Semester 3 Unit 4

Which task could the registered nurse delegate to unlicensed assistive personnel (UAP) during the care of a patient who has had recent transverse rectus abdominis musculocutaneous (TRAM) flap surgery?

Mobilize the patient in a slightly hunched position.

Which statement regarding continuous ambulatory peritoneal dialysis (CAPD) would be most important when teaching a patient new to the treatment?

"It is essential that you maintain aseptic technