurse in an urgent care clinic is observing unlicensed assistive personnel (UAP) obtain temperature measurements for assigned clients. Which of the following actions by the UAP requires intervention? A Obtaining a rectal temperature for a 2-month-old client whose parent reports frequent vomiting Correct Answer (Blank) B Obtaining a temporal artery temperature on a 4-year-old client who is reporting an earache C Obtaining an oral temperature for a 56-year-old client who is reporting a headache and fatigue D Obtaining a tympanic temperature for an 86-year-old client whose family member is reporting new onset of confusion

Rationale: It requires intervention if the UAP is observed obtaining a rectal temperature on a 2-month-old client. Rectal temperatures are contraindicated in infants due to increased risk of rectal perforation, as well as clients experiencing diarrhea, a history of rectal surgery, or bleeding hemorrhoids. The other actions all indicate appropriate techniques for obtaining temperature measurements for the clients' situations.

The nurse is caring for a client who had a transurethral resection of the prostate (TURP) 1 day ago and has continuous bladder irrigation in place. Which of the following findings requires intervention? A Pink-tinged urine is in the urinary drainage bag. B The amount of drainage output in the urinary drainage bag is less than the irrigant input. Correct Answer (Blank) C Small amounts of blood clots are in the drainage bag. D The client reports occasional bladder spasms while the irrigant is infusing.

Rationale: It requires intervention if the amount of output in the drainage bag is less than the input, which may indicate a blockage in the system. The output should equal the input plus regular urinary output and if not, the irrigation should be stopped, and the surgeon should be notified. Clients may have clots in the drainage bag postoperatively, and irrigation should be titrated to maintain pink-tinged urine. Occasional bladder spasms may occur due to irritation of the bladder wall.

The nurse is caring for a client with a percutaneous feeding tube (PEG). Which of the following actions requires intervention? A Cleansing the site with alcohol-soaked gauze Correct Answer (Blank) B Drying the site thoroughly after cleansing C Applying a split-drain dressing around the insertion site D Flushing the tube with warm water for patency

Rationale: It requires intervention if the nurse is observed cleansing the site with alcohol, which can cause skin irritation. PEG tube sites should routinely be cleansed with soap and warm water, and occasional use of hydrogen peroxide or normal saline is permitted. Sites should be dried thoroughly after cleansing, a split-drain dressing can be applied to provide comfort and prevent skin breakdown, and warm water should be used to flush the tube for patency.

The nurse is performing interventions to regain patency of a percutaneous feeding tube. Which of the following actions by the nurse requires intervention? A Flushing the tube with a small amount of air B Inserting a stylet to break up any clogs Correct Answer (Blank) C Instilling a small amount of warm water D Aspirating any formula remaining in the tube

Rationale: It requires intervention if the nurse is observed inserting a stylet into the tube to break up a clog to regain patency. This can cause damage to the tube and stomach mucosa. Techniques to regain patency include aspirating the remaining formula in the tube and flushing with either air or warm water and repeating until the tube patency is regained.

The nurse is observing a newly hired nurse implement measures to reduce the risk of falls in a client with altered mental status. Which of the following actions requires intervention? A Placing padding on the floor B Raising all side rails Correct Answer (Blank) C Maintaining the bed in the lowest position D Moving the client closer to the nurse's station

Rationale: It requires intervention if the nurse is observed raising all side rails on the client's bed. This can be seen as entrapment and can often increase the risk of falls when the client attempts to climb over the side rails. It is correct for the nurse to place padding on the floor along the sides of the beds to reduce impact or injury in the event of a fall, to maintain the bed in the lowest position to decrease the risk of injury from fall, and to move the client closer to the nurse's station to improve observation.

The nurse is observing a newly hired nurse apply thigh-length sequential compression devices (SCD) for a client. Which of the following observations requires intervention? A Using the widest part of the thigh circumference to measure for size B Securing the sleeves around the leg with 4 fingerbreadths between the leg and the sleeve Correct Answer (Blank) C Connecting the control unit tubing to the sleeves with the arrows in alignment D Ensuring the control unit pressure is set between 35 to 55 mmHg

Rationale: It requires intervention if the nurse is observed securing the sleeves around the leg with 4 fingerbreadths between the leg and the sleeve. The sleeve should have 2 fingerbreadths between the leg and the sleeve to ensure adequate compression during inflation while also avoiding impairment in circulation while inflated if secured too tightly. It is the correct technique to measure the thigh circumference for proper fitting, to align the arrows on the control unit to avoid obstruction of the tubing by kinks or twists, and to maintain the pressure setting of the device between 35 to 55 mmHg.

The nurse is observing a newly hired nurse obtain a capillary blood glucose specimen for a client. Which of the following actions by the newly hired nurse requires intervention? A Calibrating the glucose meter before testing B Wiping off the first drop of blood before measurement C Puncturing the tip of the client's thumb Correct Answer (Blank) D Placing the finger in the dependent position

Rationale: It requires intervention if the nurse is observed selecting the tip of the thumb as the puncture site for specimen collection. The preferred site is the middle or ring finger and along the side of the finger, not the tip. This promotes client comfort, provides accurate test results, and prevents nerve, skin, or bone injury. It is the correct technique to calibrate the meter, wipe off the first drop of blood, and place the finger in the dependent position to facilitate blood flow for the sample.

The nurse is observing a newly hired nurse implement precautions during a client's seizure. Which of the following actions requires intervention? A Applying padding to the client's bed rails B Tucking the client's chin to prevent aspiration Correct Answer (Blank) C Recording the time of onset of the seizure D Removing sharp or hard objects to prevent injury

Rationale: It requires intervention if the nurse is observed tucking the client's chin during a seizure. The nurse should turn the head to the side to prevent aspiration as well as maintain a patent airway and adequate oxygenation. It is the correct technique for the nurse to record the time of onset of the seizure, apply padding to the side rails, and remove all hard or sharp objects.

The nurse is caring for a client with a pneumothorax who has a pleural chest tube connected to a drainage system. Which of the following findings requires intervention? A Bubbling in the water seal chamber during coughing B Tidaling in the water seal chamber during inhalation and exhalation C Absence of drainage in the drainage collection chamber Correct Answer (Blank) D Continuous bubbling in the suction control chamber

Rationale: It requires intervention if there is an absence of drainage in the drainage collection chamber, which may indicate tube blockage or kinks which can result in a tension pneumothorax. Bubbling in the water seal chamber during coughing, sneezing, or forceful exhalation is expected, however, continuous bubbling may indicate an air leak and requires follow-up. Tidaling in the water seal chamber and continuous gentle bubbling in the suction control chamber indicate proper functioning of the chest tube.

The client underwent a laparoscopic removal of the appendix. Which post-operative instructions will the nurse reinforce? Select all that apply. Gently scrub off the "skin glue" when you feel able Maintain bedrest for 24 hours before gradually resuming regular activities Some shoulder discomfort can be expected Correct Answer (Blank) Restrict diet to bland, easily digestible food for a few days Correct Answer (Blank) Use 2 tablespoons of Milk of Magnesia (MOM) if no bowel movement (BM) 3 days after surgery Correct Answer (Blank) No showering for 48 hours after surgery Correct Answer (Blank)

Rationale: Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days.

The pediatric nurse is screening a child for suspected lead poisoning. Which assessment finding would support this diagnosis? A Excessive perspiration B Obesity C Developmental delays Correct Answer (Blank) D Enuresis

Rationale: Lead can affect any part of the body, including the renal, hematologic, and neurologic systems. Of most concern for young children is the developing brain and nervous system. The lead levels identified in children have declined since the initiation of screening for children at risk for lead poisoning. Long-term neurocognitive signs of lead poisoning include developmental delays, lowered intelligence quotient (IQ), reading skill deficits, visual-spatial problems, visual-motor problems, learning disabilities, and lower academic success. The other findings are not typically seen with lead poisoning.

A nurse is performing intermittent auscultation of the fetal heart rate on a client in labor. Which action by the nurse indicates the correct method of auscultation? A Placing the listening device over the area of fetal movement B Counting the fetal heart rate for 15 seconds between contractions C Performing Leopold maneuvers prior to placing the listening device over the fetal heart rate Correct Answer (Blank) D Palpating the uterine fundus to assess for maximum fetal heart rate intensity

Rationale: Leopold maneuvers help to identify fetal presentation and placement of the auscultation device near the area of maximal fetal heart rate intensity. The listening device should be placed over the area of maximal fetal heart rate intensity, not movement. The fetal heart rate should be counted for 30 to 60 seconds between uterine contractions to obtain the baseline. Palpating the uterine fundus determines uterine contractions, not the fetal heart rate.

The nurse is caring for a client newly diagnosed with hypertension (HTN) and receiving their first dose of prescribed lisinopril. The client reports dizziness with ambulation, and the nurse notes the client's blood pressure (BP) to be 90/50 mm/Hg. Which action should the nurse take? A Instruct the client to remain on bedrest until the BP has increased B Hold all prescribed anti-hypertensive medications until BP has improved C Obtain a prescription for a bolus of 0.9% normal saline (NaCl) Correct Answer (Blank) D Encourage the client to increase oral fluid intake

Rationale: Lisinopril is an ACE inhibitor, which blocks the renin-angiotensin-aldosterone system which causes peripheral vasodilation and diuresis. The therapeutic effect of an ACE inhibitor is a decrease in blood pressure. Some clients may experience hypotension and dizziness when first starting an ACE inhibitor. A client experiencing hypotension following the first dose will require a bolus of fluids to increase blood pressure. Holding medications does not address the low blood pressure. Encouraging fluid intake will not increase blood pressure. Remaining on bedrest could increase the risk for hypotension.

A nurse is assessing the home of a client with a toddler. Which action will the nurse perform to prevent the risk of aspiration? A Place plastic bags out of reach B Inspect the home for any paint chips C Check the toys for loose parts Correct Answer (Blank) D Ensure medications are in child-proof containers

Rationale: Loose parts on toys or objects around the home increases the risk of aspiration. The toddler may place the loose part in their mouth and cause an obstruction. Plastic bags increase the risk of suffocation, not aspiration. Paint chips are a source of lead and can lead to poisoning if ingested, not aspiration. Ensuring medications are in child-proof containers decreases the risk of poisoning, not aspiration.

The nurse is caring for a client who had a lumbar puncture. Immediately following the procedure, the client will be placed in which of the following positions to reduce the risk of complications? A Prone Correct Answer (Blank) B Side-lying C Supine D Semi-Fowler's

Rationale: Lumbar punctures are performed in the side-lying position with the knees pulled up to the chest and the head flexed forward. Once completed, lying prone after a lumbar puncture reduces the risk of a cerebrospinal fluid leak as it separates the alignment of the dural and arachnoid needle punctures in the meninges. This is a similar concept to the z-track method of IM injections. Cerebral spinal fluid (CSF) leaks result in severe headaches.

The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of equipment should the UAP make sure to place in the room? A A bedside commode B Soft wrist restraints C Pads to be placed over the bed's side rails Correct Answer (Blank) D An oral airway

Rationale: Maintaining safety is the primary concern for the health care team when caring for a client with seizures. The room should be set up with equipment to have readily available in case the client has a seizure. Soft pads placed over the bed's side rails will help protect the client from injury should a seizure occur while the client is in bed. The other pieces of equipment are not appropriate or indicated for seizure precautions.

A postoperative client is admitted to the post-anesthesia care unit (PACU). The anesthetist reports that malignant hyperthermia occurred during surgery. The nurse should approach the care of this client with what knowledge about this complication? A It is an allergic response to general anesthesia. B A genetic predisposition acts as the stimulus to such a reaction. Correct Answer (Blank) C A pre-existing bacterial infection precipitated the situation. D Selected surgical procedures place clients at a higher risk for this complication.

Rationale: Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics. There is a genetic predisposition to this disorder. Findings include a rapid rise in temperature to 105°F (40.5°C) or higher, muscle rigidity and stiffness, dark brown urine, and muscle aches without a history of obvious exercise to explain sore muscles.

The nurse is caring for a client following total knee replacement surgery. Which intervention will be most effective in preventing the complication of deep vein thrombosis in this client? A Use elastic stockings continuously B Place pillows under the knees C Encourage range of motion and ambulation Correct Answer (Blank) D Massage the legs twice daily

Rationale: Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client. The postoperative client would wear either compression elastic stockings and/or external pneumatic compression devices; elastic stockings should be removed at least once a shift to assess skin integrity. Pillows should never be placed under the knees, as it can prevent appropriate venous return.

A nurse is assessing a client with a suspected abdominal aortic aneurysm. Which action does the nurse perform when providing care to this client? A Palpate the abdomen for any pulsations B Monitor the client's blood pressure Correct Answer (Blank) C Administer prescribed fluid boluses D Prepare the client for immediate surgery

Rationale: Monitoring the client's blood pressure is essential in preventing an aneurysm rupture. The nurse should immediately report an increase in blood pressure. Pulsations in the abdomen should not be palpated as this can cause a rupture of the aneurysm. Administering fluid boluses is not indicated at this time. Fluid resuscitation is necessary during an aneurysm rupture. Preparing the client for surgery is not indicated. Immediate surgery is indicated for ruptured aneurysms.

The nurse is caring for a client in radiology receiving contrast medium for an intravenous pyelogram (IVP). During the initial injection of the contrast medium, the client turns a ruddy red color and says, "I can't seem to catch my breath." Which of the following interventions is the nurse's first priority? A Administer epinephrine and stop administering the contrast medium Correct Answer (Blank) B Ask the client to take two slow deep breaths C Continue to assess vital skins and skin color D Ask the technician to slow the rate of administration of the contrast medium

Rationale: Most acute severe adverse reactions to intravenous contrast media (ICM) occur within 20 minutes of the injection. Infusion of the ICM should be stopped. When the client is experiencing respiratory difficulty, epinephrine should be injected. The nurse should also prepare for oxygen administration at 10-12 L/minute and possible intubation. Slowing the rate of the contrast will not resolve the situation. The nurse will continue to assess the client, but this is not the priority action. Asking the client to take slow deep breaths will not resolve the situation.

The nurse is assessing the skin of a postoperative client. Which finding would indicate to the nurse a risk for skin breakdown? A Perspiration that requires frequent linen changes Correct Answer (Blank) B Occasional ambulation with minimal assistance C Frequent repositioning because the bed is uncomfortable D Client requests snacks as well as scheduled meals

Rationale: Most pressure injury risk assessment tools include an assessment of mobility, nutrition, and moisture. Skin that is constantly exposed to moisture is at high risk of skin breakdown. Whether the moisture is from perspiration, wound drainage, urine, or stool, the skin is compromised. Moisture can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture).

A 57-year-old male client has a hemoglobin of 10 g/dL (6.21 mmol/L) and a hematocrit of 32% (0.32). What would be the most appropriate follow-up by a home care nurse? A Call 911 and send the client to the emergency department B Refer the client to schedule an appointment with a hematologist C Ask the client if the client has noticed any bleeding or dark stools Correct Answer (Blank) D Schedule a repeat hemoglobin and hematocrit in one month

Rationale: Normal hemoglobin for males is 14-18 g/dL (8.69-11.17 mmol/L). Normal hematocrit for males is 42-52% (0.42-0.52). The lab values for this client are below normal and indicate mild anemia. The nurse should ask if the client has noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

The nurse is caring for a client with hyperkalemia. Which of the following serum potassium laboratory values is consistent with this diagnosis? A 2.8 mEq/L B 3.5 mEq/L C 4.5 mEq/L D 5.5 mEq/L Correct Answer

Rationale: Normal serum potassium levels are 3.5 to 5.0 mEq/L. A serum potassium level of 5.5 mEq/L indicates hyperkalemia.

The telemetry nurse is caring for a client who was admitted with a diagnosis of diarrhea due to norovirus infection. The nurse notes several premature ventricular contractions on the client's cardiac monitor. The premature ventricular contractions are most likely related to which lab result? A Activated partial thromboplastin time of 30 seconds B Calcium level of 9 mg/dL C Potassium level of 2.5 mEq/L Correct Answer (Blank) D Magnesium level of 2.4 mEq/dL

Rationale: Norovirus causes gastroenteritis and diarrhea. Diarrhea causes potassium loss through the stool and leads to serum hypokalemia. Potassium is needed for cardiac conduction and the normal value range for serum potassium is approximately 3.5 to 5.0 mEq/L. A low serum potassium level can lead to ventricular dysrhythmias (e.g., premature ventricular contractions). The other lab values are near or within normal ranges.

A nurse is providing care to a client in labor with continuous internal fetal monitoring. Which action by the nurse ensures safe fetal monitoring? A Obtaining the client's temperature every hour Correct Answer (Blank) B Securing the electrode wire with a band around the client's abdomen C Adjusting the electrode on the fetal presenting part after every contraction D Instructing the client to remain supine in bed

Rationale: Obtaining the client's temperature every hour ensures that there is no fever present. Internal fetal monitoring is an invasive procedure with a risk for infection. The electrode wire should be secured to the client's thigh closer to the fetal presenting part. The nurse should not touch the electrode after it has been placed by the provider as it can cause injury to the fetus. The nurse's role is to monitor the client and the fetal heart rate. The client is able to reposition frequently with an internal fetal monitor. Tracing is not affected by movement.

The nurse is caring for a client who has a nasogastric tube in place that is being used for enteral feeding and medication administration. Which method is most appropriate to confirm correct placement of the tube? A Auscultate the abdomen while instilling 10 mL of air into the tube B Measure the length of tubing from the nose to the epigastrium. C Place the end of the tube in water and observe for bubbling D Measure the pH level of the aspirated gastric contents. Correct Answer (Blank)

Rationale: Once the initial placement of the nasogastric (NG) tube has been confirmed by an X-ray, the nurse should check the pH of the aspirated contents before administering medications or feedings through the NG tube. An acidic pH of aspirated stomach contents confirms the NG tube is in the stomach and is safe to use. This is the most appropriate method to confirm the NG tube's placement. The other methods are unreliable to determine NG tube placement.

A nurse is reviewing the findings of a nonstress test performed on a client who is 34-weeks pregnant. Which finding indicates further assessments are required? A There was 1 fetal heart acceleration for a period of 10 seconds throughout the test. Correct Answer (Blank) B Fetal heart rate decelerations were present with 50% of uterine contractions. C There is an absence of fetal heart decelerations with 3 uterine contractions. D The fetal heart rate accelerated 15 beats/min for 15 seconds multiple times.

Rationale: One fetal heart rate (FHR) acceleration for a period of 10 seconds is not an expected finding on a nonstress test. A normal nonstress test on a client who is at least 32-weeks pregnant is characterized by two or more fetal heart rate accelerations lasting 15 seconds or more. Fetal heart rate decelerations in response to uterine contractions are abnormal findings with a contraction stress test, not a nonstress test. The absence of FHR decelerations in relation to uterine contractions is a normal finding of a contraction stress test. Multiple FHR accelerations lasting 15 seconds with an acceleration of 15 beats/min is an expected finding.

A nurse is preparing to collect a stool sample from a client. Which action will the nurse perform when collecting the sample? A Inform the client to defecate into the toilet B Place 1 inch of formed stool into the specimen container Correct Answer (Blank) C Collect the specimen 30 minutes after the client defecates D Instruct the client to clean the rectal area before providing a stool sample

Rationale: One inch of formed stool or 15 to 30 milliliters of liquid stool is a sufficient amount for analysis. The stool sample should be collected from a sterile bedpan or a container to avoid contamination of the specimen with toilet water. The specimen should be collected immediately after the client defecates to obtain accurate results. Cleaning the rectal area with soap before defecation may alter the test results.

The nurse is caring for a client who has atrial fibrillation. Which of the following assessment findings indicates a possible complication of this condition? A Slurred speech Correct Answer (Blank) B Decreased respiratory drive C Skin breakdown D Muffled heart sounds

Rationale: One of the most dangerous complications of atrial fibrillation is the possibility of ischemic stroke. If the client exhibits slurred speech, the nurse should be concerned that a cerebrovascular accident may be occurring. Respiratory drive and skin integrity are not directly affected by atrial fibrillation. Muffled heart sounds would indicate cardiac tamponade but this is not a complication of atrial fibrillation.

The home health nurse is working with a client who was recently discharged from the hospital and is diagnosed with orthostatic hypotension. Which client statement indicates that additional teaching is needed? A "I should take my time getting out of bed in the morning." B "I should check my blood pressure before taking my morning medications." C "I will purchase a home blood pressure machine." D "I should drink no more than six glasses of water per day." Correct Answer (Blank)

Rationale: Orthostatic hypotension occurs when there is a precipitous decrease in blood pressure upon a change in position, such as sitting or standing. For this reason, clients must stay adequately hydrated, and should assure adequate time for acclimation when changing position. Restricting fluid intake to less than six glasses of water per day may exacerbate orthostatic hypotension and is an incorrect statement that requires additional teaching. Clients should monitor vital signs prior to taking any medications that can lower blood pressure to avoid worsening orthostatic hypotension.

The nurse is assessing the drainage in a suction canister from a client's newly placed nasogastric tube (NG). Which of the following would be an expected finding? A Coffee ground appearance B Drainage pH of 7.0 C No drainage in 2 hours D Green colored output Correct Answer (Blank)

Rationale: Output from the stomach is typically green in color. A coffee ground appearance indicates the presence of blood. There should be output after the initial insertion of an NG tube, so lack of output may indicate that the tube is not in the stomach. Output pH should be less than 5.5.

The nurse is providing care to a client who is receiving oxygen therapy via nasal cannula. During the provision of care, which nursing intervention would be most appropriate? A Maintain sterile technique when handling the tubing B Inspect the nares and areas around the ears for skin breakdown Correct Answer (Blank) C Determine that adequate mist is supplied D Lubricate the tips of the cannula before insertion in the nose

Rationale: Oxygen therapy by nasal cannula can cause drying of the nasal mucosa. Pressure from the plastic tubing can cause skin irritation inside the nares or around the tops of the ears (padding is available, which helps, but does not eliminate, the problem around the ears). Nasal cannula tips for the administration of oxygen should be cleaned regularly and should never be lubricated with petroleum jelly.

The nurse is caring for a client who has just undergone a lower extremity arterial bypass graft. Which of the following assessments should the nurse complete to ensure adequate peripheral circulation? A Assess the apical pulse B Palpate pulses in the extremities Correct Answer (Blank) C Auscultate vascular sounds in the abdomen D Obtain the client's blood pressure

Rationale: Palpating pulses in all extremities allows the nurse to evaluate the circulation to each extremity. Pulses should be symmetrical. Assessing the apical pulse indicates cardiac output but does not adequately assess peripheral circulation. Auscultating abdominal vascular sounds assesses for aneurysms but does not assess for peripheral circulation. The client's blood pressure measures stroke volume and cardiac output.

The nurse is caring for a client who has just undergone an abdominal aortic aneurysm repair. Which of the following assessments should the nurse perform to ensure adequate peripheral circulation? A Palpate the lower extremity pulses Correct Answer (Blank) B Auscultate the carotid arteries C Obtain manual blood pressure readings D Inspect the surgical site

Rationale: Palpating pulses in the extremities allows the nurse to evaluate the circulation to each extremity. Pulses should be symmetrical. The nurse would inspect the surgical site for signs of bleeding or infection. Blood pressure measures cardiac output and stroke volume but does not adequately assess peripheral circulation. The nurse would auscultate the carotid arteries to assess for occlusions, which impair blood flow to the brain, not peripheral circulation.

A nurse is providing care to a client post esophagogastroduodenoscopy (EGD). The results indicate gastric ulcers. Which intervention does the nurse expect to perform next? A Request a type and crossmatch B Prepare to administer intravenous pantoprazole Correct Answer (Blank) C Administer a bolus of normal saline solution D Provide the client with a bland diet

Rationale: Pantoprazole is a proton pump inhibitor (PPI) that decreases gastric acid secretion. PPIs are the preferred drug class for treating acid-related disorders. Requesting a type and crossmatch is indicated for clients who exhibit signs of gastrointestinal bleeding. The client's diagnostic results are not indicative of an active bleed. Administering a bolus of normal saline is not specifically indicated for a client with a gastric ulcer. A bland diet is indicated for a client with a gastric ulcer. However, the client should be kept NPO (nothing by mouth) until the gag reflex returns. An absent gag reflex can lead to aspiration.

The nurse is caring for a client who is being tapered off an infusion of total parenteral nutrition. Which of the following findings would alert the nurse that the infusion rate was reduced too rapidly? A Urine output increases. B The client reports feeling thirsty. C The EKG shows increasing heart rate. Correct Answer (Blank) D The client reports dry mouth.

Rationale: Parenteral nutrition infusion rate changes are made incrementally to avoid severe hyperglycemia or hypoglycemia. Infusions are tapered off slowly to try to avoid hypoglycemia. In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated causing symptoms such as sweating, tremor, tachycardia, palpitation, and nervousness. Hyperglycemia results in increased urination (polyuria), increased thirst (polydipsia), and increased appetite (polyphagia), along with many other symptoms.

The nurse is caring for a client who complains of pain in the epigastric region. The client has a history of peptic ulcer disease. Which finding should the nurse immediately report to the health care provider? A White blood cell count of 8,000/µL B Platelet count of 220,000 mm3 C Positive test result for Helicobacter pylori D Hemoglobin level of 7.4 g/dL Correct Answer (Blank)

Rationale: Peptic ulcer disease (PUD) results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin. A peptic ulcer is a mucosal lesion in the stomach or duodenum. The most serious complication of PUD is hemorrhage. The serum hemoglobin (Hgb) level will drop as a result of bleeding. The normal range for Hgb is 14 to 18 g/dL in males and 12 to 16 g/dL in females. This client's level is 7.4 g/dL, which is low and indicates possible hemorrhage. The normal range for white blood cell count (WBC) is 5,000 to 10,000/µL. The normal range for platelet count (PLT) is 150,000 to 400,000 mm3. Helicobacter pylori infection plays a role in the development of gastric ulcers. While a positive Helicobacter pylori test is pertinent to the client's history of PUD, possible hemorrhage is the most serious problem for this client and should be reported to the health care provider (HCP) immediately.

The nurse is caring for a child who requires chest physiotherapy (CPT). Which nursing action is appropriate? A Confine the percussion to the rib cage area Correct Answer (Blank) B Schedule the therapy 30 minutes after meals C Teach the child not to cough during the treatment D Place the child in a prone position for the duration of the therapy

Rationale: Percussion (clapping) should be done in the area of the rib cage anterior and posterior. This often requires various positions to remove all secretions. This therapy should be done one hour prior or two hours after meals. Children are encouraged to cough during treatments to help expel mucus.

The nurse is caring for a client who had plasmapheresis. Which manifestation reported by the client would indicate a complication of the treatment? A Vomiting B Back pain C Dizziness Correct Answer (Blank) D Malaise

Rationale: Plasmapheresis is the removal of plasma-containing components that can cause disease, such as autoimmune disorders. The complications of plasmapheresis are hypotension from a fluid shift and citrate toxicity. Citrate, which is an anticoagulant, can cause hypocalcemia, resulting in a headache, dizziness, and paresthesia. Back pain is a manifestation of hemolytic blood transfusion. Malaise and vomiting are manifestations of infection.

The nurse is reviewing the medical record of a client who was admitted for poor oral intake and dysphagia. Which blood test result is most important for the nurse to report to the health care provider? A Creatinine level of 3.5 mg/dL Correct Answer (Blank) B Sodium level of 148 mEq/L C Chloride level of 108 mEq/L D Hematocrit level of 55%

Rationale: Poor oral intake (caused by dysphagia) has likely caused a fluid volume deficit (i.e., hypovolemia) in this client. When there is decreased circulating blood volume, the blood is more concentrated and acute kidney injury can occur. High creatinine levels (e.g., 3.5 mg/dL) indicate acute renal failure. It is most important for the nurse to report this finding to the health care provider. The other lab values are also outside of the normal range which is most likely related to hemoconcentration caused by the hypovolemia.

The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client's history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period? A Past hypersensitivity to heparin B Family history of uterine cancer C Estrogen replacement therapy for the past three years Correct Answer (Blank) D History of acute hepatitis A

Rationale: Post-menopausal women using hormone replacement therapy have a higher risk of DVT and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for the development of a DVT. The other information in the client's history is unremarkable for postoperative complications, such as DVT.

A client is being prepared for an above-the-knee amputation. Which actions by the nurse would represent appropriate care of this client? Select all that apply. Explain the procedure, including any risks, before the client signs the surgical consent form Verify that the informed consent form is signed Correct Answer (Blank) Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site Correct Answer (Blank) Have the client confirm his or her identity, the surgical site, and the procedure before administration of any medications Correct Answer (Blank) Verify any allergies Correct Answer (Blank)

Rationale: Prior to surgery, the nurse can witness the client's signature on the consent form, but the explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site, and the procedure.

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer nutritional feedings and medications. Which nursing action is best to ensure patency of the tube? A Warming nutrition feedings before administration B Squeezing the tube to dislodge obstructions C Adequately flushing the tube with water before and after use Correct Answer (Blank) D Completely crushing all medications prior to administration

Rationale: Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency (while providing hydration). Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use.

The nurse is assessing a client who received procedural sedation for a cardioversion. The client's respirations are 10 breaths/min. Which action should the nurse take next? A Activate the rapid response team B Evaluate breathing for depth and effort Correct Answer (Blank) C Notify the health care provider immediately D Obtain a pulse oximeter reading

Rationale: Procedural sedation, also called moderate or conscious sedation, involves the administration of a short-acting sedative such as midazolam, a benzodiazepine, or a similar drug. This class of drugs tends to depress the central nervous system causing respiratory depression. In addition to the respiratory rate, the nurse should next assess the client's respiratory effort and depth since those will provide additional data for the nurse to determine if the client's respiratory efforts are adequate. A pulse oximeter reading would indicate how well the client is oxygenating, but it does not help with assessing if the client's breathing is insufficient. That would be more appropriately measured with capnography. The other actions are premature at this time.

The perioperative nurse must place the anesthetized client into the lithotomy position for a cystoscopic procedure. What is the safest technique for moving the client into this position? A Rotate hips and flex knees one at a time before placing in stirrup B Abduct legs, then flex knee of one leg before placing in stirrup; repeat with other leg C Raise one leg, flex the knee, and place leg in stirrup; repeat with other leg D Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in padded stirrups Correct Answer (Blank)

Rationale: Proper positioning of the client during a surgical procedure, is a way to help prevent intraoperative nerve injury. The client can become injured while being placed in the lithotomy position. Positioning the client for surgical procedures is the responsibility of the nurse. In some cases, a client under anesthesia may lose some of their protective reflexes and cannot feel or express sensation that might reveal a potential nerve injury. When placing the client in this position, both legs should be moved at the same time to avoid overstretching the nerves of the lumbosacral plexus. Stirrups should be padded so that the client's legs don't touch the poles of the stirrups directly. Compression along the medial and lateral aspects of the calf can damage the saphenous nerve and peroneal nerve. This may lead to weakness in the lower extremities during the postoperative period.

The nurse is caring for a client who had surgical wound debridement and vacuum-assisted wound closure dressing applied to a stage 4 sacral pressure injury. Which finding should indicate to the nurse that the client has an increased risk for delayed wound healing? A Low serum albumin levels Correct Answer (Blank) B Serosanguinous drainage in the vac tubing C Increased granulation tissue in the wound bed D Elevation in white blood cell count

Rationale: Protein deficiency must be corrected to promote the healing of the pressure ulcer. Carbohydrates are necessary to "spare" the protein and to provide an energy source. Vitamin C and trace elements, especially zinc, are necessary for collagen formation and wound healing. Vacuum-assisted closure (VAC) involves the use of a negative-pressure sponge dressing in the wound to increase blood flow, increase the formation of granulation tissue and nutrient uptake, and decrease bacterial load; therefore, increased granulation tissue indicates the therapy is working. An elevation in white blood cell count is normal with a client who had surgery and has a stage 4 sacral pressure injury from the inflammatory process.

The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN) through a nasogastric tube. Which findings indicate that the client may be experiencing a complication from the EN? Select all that apply. 200 mL dark yellow urine voided in the last eight hours Correct Answer (Blank) Pale and dry oral mucous membranes Correct Answer (Blank) Gastric residual volume of 100 mL New onset adventitious lung sounds Correct Answer (Blank) Aspirated gastric fluid has a pH of 4 A weight loss of 2 kg in 24 hours Correct Answer (Blank)

Rationale: Pulmonary aspiration of enteral feeding formula is a risk for clients receiving EN. New onset of adventitious or abnormal lung sounds on auscultation in a client receiving EN are indicative of possible aspiration. Due to the nutrient-dense, hypertonic composition of enteral feeding formulas, clients on EN are at risk for developing hyperosmolar dehydration. Signs and symptoms of clinical dehydration include weight loss, postural hypotension, tachycardia, thready pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when supine, and dark yellow urine. If the dehydration is severe, the symptoms will include thirst, restlessness, confusion, hypotension, oliguria (urine output below 30 mL/hr), and cold, clammy skin.

The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a pulmonary embolism. For which laboratory result should the nurse notify the health care provider immediately? A Serum troponin level of 0.1 mg/mL B D-dimer level of 1.2 mcg/mL C Serum creatinine level of 2.8 mg/dL Correct Answer (Blank) D Arterial blood gas PaO2 level of 80 mmHg

Rationale: Pulmonary embolism means the blockage of a pulmonary artery by a thrombus. A spiral CT scan, i.e., CT angiography, is the test most frequently used to confirm a pulmonary embolism (PE). An intravenous injection of contrast media (dye) is required to visualize the pulmonary vasculature. The dye has the potential to cause renal failure and should be used with caution in clients with impaired renal function. The client's creatinine level is significantly elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced renal failure, and the nurse should notify the health care provider of this lab result immediately. The elevated D-dimer level is to be expected. The PaO2 and troponin levels are within normal limits.

The nurse is providing discharge teaching to a client who had a radiofrequency catheter ablation for treatment of atrial fibrillation. Which information is most important to include in the teaching? A Schedule a follow-up appointment in two weeks. B Take all cardiac medications as prescribed. Correct Answer (Blank) C Call the cardiologist's office with any questions. D Maintain oral fluid intake of 2 to 3 liters daily.

Rationale: Radiofrequency catheter ablation is an invasive procedure performed to treat cardiac arrythmias. Ablation is used to destroy any abnormal cardiac pacemaker cells so that erratic electrical signals are normalized. After an ablation, the client will typically continue taking an antiarrhythmic medication and possibly an anticoagulant as well. Therefore, it is most important to teach the client to adhere to their prescribed medication regimen to avoid potentially life-threatening cardiac complications (e.g., lethal arrhythmias) because the cardiac cells tend to be irritable in the weeks following the procedure.

A nurse is preparing to feed a client with right hemiplegia and dysphagia. Which action will the nurse perform to prevent aspiration A Place the food tray on the client's left side B Raise the head of the bed to a high Fowler's position Correct Answer (Blank) C Instruct the client to extend the neck back while swallowing D Ensure the food on the tray is liquid consistency

Rationale: Raising the head of the bed to a high Fowler's position reduces the risk of regurgitation and aspiration during meals. Placing the food tray on the client's left side will facilitate participation from the client during meals; however, this does not prevent aspiration. The neck should be flexed slightly forward when swallowing to decrease the risk of aspiration. Extending the neck back may cause choking. The consistency of the food should be determined by the speech-language pathologist to minimize the risk of choking. Liquid food may need to be thickened before administering.

A nurse is providing care to a client with a deep vein thrombosis on the right lower extremity. Which action will the nurse perform to prevent circulatory complications? A Massage the affected extremity to decrease discomfort B Place a pillow under the right knee to elevate the extremity C Apply ice packs to the extremity to decrease edema D Encourage range of motion exercises to increase mobility Correct Answer

Rationale: Range of motion exercises should be encouraged to promote circulation and maintain mobility while in bed. Massaging the affected extremity is contraindicated. Massaging the limb may cause the blood clot to dislodge and enter the systemic circulation. Placing a pillow below the knee will cause pressure and decrease circulation to the extremity. The pillow should be placed along the calf area. Ice packs will cause vasoconstriction and decrease circulation. The nurse should use warm, moist compresses as prescribed.

The nurse is caring for a client who had a femoral cardiac catheterization with coronary artery stent placement. Which of the following nursing actions is appropriate? A Check the gag reflex prior to feeding the client B Complete a neurovascular check of the lower extremities Correct Answer (Blank) C Perform passive range of motion to all extremities D Keep the client in high Fowler's position

Rationale: Rare, but serious, complications associated with cardiac catheterization include bleeding, infection, and arterial obstruction. Nursing responsibilities after cardiac catheterization include observing the site for bleeding or hematoma formation, assessing peripheral pulses, and evaluating temperature, color, and capillary refill. Additional components of the neurovascular check include assessing for pain, numbness, and tingling sensations that may indicate arterial insufficiency. Clients will also be monitored for dysrhythmia. Bedrest will be maintained for a duration determined by hospital policy and type of catheterization. The leg will remain straight, and the head of the bed will be elevated less than 30 degrees.

A nurse is assessing a client who was placed on a volume-cycled ventilator. Which finding indicates that the nurse needs to suction the client? A Restlessness Correct Answer (Blank) B Report of nausea C Heart rate of 82 BPM D Drowsiness

Rationale: Restlessness suggests the client may be experiencing hypoxia due to the presence of secretions in the airways. Other symptoms of hypoxia include tachycardia. The report of nausea is not relevant to the need for suctioning. Drowsiness may occur if the pCO2 is high but is not an indication for suctioning.

The nurse is caring for a client with orders for oxygen (O2) per nasal cannula at 5 L/min. Approximately what fraction of inspired oxygen (FiO2) is the client receiving? A 28% B 21% C 40% Correct Answer (Blank) D 36%

Rationale: Room air has an O2 concentration of approximately 21%. Supplemental O2 therapy is prescribed when the client's oxygenation needs are not met by room air. A nasal cannula can provide O2 at 0.5 to 6 L/min, corresponding to a FiO2 range of 25% to 40%. At 5 L/min, the client would be receiving approximately 40% O2. If the client's oxygenation needs are still not met, the O2 delivery system should be changed from a low-flow system like a nasal cannula to a high-flow system such as a nonrebreather mask.

A nurse is providing care to a client admitted for chest pain. The client's electrocardiogram reveals an ST elevation. Which action does the nurse perform first? A Positions the crash cart at the bedside B Initiates intravenous lines C Places the client on a cardiac monitor D Administers oxygen to the client Correct Answer (Blank)

Rationale: ST elevation on an electrocardiogram is indicative of myocardial infarction (MI). The priority intervention is to administer oxygen to maintain perfusion. Positioning the crash cart at the bedside ensures readiness if the client's condition deteriorates. However, the nurse should secure oxygenation first. At least two intravenous lines should be initiated on a client with an MI to administer medications. However, the nurse should administer oxygen first. Placing the client on a cardiac monitor is an expected intervention for a client experiencing an MI. However, the nurse should secure the airway, breathing, and circulation first.

A nurse is preparing to collect a guaiac fecal occult blood test from a client with suspected gastrointestinal bleeding. Which action does the nurse perform when collecting the sample? A Collects two samples from different areas of the stool Correct Answer (Blank) B Uses one wooden applicator to smear the samples of stool on the test card C Places a couple of drops of developer over the stool samples D Obtains the stool samples from the toilet bowl

Rationale: Samples should be collected from different areas of the stool to increase the accuracy of detecting occult blood. A different applicator should be used for each smear to ensure a fresh sample is applied each time. The developer should be placed on the opposite side of the test card. Samples should not include toilet bowl water as this can cause errors in the testing.

The nurse is teaching a client with varicose veins about sclerotherapy. Which information should the nurse include in the teaching? A "You must avoid wearing compression stockings before the procedure." B "You will be under general anesthesia for the procedure." C "You will receive intravenous injections during the procedure." Correct Answer (Blank) D "You must remain on bed rest for 24 hours after the procedure."

Rationale: Sclerotherapy involves the injection of a liquid or foam sclerosing substance directly into varicose veins. The sclerosing agent causes endothelial inflammation ultimately resulting in the destruction of varicose veins, which are subsequently disintegrated. Wearing compression stockings generally improves varicose vein symptoms in clients awaiting sclerotherapy; there is no reason to avoid wearing them even immediately prior to the procedure. Sclerotherapy is performed in an outpatient setting without anesthesia. Bed rest is not necessary after sclerotherapy.

The nurse is caring for a client who was admitted with a new onset of seizures. While the nurse is assessing the client, the client begins having a generalized tonic-clonic seizure. Which action should the nurse take first? A Turn the client on their side. Correct Answer (Blank) B Pad the side rails of the client's bed. C Apply oxygen to the client. D Establish an IV saline lock.

Rationale: Seizures must be treated promptly and aggressively. The nurse should follow the ABCs (airway, breathing and circulation) and first protect the client's airway by turning them on their side. If possible, the nurse should also turn the client's head to the side to prevent aspiration and allow secretions to drain out of their mouth. If necessary, a nasal airway is recommended for a client having a seizure to establish a clear path for oxygen and ventilation. Nothing should be inserted into the mouth of a client having a seizure. Then the nurse should administer oxygen using a nasal cannula or face mask as indicated by the client's condition. If not already in place, an IV should be established for ready access in case IV medications need to be given to stop the seizure. Finally, padding the side rails can be done to prevent the client from injury during the seizure.

The nurse is assessing the mental status of a client. Which option would best evaluate the functioning of the client's short-term memory? A Ask the client to calculate a simple arithmetic operation. B Ask the client to copy an image of two simple, intersecting geometric shapes. C Ask the client to recall three words the nurse had previously asked the client to remember. Correct Answer (Blank) D Ask the client to name the last four presidents.

Rationale: Short-term memory refers to the temporary storage of information in the memory and the management of the information so that it can be used for more complex cognitive tasks. Tests of cognitive function evaluate cognitive impairment. The Mini-Mental Status Exam (MMSE), for example, measures orientation to time and place, calculation, language, short-term verbal memory and immediate recall. Asking the client to recall three words that the client had previously been asked to remember is the best approach to determine short-term memory function. Asking the client to recall facts from history would assess long-term memory. Asking the client to copy an image assesses visual-spatial skills and complex commands. Simple arithmetic operations, such as counting backward from 100 by sevens, evaluates attention and calculation.

The nurse is educating clients at a community center about preventing complications of hypertension. Which of the following statements should the nurse include in the teaching? A "Only take your medication if your blood pressure is high." B "Quitting smoking tobacco will reduce your risk of stroke." Correct Answer (Blank) C "Increase your calorie intake to have more energy." D "Physical activity should be minimal to avoid cardiovascular stress."

Rationale: Smoking and hypertension significantly increase the risk of cerebrovascular accidents; therefore, the client who has high blood pressure should be educated on the importance of smoking cessation. Blood pressure medications should be taken consistently to maintain normal blood pressure. Calories should not be increased, and physical activity is beneficial for hypertensive clients.

The nurse is assessing the abdominal incision of a client who is postoperative one week. Which finding would indicate a delay in wound healing? A Sanguineous drainage from the center of the incision is present. Correct Answer (Blank) B Incision edges are approximated. C A scab has formed over the incision. D There is slight tenderness around the incision line.

Rationale: Some manifestations of inflammation are to be expected (e.g., wound tenderness, slight erythema, and edema); however, this should decrease over time, and there should be no evidence of an infection at the wound site. Increased erythema and drainage are indicative of infection. Pain that is controlled without narcotics is also to be expected.

The nurse has completed discharge teaching to a client who had a total hip arthroplasty. Which statement made by the client indicates further teaching is needed? A "When I go home, I should not stand for long periods." B "If my hip pain gets worse I should call my doctor." C "Now I will be able to bend forward to tie my shoes without pain." Correct Answer (Blank) D "I'll use an electric razor to shave."

Rationale: Someone who had a total hip replacement should not sit or stand for prolonged periods of time to help prevent thromboembolism and muscle fatigue. Because anticoagulants are typically used postoperatively, the use of an electric razor is indicated. Any increase in hip pain must be evaluated for complications. Following hip replacement surgery, a person should never bend at the waist more than 90 degrees, which would mean the person should not bend over to tie shoes.

A nurse is assessing a client with a spinal cord injury. Upon assessment, the nurse notes a soft, distended abdomen. Which action will the nurse expect to perform to prevent complications of neurogenic bowel? A Administer a laxative suppository Correct Answer (Blank) B Place the client on NPO status C Gather supplies to insert a nasogastric tube D Prepare the client for surgery

Rationale: Spinal cord injuries can cause neurogenic bowel. Neuron injuries prevent adequate peristalsis and can lead to constipation. The nurse should expect to administer laxative suppositories to stimulate bowel movements. Placing the client on a nothing by mouth (NPO) status is not indicated. Neurogenic bowel is a common result of spinal cord injuries and is treated with other methods. A nasogastric (NG) tube is not indicated for the client at this time. The client's abdomen is distended but soft. This does not indicate an obstruction. Surgical intervention is not indicated for the client at this time. The client's symptoms are not indicative of bowel perforation.

A client who has cirrhosis of the liver underwent a paracentesis yesterday. Today, the unlicensed assistive personnel (UAP) reports the client is lethargic and has musty-smelling breath. Which assessment should the nurse perform next? A Measure the abdominal girth changes B Auscultate the upper abdomen for bruits C Monitor the client's clotting status D Assess for flap-like tremors of the hands Correct Answer (Blank)

Rationale: Subtle changes in mental status and a musty odor to the breath are findings associated with hepatic encephalopathy. Hepatic encephalopathy is often seen in people with chronic liver disease (cirrhosis or hepatitis). A classic sign of this disorder is flapping tremors of the hands (asterixis).

A nurse is providing oral hygiene to a client who is unconscious. Which action will the nurse perform to prevent aspiration? A Gently brush the client's teeth with a soft toothbrush B Position the client supine with the head turned away C Ensure suction set up is available at the bedside Correct Answer (Blank) D Place a finger on top of the client's tongue while brushing

Rationale: Suction equipment should be available at the bedside when performing oral hygiene on a client who is unconscious. The nurse should be prepared to suction oral secretions to prevent aspiration. Brushing the client's teeth with a soft toothbrush will protect a fragile oral mucosa; however, it will not prevent aspiration. The client's head should be turned towards the nurse for better visualization of secretions. Fingers should never be placed into the mouth of a client who is unconscious. The client may accidentally bite down and cause injury to the fingers.

The nurse is preparing to suction a client's tracheostomy. Which interventions should the nurse implement? Select all that apply. Use a sterile suction catheter Correct Answer (Blank) Explain the procedure to the client Correct Answer (Blank) Hyperoxygenate the client prior to suctioning Correct Answer (Blank) Administer a mild sedative prior to suctioning Instill a small amount of saline prior to inserting the catheter Auscultate lung sounds before and after Correct Answer (Blank)

Rationale: Suctioning a tracheostomy should be done with a sterile catheter unless the client has a closed suction system connected to the tracheostomy. Hyperoxygenation for a few minutes prior to suctioning is recommended to prevent hypoxia during the procedure. The nurse should assess the client's lung sounds before and after and should explain to the client what the nurse is about to do. According to evidence-based practice, the use of saline is no longer recommended during routine suctioning. A sedative is not routinely given for suctioning a tracheostomy.

The nurse is assessing a 72-year-old client with a full-leg cast on his left leg three days after cast application and finds bilateral pedal edema. Based on this finding, what condition should the nurse consider? A Heart failure Correct Answer (Blank) B Compartment syndrome C Infection D Thrombophlebitis

Rationale: Swelling after injury or surgery and reduction usually peaks within 24 to 48 hours with only minimal swelling expected afterward. If the client had pedal edema only on the casted leg, the nurse should consider an extension of the initial injury/trauma, compartment syndrome, or thrombophlebitis. However, with bilateral pedal edema, the nurse should consider right-sided heart failure.

The nurse is preparing a client with atrial fibrillation for synchronized cardioversion. Which action is the priority for the nurse to take? A Remove the client's oxygen Correct Answer (Blank) B Disconnect the client's IV fluids C Place a bite guard in the client's mouth D Disconnect the client blood pressure monitor

Rationale: Synchronized cardioversion is the external administration of an electrical impulse to reset the cardiac conduction. Pads are placed on the client's chest, which is used to conduct the electrical current. The priority of the nurse is to remove the client's oxygen source, which could spark a fire if contact with the electrical current occurs. The client can still be connected to the IV fluids and blood pressure monitor. A bite guard can be used, but it is not the priority.

The nurse is providing care to an adult client in the post-anesthesia care unit who is recovering from an emergency appendectomy. The client is sleepy, but arousable and reports zero pain on a numeric pain scale. Which assessment finding requires immediate action by the nurse? A A blood pressure of 100/60 mmHg B A temperature of 99.1°F (37.3°C ) C A pulse oximetry reading of 92% D A resting heart rate of 128 bpm Correct Answer (Blank)

Rationale: Tachycardia (i.e., a heart rate greater than 100 beats per minute) is an early physiological response to a number of potential postsurgical complications, especially in the absence of obvious contributing factors such as pain or anxiety. A resting heart rate of 128 could indicate hypovolemia due to internal bleeding from the surgery. The client's blood pressure and oxygen saturation are within acceptable ranges. A low-grade fever (e.g., 99.1°F or 37.3°C) can occur post-operatively and is typically not a cause for immediate concern. Therefore, the nurse should notify the health care provider of the client's resting heart rate immediately.

A nurse is preparing to administer bolus feedings to a client with a nasogastric tube. Which action will the nurse perform to prevent aspiration? A Turn off the suction after administering the feedings B Hold the feeding syringe above the level of the abdomen C Test the pH level of collected gastric contents Correct Answer (Blank) D Ensure the formula is administered at room temperature

Rationale: Testing the pH level of gastric contents is one method of checking for tube placement. A gastric pH level below 4 is expected. The nurse should follow up with an alternate placement check if the pH level is out of range. Turning off the suction allows for nutrient absorption; however, it does not prevent aspiration. Holding the syringe above the level of the abdomen will help the feedings flow by gravity; however, this does not prevent aspiration. Ensuring the feedings are administered at room temperature will decrease gastric discomfort; however, it will not prevent aspiration.

The nurse is teaching a client how to properly use their peak flow meter at home. Which statement by the client indicates an understanding of the teaching? A "I will take a deep breath and exhale slowly and steadily into the mouthpiece." B "I will exhale completely then inhale quickly into the mouthpiece." C "I will take a deep breath and then blow out hard and fast into the mouthpiece." Correct Answer (Blank) D "I will exhale completely then inhale slowly and steadily into the mouthpiece."

Rationale: The Peak Expiratory Flow Rate (PEFR) is the point of highest flow during maximal expiration. The normal range is calculated for clients individually based on their height and weight. The steps for correctly using the peak flow meter include: move the indicator to the bottom of the numbered scale, stand up, take a deep breath, place the mouthpiece in mouth and close lips around it, blow out hard and fast with a single blow, and record the number achieved on the indicator. The steps should be repeated two more times, for a total of three attempts and the highest peak flow reading of the three should be recorded.

A nurse is assessing a client with suspected atrial fibrillation. The client's apical and radial pulses are inconsistent when palpated. Which finding does the nurse expect to observe on the electrocardiogram (ECG)? A Atrial rate of 150 beats/min B ST elevation C QRS complex of 0.24 D Absent P waves Correct Answer

Rationale: The absence of P waves on an electrocardiogram (ECG) is indicative of atrial fibrillation. The P wave represents atrial contractions, which are ineffective in atrial fibrillation. An atrial rate of 150 beats/min is not consistent with atrial fibrillation. In atrial fibrillation, the atrial rate is often unmeasurable and can exceed 350 beats/min. A QRS complex of 0.24 is not characteristic of atrial fibrillation. Prolonged QRS complexes are common with ventricular dysrhythmias. ST elevation is not characteristic of atrial fibrillation; it is used to measure ventricular conduction.

The nurse is completing a follow-up assessment on a client who is one hour postoperative following an abdominal surgery. Prior to surgery, the client was mildly hypertensive but all other assessment findings were within normal limits. Which of the following findings requires action by the nurse? A Blood pressure 90/62 mmHg Correct Answer (Blank) B Heart rate 62 bpm C Respiratory rate 22 bpm D Oral temperature 37.2°C

Rationale: The blood pressure of 90/62 is a significant decrease if the client was mildly hypertensive previously. The nurse should be concerned about the possibility of postoperative bleeding when blood pressure decreases significantly. The heart rate and temperature are within normal limits, and the respiratory rate is slightly elevated but not a cause for concern.

The nurse is assessing a client's pulse rate and quality. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? A Popliteal B Carotid Correct Answer (Blank) C Femoral D Brachial

Rationale: The carotid arteries should never be palpated at the same time due to occlusion of the arteries that supply the brain. This action could cause impaired cerebral blood flow or stimulate a vagal response and therefore reflex bradycardia and hypotension. Other pulse sites may be palpated simultaneously to assess for equality.

The charge nurse is observing a newly hired nurse caring for a client with a cast applied to the left lower extremity for a femur fracture. Which of the following actions by the nurse requires intervention? A Performing frequent neurovascular checks on the left lower extremity B Positioning the casted extremity below the level of the heart Correct Answer (Blank) C Applying ice to the casted extremity D Encouraging the client to increase their fluid intake

Rationale: The casted extremity should be positioned above the level of the heart to reduce edema. The charge nurse should intervene if the nurse positions the casted extremity below the level of the heart as this can increase edema. Increased edema can cause neurovascular complications. The nurse should perform frequent neurovascular checks, apply ice as needed, and encourage increased fluid intake to prevent complications of immobility due to fractures, such as constipation and renal stones.

A client has a history of chronic obstructive pulmonary disease (COPD). The nurse enters the client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per minute, the client's color is flushed, and the client's respirations are 8 breaths per minute. What should the nurse do first? A Remove the nasal cannula for at least five minutes Correct Answer (Blank) B Place client in a higher sitting position C Lower the oxygen's flow rate D Check the client's pulse for strength and rate

Rationale: The client has findings of oxygen toxicity so the nurse should first remove the cannula for a least five minutes. Then the nurse should perform these next sequence of actions: pulse assessment, change of position and then lower the oxygen flow rate and reapply if respirations are within normal parameters. A higher concentration of supplemental oxygen removes the hypoxic drive to breathe and leads to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis.

The nurse working on a surgical unit is caring for a client who had surgery earlier today. The client's blood pressure is 80/51 mmHg and the heart rate is 128 bpm. Which intervention should the nurse implement first? A Ensure the client has a patent airway. Correct Answer (Blank) B Check the surgical dressing for bleeding. C Increase the rate of the IV fluid infusion. D Apply supplemental oxygen therapy.

Rationale: The client is exhibiting signs of hypovolemic shock (e.g. hypotension and tachycardia). Hypovolemic shock can occur as a complication from surgery. The goals of hypovolemic shock management are to maintain tissue oxygenation, increase vascular volume, and support compensatory mechanisms. The nurse should follow the ABCs and first ensure the client has a patent airway. Then the nurse should apply supplemental oxygen to promote tissue oxygenation. The nurse should increase the rate of IV fluids to increase the client's vascular volume. The nurse should assess the client's surgical dressing for bleeding. The clients condition should be reported to the health care provider immediately.

A nurse is caring for a client who has had staples removed from an abdominal wound. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which action should the nurse take first? A Obtain the client's vital signs B Assess the client's pain level C Obtain a culture of the wound drainage D Cover the wound with a moist sterile gauze dressing Correct Answer (Blank)

Rationale: The client is experiencing dehiscence of the wound, which is when the wound opens up. The nurse should first cover the wound with a moist sterile gauze dressing to protect the wound. The nurse would then assess the client's pain, check vital signs, and obtain a culture of the wound drainage.

The nurse is caring for a client diagnosed with an aspirin overdose who is in respiratory alkalosis. Which finding was most likely the cause of this imbalance? A Hyperpyrexia B Vomiting C Tachypnea Correct Answer (Blank) D Hypokalemia

Rationale: The client is suffering from salicylate poisoning due to the over-consumption of aspirin. Classic symptoms of salicylate poisoning are ringing in the ears, nausea, abdominal pain, and fast breathing rate. The fast breathing rate, or tachypnea, is causing the client to hyperventilate which is decreasing carbon dioxide (CO2) levels as the client blows out air. This will eventually progress to hypoventilation and respiratory failure. Respiratory alkalosis is characterized by a higher ph, low PaCO2, and normal bicarbonate (HCO3).

The nurse is assessing a client and notes a left-sided facial droop that was not present during their last interaction. Which of the following assessments should the nurse perform to evaluate the client's neurological status? A Assess the client for arm drift Correct Answer (Blank) B Perform a swallow screen C Obtain the client's oxygen saturation D Assess for orthostatic hypotension

Rationale: The client should be assessed prior to completing any other neurological assessments. If the client is comatose, for example, the neurological assessment will be different from someone who is alert.

The nurse is caring for a client who has just been admitted to the acute care facility. Which of the following conditions indicates that the client is at risk for decreased peripheral vascular perfusion? A Cystic fibrosis B Osteoarthritis C Urinary incontinence D Diabetes mellitus Correct Answer

Rationale: The client who has been diagnosed with diabetes mellitus is at an increased risk for peripheral vascular deficits. Osteoarthritis, incontinence, and cystic fibrosis are not conditions that directly affect peripheral circulation.

The nurse is completing an initial assessment on a client in the acute care facility. Which of the following findings should the nurse recognize as a risk factor for skin breakdown? A Immobility Correct Answer (Blank) B Tattoos C Facial asymmetry D Memory loss

Rationale: The client who is immobile is at an increased risk for skin breakdown because they often put pressure on bony prominences. Tattoos, facial asymmetry, and memory loss do not directly affect the likelihood of skin breakdown.

The nurse is planning care for a client who is postoperative from an intermaxillary fixation for a mandibula fracture. Which of the following should be the priority of the nurse place at the client's bedside? A Nasogastric tube B Wire cutters Correct Answer (Blank) C Syringes D Tongue depressor

Rationale: The client who is postoperative intermaxillary fixation will have wires to keep the jawbone aligned. If a client experiences respiratory distress, the nurse will need to cut the wires to access the airway. A nasogastric tube is used to decompress the stomach, syringes are used to irrigate the mouth, and a tongue depressor retracts the cheeks, but these are not a priority.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving prescribed low-flow oxygen 2 l/min via nasal cannula. Which finding would indicate to the nurse that intervention is required? A SpO2 level of 88% B PaO2 level of 55% Correct Answer (Blank) C Breath sounds bilateral wheezing D Decreased effort with incentive spirometer

Rationale: The client with COPD, which is inflammation and loss of elasticity of the lung tissues, will have chronic hypoxia with SpO2 stats of 88% or greater, wheezing with inspiration, and decreased effort with an incentive spirometer. A PaO2 level of 55% is below normal, indicating the client might be experiencing respiratory distress.

The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? A Serum hemoglobin level of 15.7 g/dL B Serum potassium level of 5.0 mEq/L C Blood glucose level of 146 mg/dL D Serum creatinine level of 2.8 mg/dL Correct Answer (Blank)

Rationale: The client with dehydration will show certain increased lab values that are due to hemoconcentration - an imbalance in the ratio of plasma to solutes in the blood. Dehydration will cause a decrease in fluid, i.e., plasma, in the blood. This decrease will make the concentration of solutes such as glucose, potassium and hemoglobin appear higher than they actually are. Creatinine is excreted solely by the kidneys and is proportional to renal function. Thus, with normally functioning kidneys, the creatinine level should remain within a normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result for the nurse to report to the HCP.

The nurse is assessing a client with myasthenia gravis and notes that the client's respiratory rate is 10 and there is limited chest wall movement. Which of the following interventions should the nurse take? A Prepare the client for mechanical ventilation Correct Answer (Blank) B Administer a prescribed anticholinesterase medication C Instruct the client on pursed-lip breathing D Position the client in high-Fowler's

Rationale: The client with myasthenia gravis has muscle weakness, which can impede the movement of the chest wall and diaphragm resulting in respiratory failure. A client with a respiratory rate of 10 and limited chest wall movement is at risk for respiratory failure, and the nurse should prepare the client for mechanical ventilation. Administration of anticholinesterase medication, instructing the client on pursed-lip breathing, and positioning the client in high-Fowler's will not fix the respiratory failure.

A nurse is assessing a client with a right lower extremity fracture who is on bed rest. The nurse notes the client is unable to dorsiflex the right foot. Which action will the nurse perform to prevent neurological complications? A Secure a foot board behind the right foot Correct Answer (Blank) B Apply a heel protector on the right foot C Position a trochanter roll outside the right hip D Place a pillow beneath the right calf

Rationale: The client's inability to dorsiflex the foot is indicative of foot drop. The nurse should secure a foot board to maintain alignment of the foot while the client is on bedrest. Applying a heel protector will prevent skin breakdown, not foot drop. A trochanter roll supports the hip and prevents the outward movement of the femur. This does not prevent foot drop. Placing a pillow beneath the right calf does not help the client maintain dorsiflexion of the foot. The elevation of the leg may cause further plantar flexion.

A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention? A Check for Trousseau's sign. B Administer levothyroxine. C Administer propranolol. D Monitor the apical pulse. Correct Answer (Blank)

Rationale: The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be an appropriate precaution. Synthroid is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Hyperthyroidism can cause a mild to moderate elevation in serum calcium levels but Trousseau's sign is indicative of hypocalcemia not hypercalcemia.

A nurse is providing care to a client who sustained a spinal cord injury 1 day ago. The client suddenly develops a fever, hypotension, and bradycardia. Which action does the nurse expect to perform? A Prime intravenous tubing for prescribed antibiotics B Prepare to administer prescribed vasopressors Correct Answer (Blank) C Assess the client for the presence of a distended bladder D Remove tight clothing around the client's torso area

Rationale: The client's manifestations are indicative of neurogenic shock. Neurogenic shock occurs as a result of miscommunication within the sympathetic nervous system, resulting in loss of temperature regulation and vasodilation. The nurse should be prepared to administer vasopressors to promote vasoconstriction and increase blood pressure. Antibiotics are not indicated for neurogenic shock. The fever is due to a loss of temperature regulation. Assessing the client for a distended bladder will not correct neurogenic shock. Pressure in the lower part of the body leads to autonomic dysreflexia. Removing tight clothing is indicated for autonomic dysreflexia, not neurogenic shock.

The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first? A Computerized tomography scan Correct Answer (Blank) B Chest X-ray C Echocardiogram D Arterial blood gas

Rationale: The client's symptoms are indicative of an acute stroke. The nurse would anticipate that a non-contrast computerized tomography (CT) of the head will be done first because time is of the essence with an acute stroke. The other tests may or may not be indicated for this client.

Which condition should the nurse correlate with the following arterial blood gas values: pH 7.48, HCO3 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg? A Chronic obstructive pulmonary disease B Diarrhea and vomiting for 36 hours C Diabetic ketoacidosis D Anxiety-induced hyperventilation Correct Answer (Blank)

Rationale: The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen (O2) partial pressure. Loss of carbon dioxide (CO2) is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations. COPD would lead to respiratory acidosis due to retention of CO2. A client with diabetic ketoacidosis, a metabolic acidosis, will have a pH less than 7.35. The client's arterial blood gas (ABG) values indicate a respiratory alkalosis due to hyperventilation.

The client is scheduled for a coronary artery bypass procedure. When conducting pre-operative teaching with the client, which action should the nurse perform first? A Tour the coronary intensive care unit. B Assess the client's learning style. Correct Answer (Blank) C Mail a videotape to the home. D Administer a written pre-test.

Rationale: The first step in the teaching process consists of assessing how the client learns best. That way, the nurse increases success of the teaching by delivering the education in a format that the client understands and prefers. Therefore, the nurse should first assess the client's preferred learning style (e.g., reading a handout or watching a video).

A nurse is providing care to a client with suspected syphilis. The client's rapid plasma reagin (RPR) is reactive. Which positive diagnostic finding confirms the diagnosis? A VDRL serum test B Western blot analysis C FTA-ABS test Correct Answer (Blank) D Microscopic clue cells

Rationale: The fluorescent treponemal antibody absorption (FTA-ABS) is a confirmatory blood test for syphilis. The FTA-ABS confirms the presence of antibodies to the bacteria that causes syphilis. The venereal disease research laboratory (VDRL) serum test is a screening tool for syphilis. A positive result does not confirm the infection and can be secondary to autoimmune disorders. The Western blot analysis is used to confirm the presence of human immune deficiency virus (HIV). Microscopic clue cells are not indicative of syphilis. Clue cells are obtained from vaginal tissue and present in clients with bacterial vaginosis.

The nurse is monitoring a client who is receiving moderate sedation during a colonoscopy. Which finding would indicate to the nurse that the client is experiencing a complication of the sedation? A Blood pressure of 93/54 Correct Answer (Blank) B Heart rate of 100 C Glasgow Coma Scale of 13 D Respiratory rate of 12

Rationale: The goal of moderate sedation is to depress a patient's level of consciousness to enable surgical, diagnostic, or therapeutic procedures. With moderate sedation, the patient is able to maintain a patent airway, retain protective airway reflexes, and respond to verbal and physical stimuli. A common adverse effect of moderate sedation is hypotension. The frequent assessment of the patient's vital signs, level of consciousness, and cardiac and respiratory function is an essential component of moderate sedation.

The nurse is caring for a client who is present for a third trimester prenatal visit. While lying on the examination table in the supine position, the client reports feeling lightheaded and nauseous. What action should be taken by the nurse? A Change the client's position to semi-Fowler's B Have the client roll into the knee chest position C Turn the client onto the left side Correct Answer (Blank) D Ask the client to sit up

Rationale: The heavy uterus can fall back against the inferior vena cava in the supine position resulting in vena cava compression, which reduces venous return and decreases cardiac output and blood pressure. This change, called supine hypotensive syndrome, causes symptoms of weakness, light-headedness, nausea, dizziness, or syncope. These changes are reversed in the side-lying position, which displaces the uterus to the left and off the vena cava. Asking the client to sit up may worsen the symptoms. Knee chest position is used when fetal distress occurs due to cord compression. Semi-Fowler's positioning does not relieve vena cava compression.

The nurse working in a primary care clinic is reviewing a client's blood glucose log and notices that the client is not consistently monitoring their blood glucose. Which diagnostic test would assist the nurse in evaluating the client's overall diabetes management? A Hemoglobin A1C Correct Answer (Blank) B Fasting blood sugar C White blood cell count D Hemoglobin

Rationale: The hemoglobin A1C is the best indicator of glycemic control because it reflects an average of the blood sugar over the life of a red blood cell (approximately 90 to 120 days). The fasting blood sugar will only evaluate the client's blood sugar at that specific testing time. Hemoglobin and a white blood cell count are not used to determine blood sugar levels.

A client in labor wishes to have an epidural. The nurse reviews the client's history and laboratory results. Epidural placement is contraindicated with which of the following findings? A White blood cell count is 8,000/mcL B Platelet count is 95,000/mcL Correct Answer (Blank) C Sodium is 138 mg/dL (138 mmol/L) D Hemoglobin is 11.2 g/dL (6.95 mmol/L)

Rationale: The hemoglobin is low, but anemia is common in pregnancy. The sodium level and white blood cell count are within normal limits. Normally there is a decrease in platelets during pregnancy but this client's platelet count is significantly reduced and places the client at risk for bleeding; therefore, the epidural is contraindicated for this client. Thrombocytopenia in pregnancy can be defined as a platelet count less than 116,000 per microliter (in nonpregnant individuals, thrombocytopenia is usually defined as a platelet count less than 150,000 per microliter).

A client with a new tracheostomy is becoming frustrated because of being unable to speak. Which nursing intervention would be the most effective to help the client to communicate? A Provide the client with a communication board and check on them frequently. Correct Answer (Blank) B Reassure the client that in time they will get used to the speech difficulties. C Explain to the client that their speech will be clear and distinct with a fenestrated tube. D Place a sign above the client's bed indicating that the client cannot speak.

Rationale: The inability to talk is a major stressor for a client with a new tracheostomy. It is important to maintain communication with the client. The nurse can use a writing tablet, a board with pictures and letters, communication flash cards on a ring, hand signals and smartphones to promote communication and decrease frustration from not being able to speak or be understood. The other interventions, while important, would not be as effective. The nurse should phrase questions to solicit "yes" or "no" answers to help the client respond more easily and place a note at the central call light system intercom to indicate that the client cannot speak.

The nurse is caring for a client with suspected septic shock. Which of the following interventions should the nurse implement first? A Initiate intravenous norepinephrine as prescribed B Administer intravenous normal saline bolus as prescribed Correct Answer (Blank) C Obtain prescribed blood, sputum, and urine specimens for culture and sensitivity (C&S) D Initiate prescribed intravenous broad-spectrum antibiotic therapy

Rationale: The initial intervention for septic shock should be to restore adequate fluid volume status by volume resuscitation with intravenous crystalloids. If this is unsuccessful, vasopressor therapy may be considered. After initiation of fluid resuscitation, the nurse should obtain cultures followed by antimicrobial therapy.

A community health nurse has been caring for a woman who is 22 weeks pregnant and has a history of morbid obesity, asthma and hypertension. Which of these lab reports should be communicated to the primary health care provider immediately? A Blood urea nitrogen 28 mg/dL and Glucose 225 mg/dL B Magnesium 0.8 mEq/L and Creatinine 3 mg/dL Correct Answer (Blank) C Hemoglobin 13 g/dL and Calcium 5.1 mg/dL D Hematocrit 35% and platelets 200,000/mm3

Rationale: The lab reports of highest concern are the magnesium and creatinine. The magnesium level is low and the creatinine level is high, indicating acute renal failure, most likely related to gestational hypertension or preeclampsia. Hypomagnesemia can lead to seizure activity. These lab reports should be communicated to the primary health care provider (HCP) immediately.

The nurse is assessing a client with a wound on the left great toe. Which finding would indicate to the nurse thatthe client is experiencing arterial insufficiency? A Copious serous drainage from the wound B Opaque toenails that are thick Correct Answer (Blank) C Peripheral pulses palpated 2+ bilaterally D Bilateral pedal +4 pitted edema

Rationale: The legs are most frequently affected by arterial insufficiency. Symptoms include coldness, numbness, intermittent claudication, ulcerations, and muscle atrophy. Nails will become thickened and opaque. Ulcerations are typically on the tips of the toes or between the toes. Chronic venous insufficiency is characterized by pain described as aching or heavy. The foot and ankle may be edematous. Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area.

The nurse is providing perineal care for the client with an indwelling urinary catheter. What actions should be included in the care? A Apply a new leg strap to the catheter B Keep the drainage bag on the bed with the client C Wash the external catheter surface with soap and water Correct Answer (Blank) D Lay the drainage bag on the floor to allow for maximum drainage through gravity

Rationale: The meatus should be gently washed with soap and water to remove obvious encrustations from the external catheter surface. Leg straps are changed when soiled and are not part of peri-care. To avoid the backflow of contaminated urine into the bladder, increasing the chance of infection, don't raise the collection bag above the level of the client's bladder. To prevent contamination of the closed system, never let the drainage bag touch the floor; hang it on the bed in a dependent position.

The nurse in the ambulatory surgical center is assessing a client scheduled for surgery requiring general anesthesia. The client states, "I ate a light breakfast about 2 hours ago." Which of the following statements by the nurse would be appropriate? A "We will have to wait another 2 hours to do your surgery." B "You will receive medication to prevent you from vomiting during the surgery." C "There is a possibility that your surgery will be rescheduled." Correct Answer (Blank) D "You may experience nausea after the surgery."

Rationale: The minimum fasting period after eating a light meal is 6 hours, so the nurse should notify the anesthesiologist, and the surgery will likely be rescheduled. Obtaining urine and blood samples prior to surgery is often done a few days prior to surgery. Clients may experience nausea and may be given anti-emetics postoperatively, but it is independent of the minimum fasting period.

The nurse is caring for a 15-month-old child who is diagnosed with iron-deficiency anemia. The child's parent asks the nurse what anemia is. How should the nurse respond? A "The health care provider would need to discuss the results with you." B "The blood cells that carry oxygen are sickle-shaped." C "The blood cells that carry nutrients to the cells are too large." D "Your child has fewer red blood cells that carry oxygen." Correct Answer (Blank

Rationale: The most common causes of iron-deficiency anemia include inadequate nutritional intake along with rapid growth, low birth weight and excessive consumption of cow's milk. Children with iron-deficiency anemia will present with pallor, fatigue, decreased exercise tolerance, tachycardia and loss of appetite. The results of a complete red blood cell count in clients with iron-deficiency anemia will show decreased red blood cell numbers, a low hemoglobin and microcytic, hypochromic red blood cells. It would be appropriate to tell the parents that their child has fewer red blood cells, as this is a simple and clear explanation of anemia. There is no reason to defer answering the question to the health care provider.

The nurse is discussing with a client who has a prescription for thyroid-stimulating level the purpose of the diagnostic test. Which statement should the nurse make? A "This test measures the function of your thyroid gland." Correct Answer (Blank) B "This test detects if there are antithyroid antibodies in your blood." C "This test measures the rate of absorption of iodine by your thyroid gland." D "This test detects the amount of thyroid hormone circulating in your blood."

Rationale: The most reliable laboratory test for thyroid function is the thyroid-stimulating hormone (TSH) level. The TSH measures if the thyroid is overactive (hyperthyroidism) or underactive (hypothyroidism).

A nurse is reviewing laboratory results for a client with diabetes type 2. Which finding indicates the client is effectively managing their disease? A Glucose level of 200 mg/dL post glucose tolerance test B Urine ketone level of 25 mg/dL C Hemoglobin A1C level of 5.7% Correct Answer (Blank) D Fasting blood glucose level of 130 mg/dL

Rationale: The normal hemoglobin A1C level is 5.7% or below. Hemoglobin A1C measures the average blood sugar over the last 3 months. A glucose level of 200 mg/dL post glucose tolerance test is abnormal. The normal finding is a blood glucose level below 140 mg/dL. The presence of ketones in the urine is an abnormal finding. Urine ketones are indicative of poorly controlled diabetes. A fasting blood glucose level of 130 mg/dL is an abnormal finding. The normal fasting blood glucose level is below 100 mg/dL.

The emergency department nurse is caring for a client who was brought to the emergency department for syncope, hypotension, and frequent episodes of diarrhea. Which of the following laboratory results supports the diagnosis of gastrointestinal (GI) bleeding? A Hemoglobin level of 6.7 g/dl Correct Answer (Blank) B Red blood cell (RBC) count of 5.2 x 106 mm3 C Hematocrit of 45% D Platelet count of 160,000 µl

Rationale: The normal hemoglobin range is 12 to 18. This client's hemoglobin indicates severe anemia, likely from blood loss since the client is experiencing hypotension. Low hemoglobin leads to poor cerebral and peripheral tissue perfusion leading to syncope. The other values are all in the normal ranges.

The nurse is reviewing the morning laboratory results for clients on the orthopedic unit. Which client needs to be assessed first? A aPTT is 75 seconds for the client receiving a heparin infusion for pulmonary embolism. B Hemoglobin is 14 g/dl on a client postoperative day 1 after a hip replacement. C Red blood cell count is 4.8 x 106/mm3 for a client preoperative knee surgery. D Platelet count is 75,000 in a client with a pelvic fracture. Correct Answer

Rationale: The normal platelet count is 150,000 to 400,000 µl. Clients with pelvic injuries are at high risk for hemorrhage, and the low platelet count is a sign that bleeding has or may take place. Heparin protocols use the aPTT to determine the therapeutic window. The goal of treatment is to achieve a value between 60 and 80. A hemoglobin value of 14 is considered acceptable, as is the RBC of 4.8.

The nurse is accessing an implanted port for blood specimen collection. Which action should the nurse take? A Place the non-coring (Huber) needle at a 90-degree angle to access the port Correct Answer (Blank) B Clean the port with sterile water before accessing the port C Instill 20 mL of heparin into the port after accessing the port D Don a gown, gloves, and a mask prior to starting the procedure

Rationale: The nurse should access the implanted port using a non-coring (Huber) needle inserted at a 90-degree angle. Ports should have 10 ml of heparin instilled or flushed with normal saline after accessing the port for blood specimens. Masks should be worn prior to accessing the port, but a gown is not required. Ports should be cleansed with chlorhexidine solution prior to accessing the port.

The nurse is caring for a client who is seeking care for congestive heart failure. Which of the following techniques should the nurse use to assess for peripheral edema? A Palpate the dorsalis pedis pulse and release B Pinch skin on the dorsal surface of the hand C Use two fingers to depress the skin over the tibia Correct Answer (Blank) D Apply pressure to the client's toe nails

Rationale: The nurse should assess for edema on the anterior surface of the tibia by depressing the client's skin for at least five seconds and releasing to look for indentations left by the fingers. Pinching skin on the dorsal surface of the hand is assessing turgor, and applying pressure over the client's nail surface is capillary refill. The nurse will palpate the dorsalis pedis pulse to assess perfusion in the extremity.

The nurse is assessing a client who is receiving intravenous hydration. Which of the following actions by the nurse would be appropriate to assess for fluid volume excess? A Assess for pitting edema Correct Answer (Blank) B Auscultate heart sounds C Palpate for abdominal tenderness D Obtain the client's respiratory rate

Rationale: The nurse should assess the client for pitting edema, crackles in the lungs, turgor, and bounding pulses to evaluate the client's hydration status. All other responses do not assess fluid volume.

The nurse in an orthopedics office is evaluating a client with an arm cast who reports worsening, unrelieved pain underneath the cast. Which action should the nurse take first? A Notify the health care provider B Prepare for removal of the cast C Assess color, temperature, and movement of the exposed fingers Correct Answer (Blank) D Apply an ice pack to the area of the fracture

Rationale: The nurse should follow the nursing process and first assess the client by checking the 5 Ps that can indicate compartment syndrome: pain, pallor, pulselessness, paresthesia, and paralysis of the arm with the cast. Compartment syndrome is a potential complication of a cast and refers to swelling (edema) that causes increased pressure within a limited space (muscle compartment). The edema can create enough pressure to obstruct circulation and cause venous occlusion, which further increases edema. Arterial flow is eventually compromised causing ischemia in the extremity. Prompt diagnosis of compartment syndrome is critical.

The nurse is reviewing laboratory results for a group of clients with diabetes. Which of the following findings is of greatest concern to the nurse? A Serum blood glucose level of 260 mg/dl B Serum pH of 7.35 C Serum HC03 level of 18 mEq/l D Hemoglobin A1C of 13% Correct Answer

Rationale: The nurse should follow up for a hemoglobin A1C of 13%, which indicates long-term uncontrolled blood glucose levels in a diabetic client. This places the client at greater risk of complications of diabetes, such as diabetic ketoacidosis. The serum blood glucose is elevated; however, this can be attributed to several factors, and the hemoglobin A1C is a better indicator of diabetic glucose control. The serum pH and bicarbonate are within normal limits and indicate the absence of complications, such as acidosis.

The nurse is planning a staff education conference about performing a paracentesis. Which statement should the nurse include in the teaching? A "Clients should be instructed to void immediately before the procedure." Correct Answer (Blank) B "Clients should be placed in the prone position for the procedure." C "Clients should be instructed to expect dizziness while fluid is being removed." D "Clients will typically have several liters of fluid removed during the procedure."

Rationale: The nurse should have the client void immediately prior to the procedure as an empty bladder reduces the possibility of puncturing the bladder during the procedure. Clients should be placed in the supine position. Clients should report any dizziness and be monitored closely for hypotension or shock induced by fluid loss. The maximum amount of fluid that should be removed at one time during a paracentesis is 1,500 ml.

A nurse is reviewing laboratory results for a client with pyelonephritis. Which finding should the nurse immediately report to the healthcare provider? A White blood cell count of 11,000/mm³ B BUN level of 22 mg/dl C Lactate level of 2.5 mmol/l Correct Answer (Blank) D Creatinine level of 1.4 mg/dl

Rationale: The nurse should immediately report a lactate level of 2.5 mmol/l. Increased lactate levels are indicative of acidosis and urosepsis. A white blood cell (WBC) count of 11,000/mm³ is an expected finding for a client with a kidney infection. The normal WBC count is 5,000 to 10,000/mm³. A blood urea nitrogen (BUN) level of 22 mg/dl and a creatinine level of 1.4 mg/dl are expected findings in an acute episode of pyelonephritis. The normal BUN level is 10 to 20 mg/dl, and the normal creatinine level ranges from 0.5 to 1.3 mg/dl.

A nurse is reviewing laboratory results for their assigned clients. Which finding should the nurse immediately report to the healthcare provider? A Potassium level of 6.7 mEq/l in a client with chronic kidney disease Correct Answer (Blank) B Serum glucose level of 225 mg/dl in a client with diabetes type 2 C Hemoglobin level of 10.5 g/dl in a client with chronic anemia D White blood cell count of 12,000/mm³ in a client with meningitis

Rationale: The nurse should immediately report a potassium level of 6.7 mEq/l regardless of the client's medical history. A potassium level of 6.7 mEq/l is a critical value and can lead to cardiac dysrhythmias. A glucose level of 225 mg/dl is not a critical finding in a client with a history of diabetes type 2. Glucose levels above 250 mg/dl should be reported promptly. A hemoglobin level of 10.5 g/dl is not uncommon in a client with chronic anemia. The normal hemoglobin level ranges from 12 to 18 g/dl. A white blood cell (WBC) count of 12,000/mm³ is an expected finding in a client with meningitis. Leukocytosis is common with an infectious process. The normal WBC count is 5,000 to 10,000/mm³.

A nurse is reviewing the laboratory results of a client admitted with heat exhaustion. Which laboratory finding will the nurse immediately report to the healthcare provider? A Glucose level of 70 mg/dl B Sodium level of 125 mEq/l Correct Answer (Blank) C BUN level of 26 mg/dl D Potassium level of 3.2 mEq/l

Rationale: The nurse should immediately report a sodium level of 125 mEq/l. If not promptly treated, hyponatremia can lead to seizures, coma, and death. The normal sodium level is 135 to 145 mEq/l. A glucose level of 70 mg/dl is a low-normal finding. Hypoglycemia is expected in a client with heat exhaustion. The normal glucose level is 65 to 99 mg/dl. A blood urea nitrogen (BUN) level of 26 mg/dl is slightly above normal and expected in dehydration due to hemoconcentration. The normal BUN level is 6 to 20 mg/dl. A potassium level of 3.2 mEq/l is slightly below normal. Dehydration due to skin water loss leads to hypokalemia. The normal potassium level is between 3.5 and 5.0 mEq/l.

The nurse is planning a staff education conference about proper techniques for obtaining blood pressure measurements. Which of the following should the nurse include? A If the blood pressure is measured soon after exercising, it is possible to obtain a falsely low blood pressure. B If the blood pressure cuff is too narrow, it is possible to obtain a falsely high blood pressure. Correct Answer (Blank) C If the blood pressure cuff is deflated too slowly, it is possible to obtain a falsely low blood pressure. D If the client's arm is above the level of the heart, it is possible to obtain a falsely high blood pressure.

Rationale: The nurse should include in the teaching that a blood pressure cuff that is too narrow may cause a falsely elevated blood pressure reading. Similarly, a cuff that is too wide may cause a falsely low reading. Obtaining a blood pressure soon after exercise or smoking may cause a falsely high reading. Deflating the cuff too quickly may result in a falsely low blood pressure. Positioning the client's arm above the level of the heart during measurement may cause a falsely low blood pressure reading.

The nurse is planning a staff education conference about performing a liver biopsy. Which of the following should the nurse include in the teaching? A "Vitamin K should be withheld for several days prior to a liver biopsy." B "Clients should be positioned in the prone position during the procedure." C "Clients should be instructed to hold their breath as the needle is inserted." Correct Answer (Blank) D "Clients must lie on their left side for several hours following the procedure."

Rationale: The nurse should include that client will be instructed to hold their breath for up to 10 seconds while the needle is being inserted and prepare them to do so for the procedure. Vitamin K may be administered several days before the procedure to reduce the risk of hemorrhage, particularly in clients with liver disease and coagulopathies. Clients should be positioned supine with the upper right quadrant of the abdomen exposed. Clients will need to lie on their right side for several hours after the procedure to place pressure on the insertion site, which reduces risk of bleeding.

The nurse is planning a staff education conference about lumbar punctures. Which statement should the nurse include in the teaching? A "Clients should be positioned laterally with the head bent toward the chest and the knees flexed into the abdomen." Correct Answer (Blank) B "A needle will be inserted into the spinal cord and cerebral spinal fluid with be withdrawn." C "The client will need to remain in the prone position following the procedure." D "Clients will require restraints in order to limit movement during the procedure."

Rationale: The nurse should include that the client should be positioned laterally with the head bent toward the chest and the knees flexed into the abdomen, as this position allows for the physician to access the space between the 3rd and 4th lumbar vertebrae. A needle will be inserted into the subarachnoid space in the spinal canal, avoiding the spinal cord to prevent damage. The client will need to lie flat in a supine position following the procedure to place pressure on the insertion site. The client may require sedation to reduce movement during the procedure, not restraints.

The nurse is planning a staff education conference about performing a thoracentesis. Which of the following should the nurse include in the teaching? A "Instruct clients to take a deep breath while the needle is being inserted to reduce risk of puncturing the pleura." B "Position clients sitting forward and leaning over a tray table or pillow." Correct Answer (Blank) C "Encourage clients to take shallow breaths following the procedure to reduce postprocedural pain." D "Inform the client to expect to have several liters of fluid removed during the procedure."

Rationale: The nurse should include that the client should be positioned sitting forward and leaning over a tray table or pillow, as this position widens the space between the ribs and permits easier access to the pleural fluid. Clients should be instructed not to move, cough, or take deep breaths during insertion of the needle to avoid puncture of the pleura or lung. Clients should be instructed to take deep breaths following the procedure to promote lung expansion. No more than 1 l is removed at a time during a thoracentesis to prevent re-expansion pulmonary edema.

The nurse is caring for a client with cerebral edema who has an intracranial pressure (ICP) that has increased from 15 to 20 mmHg. Which of the following actions should the nurse take? A Request a prescription to obtain a serum sodium level Correct Answer (Blank) B Increase the rate of the client's intravenous sedation C Request a prescription to discontinue the client's hypertonic saline D Place the client in a high-Fowler's position

Rationale: The nurse should request a prescription to obtain a serum sodium level. Clients with cerebral edema require careful monitoring and management of serum sodium levels with goal ranges often much higher than normal serum sodium levels. The purpose of this is to induce an osmotic effect and reduce cerebral edema by drawing water from the brain tissue into the vascular space. By evaluating the client's serum sodium status, further management can be made to reduce cerebral edema and ICP. The nurse should not discontinue the hypertonic saline as this medication is needed to reduce cerebral edema and must be titrated according to serum sodium levels. The nurse should not increase the rate of intravenous sedation based on ICP values and should only increase sedation based on client agitation if present. The client should be maintained with the head of the bed at 30 degrees, and care should be taken not to raise the head of the bed too high, such as high- Fowler's, as this can also decrease cerebral perfusion pressure by decreasing systolic blood pressure.

The nurse is reviewing discharge teaching for a client newly diagnosed with diabetes type 1 about sick day rules. Which statement made by the client would indicate to the nurse that further teaching is required? A "I should drink sugar-sweetened beverages if I experience vomiting." B "I should eat small meals of soup or gelatin six to eight times a day." C "I will need to increase my dose of insulin." Correct Answer (Blank) D "I should check my urine for ketones twice a day."

Rationale: The nurse should teach the client with diabetes type I about sick day rules, which focus on how to manage blood glucose levels and prevent complications when sick. The client should be instructed to drink sugar-sweetened beverages when experiencing vomiting to maintain a caloric intake. The client should eat small meals consisting of soft foods, such as soups, gelatins, and puddings. The client should be advised to check urine for ketones at least twice a day. The client will be taught to continue taking the prescribed insulin; however, the client should not increase the dose but may need to decrease the dose.

The nurse in a pediatric intensive care unit is developing a plan of care for a 2-year-old child scheduled for surgery to correct a congenital heart defect. Which nursing outcome is the priority following the surgery? A Effective pain management B Prevention of respiratory complications Correct Answer (Blank) C Reduction of separation anxiety and emotional distress D Maintenance of adequate cardiac output

Rationale: The nurse should use the airway-breathing-circulation (ABC) strategy to prioritize nursing goals, interventions and outcomes; therefore, preventing respiratory complications is the priority. Areas of atelectasis are common after surgery as a result of deflation of the lung during cardiopulmonary bypass. Other pulmonary complications include pneumothorax, pulmonary edema and pleural effusion. Frequent assessments of the child's respiratory status should be performed and include auscultation, respiratory rate and effort, oxygen saturation, and skin color.

The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and appears to be having severe pain. The foot on the affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the nurse take? A Notify the primary health care provider. Correct Answer (Blank) B Readjust the traction for comfort. C Reassess the affected extremity in 15 minutes. D Administer the ordered PRN pain medications.

Rationale: The pain and absence of a pulse suggests compartment syndrome. This condition occurs when there is a buildup of pressure within the muscles. This pressure decreases blood flow and can cause muscle, tissue, and nerve damage. Compartment syndrome is a medical emergency. Delaying treatment can lead to permanent damage to the extremity. Therefore, the nurse should contact the primary health care provider (HCP) immediately.

When taking a client's blood pressure (BP) after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? A Serum calcium level of 6.9mg/dL Correct Answer (Blank) B Serum sodium level of 122 mEq/L C Serum potassium level of 2.9 mEq/L D Serum potassium level of 5.8 mEq/L

Rationale: The parathyroid glands maintain calcium and phosphate balance through release of parathyroid hormone (PTH) that acts directly on the kidney, causing increased kidney reabsorption of calcium and increased phosphorus excretion.After surgical removal of the parathyroid glands, a hypocalcemic crisis can occur due to the absence of PTH. Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms and tetany.The flexion contractions that occur while measuring BP (Trousseau's sign) indicate hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia and hyponatremia.

The nurse is teaching a client with asthma how to use a peak flow meter. The nurse explains that peak flow meters are used to achieve which outcome? A Monitor atmosphere for presence of allergens B Determine the client's oxygen saturation C Provide metered doses for inhaled bronchodilator D Measure forced expiratory volumes Correct Answer (Blank)

Rationale: The peak flow meter is used to measure peak expiratory flow volumes. It provides useful information about the presence and/or severity of airway obstruction. If the result falls in the green, the client is good without any problems. If it falls into the yellow or red category, immediate action is required. The specific action should be determined with the health care provider ahead of time before this happens. Often the clients are advised to use a bronchodilator inhaler and then recheck for improvement. When teaching the colors for the peak flow meters, nurses often associated the colors and actions with those of a traffic light. Green = go; yellow = proceed with caution; and red = stop and get help.

The nurse is assisting a client who has a pneumothorax and has a left pleural chest tube connected to dry suction drainage system up to the chair. The nurse notes that during the transfer, the chest tube disconnects from the drainage system. Which action should the nurse take? A Clamp the chest tube close to the insertion site B Insert the chest tube into a bottle of sterile water Correct Answer (Blank) C Apply an occlusive dressing to the end of the chest tube D Reconnect the chest tube to the drainage system

Rationale: The pleural chest connected to a dry drainage system is a closed system that provides negative pressure to promote the expansion of the pleural space. If the chest tube becomes disconnected from the drainage system, the nurse should insert the end of the chest tube into a bottle of sterile water, which creates a seal. The nurse should not clamp or apply a dressing to the chest tube as this will increase intrapleural pressure. The nurse should not reconnect to the used drainage system. The nurse will create a water seal first, then obtain a new drainage system to connect to the chest tube.

A client has had a positive reaction to a purified protein derivative (PPD) skin test. The client asks the nurse what the test result means. How should the nurse respond? A "You most likely have a natural immunity to tuberculosis." B "You most likely have a resistant form of tuberculosis." C "This means you have been exposed to tuberculosis" Correct Answer (Blank) D "This means you have active tuberculosis."

Rationale: The purified protein derivative (PPD) skin test is used to determine the presence of tuberculosis (TB) antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive test result. This indicates the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest X-ray and a sputum culture will be needed to determine if active TB is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB.

The nurse has taught a client about arterial blood gas (ABG) testing. Which of the following statements by the client indicates the need for further teaching? A "This test will assist with measuring my respiratory function." B "I can have this test added on to my other laboratory results as needed." Correct Answer (Blank) C "I will need to have pressure applied for several minutes to my puncture site following the procedure." D "This test can determine the acidity of my blood and if my body is compensating appropriately."

Rationale: The purpose of arterial blood gas testing is to determine respiratory function, gas exchange, and acid-base balance in the body and determine any compensatory mechanisms that are occurring. The test requires a separate lab draw involving an arterial stick and cannot be added on to other standard venous laboratory testing. Since the test involves an arterial stick, pressure must be applied for several minutes to ensure hemostasis.

A client with a spontaneous pneumothorax requires the insertion of a chest tube with a flutter valve. Which statement is the best explanation that the nurse should provide to the client? A "The amount of air that enters your chest will be controlled by the flutter valve." B "The tube will drain fluid from your chest." C "The excess air from your chest will be removed by the tube." Correct Answer (Blank) D "The hole in your lung will be sealed with this tube insertion."

Rationale: The purpose of the chest tube is to create negative pressure to allow the passive removal of the air that has accumulated in the pleural space. The flutter valve is a one-way valve that allows the air to leave the pleural space. It blocks any air reentry. The use of a flutter valve with a spontaneous pneumothorax allows for increased mobility without the use of a chest seal drainage system.

The perioperative nurse is planning care for a client. Which interventions would be a priority for the nurse in the operating room? A Provide updates to the client's family members B Verify that the client received teaching Correct Answer (Blank) C Ensure safe client position D Identify discharge needs

Rationale: The role of the perioperative nurse is to maintain the client's safety, dignity, and confidentiality. Clients are at risk for neuromuscular damage from positioning in the OR, which the nurse will ensure the client is in a safe position. The preoperative nurse is responsible for teaching and identifying discharge needs. The healthcare provider will update the client's family members.

A nurse is reviewing the urinalysis (UA) of a client admitted with prolonged vomiting and diarrhea. Which finding on the UA is consistent with dehydration? A Specific gravity of 1.035 Correct Answer (Blank) B Positive ketones C Protein level of 30 mg/dl D Positive nitrites

Rationale: The specific gravity on a urinalysis (UA) measures the kidney's ability to concentrate urine. In clients with fluid volume loss due to vomiting and diarrhea, the specific gravity is expected to increase indicating dehydration. Positive ketones are not an expected finding for a client with dehydration due to water loss. Positive ketones are consistent with conditions causing ketosis. Positive protein in the urine is not an expected finding with volume loss. Proteinuria may indicate glomerular damage or decreased tubular absorption. Positive nitrites are not an expected finding with dehydration. Nitrites may indicate a urinary tract infection.

The nurse is caring for a client with suspected tuberculosis (TB). The nurse is aware of diagnostic tests to evaluate for active TB. Which should the nurse anticipate be ordered to evaluate for the presence of active TB? A Chest X-ray anterior/posterior and lateral B White blood cell count C Sputum culture for cytology Correct Answer (Blank) D Tuberculin skin testing

Rationale: The sputum culture is the method for determining if active TB is present. Tuberculin skin testing can demonstrate false positives, and chest X-rays cannot differentiate live from latent TB. White blood cell count can indicate infection, but is not specific to TB.

A nurse is obtaining a nasopharyngeal swab from a client with a suspected respiratory illness. Which action does the nurse perform while obtaining the sample? A Leaves the swab inside the nostril for several seconds before removing Correct Answer (Blank) B Instructs the client to deeply inhale while the swab is being inserted C Inserts the swab upwards through the nostril until resistance is felt D Obtains a cotton-tip swab applicator before collecting the specimen

Rationale: The swab should be left in place for several seconds before removing to ensure secretions are well absorbed. Deep inhalation is not required to obtain a nasopharyngeal swab. The client should breathe normally. The swab should be inserted parallel to the pharynx. Inserting the swab upwards may cause tissue damage. The applicator should not include cotton because it may contain substances that can alter the test results.

A nurse is obtaining an oropharyngeal swab from a client with a suspected respiratory infection. Which action does the nurse perform while collecting the sample? A Rotate the swab along the client's buccal area B Ensure the swab collects a sample from the client's tongue C Rub the swab over the client's posterior throat Correct Answer (Blank) D Collect the sample along the client's gumline

Rationale: The swab should be rubbed over the posterior pharynx and tonsillar pillars, if present in the client, to ensure an adequate sample. The buccal area is not an appropriate collection site for an oropharyngeal swab. The specimen should be collected from the back of the throat and tonsillar area. A sample from the client's tongue is not necessary for an oropharyngeal swab. The tongue should be depressed to allow visualization of the back of the throat. The swab should not touch the client's teeth, tongue, or gums.

The nurse is caring for a client after an acute myocardial infarction, who is receiving supplemental oxygen. What is the purpose of the oxygen therapy? A Prevent pneumonia B Increase myocardial tissue perfusion Correct Answer (Blank) C Reduce cardiac afterload D Decrease client's anxiety

Rationale: The tissue around the myocardium is injured due to a lack of blood flow to the myocardium; thus, the overall purpose of oxygen is to increase the oxygen concentration to the damaged myocardium. Current evidence and recommendations for oxygen administration in clients with an acute MI are to keep oxygen saturation greater than 90%. The other actions are not the purpose for or are helped by oxygen therapy.

A nurse is applying an external fetal monitor on a client in labor. Which area should the nurse secure the tocotransducer to? A Over the uterine fundus Correct Answer (Blank) B At the area of maximal fetal heart rate intensity C Above the symphysis pubis D Below the area of the last fetal movement

Rationale: The tocotransducer should be placed over the uterine fundus. A tocotransducer is used to record uterine contractions. The area of maximal fetal heart rate intensity is the landmark for the ultrasound transducer, which records the fetal heart rate. The uterine fundus is located higher in the client's abdomen during labor. The position of the fundus lowers after delivery. The area of the last fetal movement does not provide accuracy of uterine contractions.

A nurse is preparing to implement continuous external fetal monitoring on a client in labor. Which action will the nurse perform to ensure accurate fetal monitoring? A Apply the ultrasound transducer above the level of the xyphoid process B Instruct the client not to change positions while in bed C Inform the client that a vaginal examination will be performed D Secure the tocotransducer at the level of the uterine fundus Correct Answer (Blank)

Rationale: The tocotransducer should be secured at the level of the uterine fundus. The tocotransducer measures the frequency and duration of uterine contractions. The ultrasound transducer should be placed at the level of maximal fetal heart rate intensity, usually below the level of the umbilicus on a client in labor. The client should be encouraged to change positions frequently. The nurse should adjust the transducers accordingly. External fetal monitoring is not invasive. A vaginal examination is not indicated.

The nurse will plan to include information about prophylactic antibiotics before dental procedures for which client? A Client admitted with an acute myocardial infarction B Client admitted for mitral valve replacement with a mechanical valve Correct Answer (Blank) C Client admitted for cardioversion of rapid atrial fibrillation D Client admitted with exacerbation of heart failure

Rationale: The use of prophylactic antibiotics before dental procedures is indicated for clients at risk for infective endocarditis (IE). IE occurs primarily in clients who abuse IV drugs, have had valve replacements, have experienced systemic alterations in immunity, or have structural cardiac defects. Possible ports of entry for infecting organisms include the oral cavity (especially if dental procedures have been performed), skin rashes, lesions or abscesses, infections (cutaneous, genitourinary, gastrointestinal, or systemic), and surgery or invasive procedures, including intravenous line placement. Therefore, current guidelines recommend the use of prophylactic antibiotics before dental procedures for clients with prosthetic heart valves to prevent IE.

A client is admitted with a pressure ulcer in the sacral area. The partial-thickness wound is approximately 1.5 x 2.7 inches (4 cm x 7 cm) in size, the wound base is red and moist with no exudate, and the surrounding skin is intact. Which wound dressing should the nurse select for this wound? A Dry, sterile dressing with antibiotic ointment B Occlusive, moist dressing Correct Answer (Blank) C Transparent dressing D Leave open to air

Rationale: The wound as described has granulation tissue present (red and moist wound base without exudate), which indicates that the wound is healing, and this new tissue must be protected. The use of an occlusive, moist dressing is the best choice because this type of dressing will protect the wound and new tissue, and the moisture will support continued wound healing.

A nurse is obtaining a wound culture from a client with an open perirectal abscess. Which action will the nurse perform when collecting the sample? A Don a sterile glove on the dominant hand before collecting the sample B Apply an antimicrobial cleanser to the wound prior to obtaining the sample C Swab the outside perimeter of the wound while obtaining the sample D Irrigate the wound with sterile solution before collecting the sample Correct Answer

Rationale: The wound should be irrigated prior to collecting the sample to ensure wound debris and previous drainage is removed. Sterile gloves are not required for a perirectal wound. A perirectal abscess is not considered sterile. The wound should not be cleansed with an antimicrobial cleanser. An antimicrobial cleanser may eliminate organisms necessary for the identification of an infectious organism. The sample should be obtained from within the wound borders to ensure an accurate culture.

The client is diagnosed with a large spontaneous pneumothorax. The nurse anticipates that a chest tube will be inserted. The nurse understands that chest tubes are used to treat pneumothorax for which reason? A Increase intrathoracic pressure to allow both lungs to expand equally B Prevent an accumulation of blood and other drainage into the pleural cavity C Drain air from the pleural cavity and restore normal intrathoracic pressure Correct Answer (Blank) D Drain the purulent drainage from the empyema that caused the problem

Rationale: There are no clinical signs or symptoms in primary spontaneous pneumothorax until a cyst or small sac (bleb) ruptures. When air enters the pleural space, the pressure in the space equals the pressure outside the body; the vacuum is lost and the lung collapses. This causes acute onset chest pain and shortness of breath. A small pneumothorax without underlying lung disease may resolve on its own. A larger pneumothorax requires aspiration of the free air and/or placement of a chest tube to evacuate the air.

The nurse is caring for a client who is receiving a continuous heparin infusion for the treatment of a deep vein thrombosis. The nurse reviews the client's most recent lab results. Which lab value indicates the client may be experiencing a complication of heparin therapy? A Platelet count of 50,000/mm3 Correct Answer (Blank) B Hemoglobin level of 15 g/dL C Partial thromboplastin time of 90 seconds D White Blood Cell count of 8,000/µL

Rationale: Thrombocytopenia (low platelets) during heparin therapy is a complication referred to as heparin-induced thrombocytopenia (HIT). HIT results from the creation of autoantibodies directed against platelets in the blood. These can be present within 6 to 14 days after the beginning of heparin treatment. The approximate normal range for platelets is 150,000 to 450,000/µL in adults, so a level of 50,000/mm3 may indicate the client is experiencing HIT. The partial thromboplastin time (PTT) is used to monitor heparin therapy. The approximate normal range in adults is 60 to 70 seconds, and 1.5 to 2.5 times the control value for clients who are receiving heparin therapy. Although this client's level is outside of the normal range, it is within the expected range for a client who is receiving heparin therapy. The hemoglobin (Hgb) and white blood cell (WBC) results for this client are within normal ranges. (The approximate normal range for Hgb levels in adults is 14 to 18 g/dL in males and 12 to 16 g/dL in females. The approximate normal range for WBC levels in adults is 5,000 to 10,000/mm3).

The nurse is caring for a client who has undergone a cardiac catheterization procedure. Which of the following complications should the nurse monitor for in the initial 24 hours after the procedure? A Thrombus formation B Low blood pressure (BP) C Dizziness with standing D Decrease in appetite Correct Answer (Blank)

Rationale: Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A lowered BP may exist with hemorrhage of the insertion site, which is at highest risk within the first 12 hours after the procedure if a local plug is not used.

The nurse is preparing to give a tissue plasminogen activator (tPA) to a client after an ischemic stroke. Which of the following lab values should the nurse assess prior to initiating the tPA? A Blood urea nitrogen and creatinine B Potassium and magnesium C Prothrombin time and activated partial thromboplastin time Correct Answer (Blank) D Arterial blood gases and complete blood count

Rationale: Tissue plasminogen activator (tPA) has been used to resolve some of the clinical manifestations after an ischemic stroke. Tissue plasminogen activator is a thrombolytic or clot-busting medication. One of the effects of the medication is abnormal bleeding. Thus, the nurse should evaluate the prothrombin time and activated partial thromboplastin times prior to administration. Prolonged clotting times may exclude the client from receiving the tPA. The other lab values will be evaluated but do not impact the inclusion criteria to receive the tPA.

The nurse observes an unlicensed assistive personnel (UAP) providing care for a left unilateral mastectomy. The nurse should intervene if the UAP is observed doing which action? A Taking the blood pressure in the left arm Correct Answer (Blank) B Compressing the drainage device C Reinforcing the client to restrict sodium intake D Elevating the client's left arm above heart level

Rationale: To avoid the potential for lymphedema and tissue trauma to the post-operative area post-mastectomy, the client should not have blood pressure taken or a tourniquet placed on the arm of the operative side. It is acceptable for the client to elevate their arm above the heart level as long as it does not cause pain. Restricting dietary sodium intake may reduce lymphedema. Compressing the drain helps to maintain suction on the device and is appropriate.

The nurse is assisting the healthcare provider administer a Tensilon test to a client with suspected myasthenia gravis. Which medication should the nurse have at the bedside during the test? A Metoprolol B Diltiazem C Atropine Correct Answer (Blank) D Digoxin

Rationale: To diagnosis myasthenia gravis, a Tensilon test is administered by the healthcare provider. During the test, the client will receive an IV injection of edrophonium chloride which is an anticholinesterase agent. Edrophonium can cause a decrease in heart rate, requiring atropine at the bedside to counteract the effects of the anticholinesterase agent. Beta-blockers, calcium channel blockers, and cardiac glycosides increase the effects of bradycardia.

The nurse is assisting the healthcare provider administer a Tensilon test to a client with suspected myasthenia gravis. Which finding observed by the nurse would confirm the diagnosis? A The client develops a pill-rolling tremor. B The client is able to lift their arm against resistance. Correct Answer (Blank) C The client reports diplopia. D The client will have dilated pupils.

Rationale: To diagnosis myasthenia gravis, a Tensilon test is administered by the healthcare provider. During the test, the client will receive an IV injection of edrophonium chloride which is an anticholinesterase agent. If the test is positive, confirming the diagnosis, the client will have increased muscle contractions, sweating, excessive salivation, and constricted pupils.

Upon the return of a client from surgery after an open reduction internal fixation of a femur fracture, the nurse notes a small bloodstain on the dressing and marks it. Four hours later the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A Remove the pneumatic compression device from the affected extremity B Outline the new spot with a marker and continue to monitor Correct Answer (Blank) C Increase the rate of the IV fluid infusion D Request a type and crossmatch from the blood bank

Rationale: To make a mark outlining the spot is a good way to monitor the amount of bleeding over a period of time. In addition to outlining the spot, the nurse should note the date and time. If the bleeding does not appear to be excessive, monitoring the drainage is appropriate since some bleeding is expected after this type of surgery. The other actions are not appropriate or indicated at this time.

The nurse is assessing a client receiving continuous enteral nutrition via nasogastric tube and notes the presence of crackles when auscultating the lungs. Which of the following actions should be taken first to prevent further injury? A Check the client's oxygen saturation B Notify the client's healthcare provider C Measure the tube feeding residual volume D Stop administering the continuous tube feeding Correct Answer (Blank)

Rationale: To reduce the risk of injury to the client, tube feeding should immediately be stopped until placement can be confirmed. All the other actions are appropriate but do not reduce the risk of further injury to the client.

The nurse is educating a client who has peripheral vascular disease on how to prevent associated complications. Which of the following statements should the nurse include in the teaching? A "You should limit the amount of walking to minimize pain." B "Wear socks and shoes to avoid injury to your feet." Correct Answer (Blank) C "Increase dietary lipids to promote circulation." D "Avoid vitamins A and C to reduce the risk of ulcers."

Rationale: Trauma to areas of poor circulation can create non-healing wounds; therefore, properly fitted socks and shoes are an important part of the client's plan of care. The client should walk often, decrease lipid intake, and increase intake of vitamins A and C.

The nurse is caring for a client who has been diagnosed with type 2 diabetes mellitus. Which of the following findings indicates that the client may be experiencing hypoglycemia? A Orthopnea B Increased urination C Tremors Correct Answer (Blank) D Abdominal pain

Rationale: Tremors, confusion, diaphoresis, and impaired coordination are signs of hypoglycemia and should indicate to the nurse that further assessment is needed. Increased urination often occurs in hyperglycemia. Orthopnea and abdominal pain are not directly affected by blood glucose levels.

The nurse is assessing the skin of a client with dehydration. Which action by the nurse would assess skin turgor? A Push thumb into the skin and note the amount of time for the color to return B Pinch the skin between thumb and finger to observe for tenting Correct Answer (Blank) C Pull skin taut and detect temperature change D Press skin between hands and identify any protrusions

Rationale: Turgor is the ability of the skin to return to place when pinched away from the body, which assesses the skin's elasticity. When the skin tents, or stands by itself, it is documented as poor skin turgor and can indicate dehydration or extreme weight loss. Pushing a thumb into the skin and noting the amount of time color returns measures blanching, which indicates perfusion to the skin. Pulling the skin taut and checking for temperature and pressing skin between hands to identify protrusions are techniques for assessing lesions or nodules.

The pediatric nurse is teaching the parents of a 6-year-old child with recurrent otitis media about tympanostomy tubes. Which instructions should the nurse include? A "The tubes are sutured in place to prevent them from falling out." B "You will continue to see ear drainage for up to 7 days." Correct Answer (Blank) C "The tubes will have to be surgically removed in a few years." D "Your child should not swim in the pool while the tubes are in place."

Rationale: Tympanostomy tubes are pressure equalization devices (grommets) that facilitate drainage and ventilation of the middle ear. Their placement may be indicated with chronic otitis media (OM) (three episodes in 6 months or four episodes in 1 year). Most children's hearing improves right after placement, and ear drainage is common up to 1 week after insertion. They are not sutured in place. The tube is eventually pushed out of the eardrum usually 8 to 18 months after tube placement. Parents should be aware of the appearance of a tympanostomy tube (usually a tiny plastic spool-shaped tube), so they can recognize it if it falls out. Most clients, including very young children, typically do not require special water precautions.

The nurse is performing an assessment on a client with ulcerative colitis. Which of the following findings should the nurse anticipate? Select all that apply. Weight gain related to intake of high-fat foods Abdominal cramping with frequent watery diarrhea Correct Answer (Blank) Elevated white blood cell count and erythrocyte sedimentation rate (ESR) Correct Answer (Blank) Family history of ulcerative colitis Correct Answer (Blank) Low urine output and temperature of 101.3° F (38.5° C)

Rationale: Ulcerative colitis is one of two different types of inflammatory bowel disease. It causes inflammation and ulcers in the lining of the colon and rectum. An elevated white blood count and erythrocyte sedimentation rate (ESR) indicate inflammation. The hallmark manifestation of ulcerative colitis is severe watery diarrhea with abdominal cramping. Family history is one of the biggest risk factors for ulcerative colitis. Clients with ulcerative colitis do not gain weight, but instead they lose weight secondary to malabsorption related to severe diarrhea. Clients with ulcerative colitis are at risk for dehydration secondary to the diarrhea. As a result, their urine output would be low. Because ulcerative colitis is an inflammatory condition, clients will often manifest with an elevated temperature.

A nurse is providing care to a client post pacemaker placement for a third-degree heart block. Which characteristic on the electrocardiogram indicates the pacemaker is functioning properly? A The R-R interval is regular, and the PRI is absent. B The ventricular rate is 45 bpm. C The P waves are uniform and present in front of every QRS complex. Correct Answer (Blank) D The QRS complexes measure greater than 0.12 seconds.

Rationale: Uniform P waves that are present in front of every QRS complex are characteristic of a normal sinus rhythm. This is an expected finding after a pacemaker placement. A QRS complex measuring more than 0.12 seconds is not a normal finding. Prolonged QRS complexes signal ventricular abnormalities. A ventricular rate of 45 beats/min is not a normal finding. The normal ventricular rate is 60 to 100 beats/min. An absent PR interval is not a normal finding. The absence of a PRI indicates a heart block is still present.

The nurse is caring for a client diagnosed with superficial thrombophlebitis of the left leg. While developing a plan of care, the nurse should include which intervention? A Maintain complete bed rest B Place the leg in an immobilizer brace C Elevate the affected leg Correct Answer (Blank) D Apply cool compresses

Rationale: Unlike deep vein thrombosis, superficial thrombophlebitis involves a sudden inflammatory reaction (redness, pain, swelling), but it rarely involves a thrombus. Treatment consists of elevating the leg because dangling the extremity will increase the swelling and the pain. Other treatment options include warm compresses and analgesics; sometimes a low-molecular weight heparin is also prescribed. Clients do not need to be on bed rest or require an immobilizer brace.

The nurse is assisting a client with ambulation one day after a total knee preplacement. Which of the following findings indicates an appropriate response to the activity? A The client has pain that is a 7 on the numeric pain scale. B The client requires a walker for ambulation. Correct Answer (Blank) C The client reports feeling weak after taking several steps. D The client states that they have a fear of falling.

Rationale: Use of a walker, cane, or other assistive devices is normal after orthopedic surgeries. Some pain is expected, but significant pain can make ambulation unsafe. If the client feels weak at any point, the ambulation should be discontinued and reattempted at a later time. Concerns about falling should be addressed, but this does not indicate an appropriate response to ambulation.

The nurse is preparing to insert a nasogastric tube in an adult client. The nurse should take what action to determine the length of tube to be inserted? A Place the tube at the tip of the nose and measure by extending the tube to the earlobe and down to the xiphoid process Correct Answer (Blank) B Place the tube at the tip of the nose and measure by extending the tube to the earlobe and down to the top of the sternum C Place the tube at the earlobe and measure by extending to the nose and then down to the top of the sternum D Place the tube at the earlobe and measure by extending to the nose and down to the xiphoid process

Rationale: When a nurse is preparing to insert a nasogastric tube, the nurse will need to measure the client for the length of the tube. This length is an estimate of how far the nurse should insert the tube into the nasal passage, passing through into the stomach. Adequate measuring ensures that the tube is placed in the stomach and not in the airway or left in the esophagus. To measure the tube length, the nurse will place the tube at the tip of the client's nose and extend the tube to the earlobe, and then down to the xiphoid process. The remaining options identify incorrect procedures for measuring the length of the tube.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure? A Warm the enema solution prior to instillation Correct Answer (Blank) B Prepare 1,500 ml of enema fluid C Hang the enema container 24 inches above the anus D Use tap water as the enema fluid

Rationale: When administering a large-volume enema, there are specific actions the nurse is to take to perform the intervention. It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa. For a large-volume cleansing enema, the recommended amount of fluid to instill for an adult client is 750 to 1,000 ml. Tap water is a hypotonic solution that moves fluid from the colon into the interstitial spaces and can cause circulatory overload and electrolyte imbalances. For this reason, tap water enemas cannot be given more than once, and two enemas have been prescribed for this client. The height of the fluid container affects the speed of instillation. The maximum recommended height is 18 inches. Hanging the container higher than that can cause rapid instillation and possibly painful distention of the colon.

The nurse is preparing to administer a prescribed nasogastric (NG) tube feeding bolus to a client. Which action should the nurse take first? A Remove the plunger and attach the syringe to the tube B Flush the NG tube with 30 ml of water and remove the syringe C Aspirate the gastric contents and note the residual amount Correct Answer (Blank) D Unclamp the NG tube and allow the premeasured tube feed to enter by gravity

Rationale: When administering scheduled bolus tube feeding, after checking the placement of the tube, the nurse would then check residual by aspirating the stomach contents. The nurse would then flush the tube with 30 ml of sterile water, remove the plunger from the syringe, attach the syringe to the tube, pour premeasured feed into the syringe, unclamp, and allow the tube feed to enter the tube via gravity.

The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of findings would require immediate follow up by the nurse? A Edema and ecchymosis over the right hip B Right leg appears shorter than the left leg, and the client reports pain level of 6 C Diminished pedal pulse and capillary refill greater than 3 seconds in the affected extremity Correct Answer (Blank) D Adduction of the affected extremity and loss of function

Rationale: When assessing a client with a suspected right hip fracture, the nurse should expect to observe the client's affected extremity will be abducted, appear shorter than the unaffected extremity, and have edema and ecchymosis. A client with a diminished pedal pulse and capillary refill greater than 3 seconds would indicate that the client is experiencing a decrease in perfusion in the affected extremity, which would require immediate follow-up by the nurse.

The nurse is performing a cardiac assessment on a client with a history of aortic valve regurgitation. At which landmark should the nurse place the diaphragm of the stethoscope to auscultate the aortic valve? A Second intercostal space right of the sternal border Correct Answer (Blank) B Fifth intercostal space mid-clavicular line C Second intercostal space left of the sternal border D Fourth intercostal space left of the sternal border

Rationale: When auscultating heart sounds, the nurse will use landmarks to identify where to place the stethoscope. The aortic valve is located at the second intercostal space right of the sternal border. The mitral valve is located at the fifth intercostal space mid-clavicular line. The pulmonic valve is located at the second intercostal space left of the sternal border. The tricuspid valve is located at the fourth intercostal space left of the sternal border.

A nurse is caring for a client with a bowel obstruction who has a nasogastric (NG) tube placed and connected to wall suction. Which of the following actions would be appropriate for the nurse to take? A Hold the client's medications until the NG tube is discontinued B Maintain the position of the bed in Semi-Fowler's Correct Answer (Blank) C Apply an oil-based lubricant to the client's affected nares to prevent irritation D Encourage the client to lie on the right side when abdominal distention is noted

Rationale: When caring for a client with a NG tube connected to wall suction, the nurse should maintain the position of the bed in Semi-Fowler's to prevent aspiration. Water-based lubricant is preferred when inserting and maintaining an NG tube. Water-based lubricant is considered less toxic if aspirated. Abdominal distention can indicate retention of secretions. Having the client lie on the left side can dislodge a gastric tube that is suctioning against the stomach wall. Holding the client's medications is not necessary. Per the provider's order, the nurse will administer prescribed medications via the mouth and/or NG tube and hold the suction for an hour after to allow the medications to absorb.

The nurse is caring for a client with acute appendicitis. Which finding should the nurse immediately report to the healthcare provider? A Febrile B Diarrhea C Sudden decrease in abdominal pain Correct Answer (Blank) D Positive Kernig's sign

Rationale: When caring for a client with acute appendicitis, the nurse should monitor the client for potential complications including rupture of the appendix. A sudden decrease in abdominal pain is a manifestation of a ruptured appendix and requires immediate surgical intervention. Diarrhea, febrile, and positive Kernig's sign are expected manifestations of acute appendicitis.

The nurse is collecting the health history of a client who is scheduled for surgery. Which statement by the client would be a priority for the nurse to follow up? A "I got very nauseous the last time I had surgery." B "My father had an infection after surgery." C "My mother had a reaction during a surgery." Correct Answer (Blank) D "I am concerned about the pain after the surgery."

Rationale: When collecting the health history from a client who is scheduled for surgery, the nurse will assess the client's previous experiences and family history related to surgical procedures. Nausea and pain are expected effects of surgery that the nurse will educate the client about but are not the priority. A parent that had an infection after surgery is important to document but not the priority. Malignant hyperthermia, which is an adverse reaction to anesthesia, can be genetic and would be the priority for the nurse to follow up.

The nurse is collecting the health history of a client who is scheduled for surgery. Which statement by the client would be a priority for the nurse to follow up? A "I got very nauseous the last time I had surgery." B "My father had an infection after surgery." C "I am concerned about the pain after the surgery." D "My mother had a reaction during a surgery." Correct Answer (Blank)

Rationale: When collecting the health history from a client who is scheduled for surgery, the nurse will assess the client's previous experiences and family history related to surgical procedures. Nausea and pain are expected effects of surgery that the nurse will educate the client about but is not the priority. A parent that had an infection after surgery is important to document but not the priority. Malignant hyperthermia, which is an adverse reaction to anesthesia, can be genetic and would be the priority for the nurse to follow up.

The nurse is collecting the health history from a client with paraplegia from a spinal cord injury. Which statement by the client would require immediate follow up by the nurse? A "I have all the equipment to take a shower, but I prefer a bed bath." B "I spend the majority of the day in my wheelchair." Correct Answer (Blank) C "I am not ready to go out in public." D "I am still learning how to use the modified utensils."

Rationale: When collecting the health history of a client with spinal cord injury, the nurse will assess how the client is adapting to the injury and identify any potential complications. Clients with spinal cord injuries are at increased risk of pressure injuries. Pressure injuries develop from the client's inability to move or feel the sensation of pressure. A client who reports spending the majority of their day in a wheelchair requires follow-up by the nurse to ensure the client has not developed a pressure injury. A client who prefers a bed bath may need further teaching on how to use the equipment, but this is not the immediate concern. A client who reports not being ready to go out in public may be at risk for depression, but this is not the immediate concern.

The nurse is preparing to remove a client's nasogastric (NG) tube. Which action by the nurse will reduce the risk of aspiration during the removal? A Change the wall suction to high during the tube removal. B Ask the client to hold their breath while steadily pulling the tube out. Correct Answer (Blank) C Have the client swallow sips of water during the tube removal. D Pre-oxygenate the client with 100% oxygen prior to removing the tube.

Rationale: When discontinuing an NG tube, the nurse should ask the client to hold their breath. This will close the client's epiglottis and help prevent the risk of aspiration during the removal of the NG tube. Clients may be asked to sip water during insertion of an NG tube, but not during the removal. Suction should be turned off and disconnected prior to NG tube removal. There is no need to pre-oxygenate a client prior to removing an NG tube.

The nurse is inserting a nasogastric (NG) tube into a client who has a bowel obstruction. As the tube passes through the pharynx, which instruction should the nurse provide the client? A "Take little sips of water." Correct Answer (Blank) B "Tilt your head back." C "Hold your breath." D "Resist the urge to cough."

Rationale: When inserting a NG tube, the tube will pass through the pharynx which can cause a client to gag. To prevent the tube from inadvertently being inserted into the trachea, the nurse should instruct the client to take little sips of water, which encourages the swallowing of the tube. The client should be instructed that coughing is normal and protects the airway. The client should avoid tilting their head back, which can make the insertion difficult. The client should be instructed to take small, shallow breaths during the insertion.

The nurse is initiating a peripheral IV infusion insertion in a selected vein. After puncturing the skin, the nurse observes blood return in the flashback chamber of the IV catheter. Which action should the nurse perform next? A Secure the catheter to the skin with a transparent dressing B Lower the catheter until it is almost flush with the skin Correct Answer (Blank) C Advance the catheter into the vein D Remove the stylet slowly from the lumen of the catheter

Rationale: When inserting a peripheral IV, the nurse will select a vein and after cleaning the site, will puncture the skin with the IV catheter. Once the skin is punctured and blood return is observed in the flashback chamber, the nurse should then lower the catheter until it is flush with the skin. Then the nurse will advance the catheter into the vein, remove the stylet, and secure the catheter to the skin.

The nurse is inserting an indwelling urinary catheter into a male client. After cleaning the area, which action should the nurse take? A Inject the lubricant into the urinary meatus Correct Answer (Blank) B Instruct the client to take shallow breaths C Insert the catheter until urine is observed in the tubing D Hold the penis upright

Rationale: When inserting an indwelling urinary catheter into a male client, the priority of the nurse is to prevent pain and trauma to the urinary meatus. The nurse should inject the lubricant directly into the urinary meatus, which will provide adequate lubrication to prevent trauma. The nurse should hold the penis perpendicular to the body, which allows the catheter to be inserted at the natural angle of the urinary meatus. The catheter should be inserted all the way to the bifurcation to ensure that the tip of the catheter is in the bladder before inflating the balloon. The client should be instructed to bear down during catheter insertion, which relaxes the bladder sphincter.

The post-anesthesia care nurse is monitoring a client following a surgical procedure. Which finding should the nurse report immediately to the healthcare provider? A Clear emesis B Redness at the incision site C Cold skin Correct Answer (Blank) D Client reports a sore throat

Rationale: When monitoring a post-operative client, the nurse should assess for alterations of body systems. Cold, clammy skin could indicate that the client could be experiencing hemorrhage, which should be reported immediately to the healthcare provider. Clear emesis and redness at the incision site are expected findings. A sore throat could be related to irritation from the breathing tube and is not the priority.

The nurse is preparing to remove a peripheral intravenous catheter from a client who is taking prescribed clopidogrel due to a cerebrovascular accident. Which of the following actions is appropriate? A Apply pressure to the site for a longer period Correct Answer (Blank) B Leave the catheter in until the clopidogrel is discontinued C Elevate the extremity after removal D Use a warm compress on the insertion site

Rationale: When peripheral venous access is no longer required or when the insertion site shows signs of local complications, the nurse assumes responsibility for discontinuing the access device. Apply pressure immediately to the area just above the insertion site until hemostasis is achieved. The time will be prolonged in clients receiving a platelet aggregate inhibitor, such as clopidogrel but will occur. Leaving the catheter in increases the risk of other complications, such as infection or thrombosis. Elevation and warm heat are used for infiltration.

The nurse has provided preoperative teaching to a client who is scheduled for an outpatient surgery with anesthesia in 1 week. Which of the following statements by the client indicates a correct understanding of the teaching? A "I will need to refrain from drinking any clear liquids for 1 hour before my surgery." B "I should arrive on the day of surgery with the site of surgery marked with a pen to avoid surgical errors." C "I will need to have a ride home and should not drive or operate heavy machinery for 24 hours after my procedure." Correct Answer (Blank) D "I will need to cleanse my skin using an antiseptic solution twice a day for the next week."

Rationale: When providing preoperative teaching to a client, the nurse will include information on diet, mediation, preparation, and discharge planning. The nurse should instruct the client that they will need a ride home and cannot drive or operate heavy machinery for 24 hours after sedation or anesthesia following procedures due to cognitive impairment. Clear liquids must be held at least 2 hours prior to surgery and often much longer to reduce the risk of aspiration while under anesthesia. The surgeon must mark the site of the surgical procedure to reduce the risk of wrong-site surgical errors. The client may need to cleanse the skin with an antiseptic solution once either 1 or 2 days prior to the surgical procedure.

The nurse has provided preoperative teaching to a client who is scheduled for surgery in 1 week. Which of the following statements by the client indicates a correct understanding of the teaching? A "I will need to refrain from drinking any clear liquids for at least 2 hours before my surgery." Correct Answer (Blank) B "I should arrive on the day of surgery with the site of surgery marked with a pen to avoid surgical errors." C "I should stop all medications for 24 hours prior to my scheduled procedure." D "I will need to cleanse my skin using an antiseptic solution twice a day for the next week."

Rationale: When providing preoperative teaching, the nurse will include instructions on diet, medication, and preparation. The nurse will teach the client that clear liquids will need to be stopped at least 2 hours prior to the procedure and solid food typically must be stopped for a longer period to prevent aspiration. The surgeon must mark the site of the surgical procedure to reduce the risk of wrong-site surgical errors. The client should not stop all medications, particularly cardiac and antidiabetic medications, and typically these can be taken with small sips of water the morning of the procedure. The client may need to cleanse the skin with an antiseptic solution once either 1 or 2 days prior to the surgical procedure.

The nurse is educating a client with diabetes type I about exercise and glucose control. Which statement by the client would indicate to the nurse further teaching is required? A "I will keep hard candy with me when I go to the gym." B "I can go for a walk if my blood glucose level is at 200 mg/dL." C "I can eat a peanut butter on whole wheat bread before my bicycle ride." D "I will increase my daily exercise when ketones are present in my urine." Correct Answer (Blank)

Rationale: When teaching a client with diabetes type I about exercise, the nurse should explain that exercise can occur if the client has a blood glucose level greater than 100 and less than 250. Before exercising, the client should be instructed to eat a snack that has 30 grams of carbohydrates and protein, such as peanut butter on whole-wheat bread. The client should be advised to avoid exercise if ketones are present in urine, which means that fat is being used for energy, which could lead to ketoacidosis. Hard candy should be available to the client during exercise in case the client experiences hypoglycemia.

The nurse has reviewed discharge instructions with a client who is newly diagnosed with irritable bowel syndrome. Which statement made by the client would indicate that teaching was effective? A "I should increase fluids during my meals." B "I should take a bulk laxative and stool softener every day." C "I should avoid eating when I have symptoms." D "I will need to keep a 2-week diary of my food intake and symptoms." Correct Answer (Blank)

Rationale: When teaching clients about IBS, the nurse will instruct the client to keep a diary of food intake and associated symptoms. The diary will assist the client with identifying potential triggers that can exacerbate IBS. The client with IBS should avoid taking a bulk laxative or stool softener daily, which can increase bloating and dehydration. Increasing fluids during meals will fill the client up and can increase bloating. Clients with IBS should still eat with symptoms to prevent malnutrition.

The nurse in an intensive care unit is reviewing the laboratory results for several clients. Which laboratory result indicates that the client has a partially compensated metabolic acidosis? A PaCO2 of 30 mmHg Correct Answer (Blank) B HCO3 of 28 mEq/L C pH of 7.48 D Chloride of 100 mEq/L

Rationale: With metabolic acidosis, the nurse should expect to see a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L). Compensation means that the body is trying to get the pH back to a normal range of 7.35 to 7.45. A pure metabolic acidosis will elicit a compensatory response by the lungs in form of a decrease in PaCO2 (normal range is 35 to 45 mm Hg). Therefore, the PaCO2 level of 30 mm Hg indicates a partially compensated metabolic acidosis. A pH of 7.48 indicates an alkalosis and the chloride level does not pertain to the acid-base imbalance or compensation.

A nurse is caring for a 20 lb (9 kg) 6-month-old infant with a three-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated with 5% dextrose in 0.45% normal saline with 20 mEq of potassium per liter infusing at 35 mL/hr. Which finding should the nurse report to the health care provider immediately? A No measurable voiding in four hours Correct Answer (Blank) B Three episodes of vomiting in one hour C Periodic crying and irritability D Vigorous sucking on a pacifier

Rationale: With no measurable urine output, the infant may experience hyperkalemia, which could occur with continued IV potassium administration because potassium is excreted via the kidneys. Periodic crying and irritability are normal for a 6-month-old who is sick. Vigorous sucking on a pacifier may be soothing to the infant. The infant was admitted with vomiting, and though the nurse would be concerned about the frequency, the absence of urine output is a higher concern.

The nurse is caring for a client who received intravenous morphine for severe pain 15 minutes ago. Which change in vital signs would be the priority for the nurse to follow up? Blood pressure decreased from 150/82 to 115/68 mmHg. Heart rate decreased from 112 to 82 beats per minute. Respiration decreased from 16 to 6 breaths per minute. Oxygen saturation has decreased from 98% to 95%

Respiration decreased from 16 to 6 breaths per minute. Rationale: Clients who receive opioid analgesics should be closely monitored for adverse effects, such as respiratory depression. The client's respiratory rate indicates possible respiratory compromise from intravenous morphine, and it is a priority for the nurse to closely monitor the client's respiratory status. The client's elevated blood pressure and heart rate prior to morphine administration indicate the presence of pain and the change indicates therapeutic response. The heart rate and blood pressure are within range to indicate adequate circulatory status in the client. The client's oxygen saturation should be maintained at 95% or higher, and the decrease is not a priority finding at this time.

The nurse is developing the plan of care for a client with a peripheral venous access who is receiving an infusion of prescribed IV fluids. Which intervention should the nurse implement to prevent infiltration? Change the site dressing daily Rotate IV sites every 3 days Assess the site every 24 hours Secure the site with a stabilization device

Secure the site with a stabilization device Rationale: Infiltration occurs when the IV fluids leave the vascular space into the subcutaneous tissues, often from a dislodged catheter. To prevent infiltration, the nurse should use a site-stabilization device, assess the site every 4 hours, and keep tubing visible to prevent dislodgement. Changing dressing daily could increase the risk for dislodging the catheter and should only be done when visibly soiled.

The nurse is assessing a client at a follow-up appointment for diabetes management. Which of the following assessments should be performed and compared to baseline data to evaluate the progression of the condition? Otoscope examination Sensory assessment of the feet Percussion of the abdomen Oxygen saturation

Sensory assessment of the feet Rationale: Clients who have diabetes mellitus often develop peripheral neuropathy. The nurse should assess the sensory perception of the feet and compare the findings to previous visit assessment data. Otoscope examination and percussion of the abdomen are not assessments that are directly related to diabetes. Oxygen saturation will most likely be assessed but does not provide insight into the progression of diabetes mellitus.

The nurse is assessing the peripheral IV site for a client who is receiving an infusion of prescribed antibiotics and is reporting pain at the site. The nurse notes the IV site has a red streak and a palpable venous cord. Which action should the nurse take first? A Complete a client occurrence form B Document findings and actions in the electronic health record C Change the IV insertion site to a new location D Stop the infusion of the medication immediately

Stop the infusion of the medication immediately Rationale: When the site is red and painful, it indicates phlebitis. The medication needs to be immediately stopped and the site needs to be discontinued. If the client still needs the medication, a new IV site needs to be started after the previous one has been discontinued. All actions related to the IV site need to be documented, but it is not first. A client occurrence form is not needed - just documentation in the electronic health record.

The nurse is evaluating a client's response to oral intake after a surgical procedure. The client has a prescription to advance diet as tolerated. Which of the following findings indicates that the client's diet can be advanced? A The client states they are nauseous. B The client reports a feeling of fullness after a small cup of water. C The client's abdomen is distended. D The client has normoactive bowel sounds

The client has normoactive bowel sounds Rationale: The return of bowel sounds after general anesthesia indicates that peristalsis is occurring; therefore, the diet can be advanced. If the client becomes nauseous or overwhelmingly full after small amounts of intake, the diet should not be advanced. Distention of the abdomen does not indicate readiness to advance the diet.

The charge nurse is observing a newly hired nurse apply bilateral sequential compression devices (SCD) to assigned clients. It indicates correct understanding if the newly hired nurse is observed applying SCDs to which of the following clients? The client who was admitted with sickle cell crisis The client who had a lumbar fusion and is on prescribed bedrest The client with diabetes who was admitted with gangrenous lower extremity ulcers The client who has been admitted with bilateral lower extremity venous thromboembolisms

The client who had a lumbar fusion and is on prescribed bedrest Rationale: It indicates a correct understanding of SCD application if the nurse is observed applying SCDs to the client with prescribed bedrest. SCDs should be used consistently for clients with immobility to improve complications of immobility, such as reduced circulation and possible thromboembolism. SCDs should not be placed on clients with known or suspected venous thromboembolism as this could cause dislodgement of the clots. SCDs should not be placed over open wounds or infections, and clients with sickle cell crisis should have all restrictive clothing and devices removed in order to improve perfusion to all body areas, including anti-embolism stockings, SCDs, and automatic blood pressure cuffs.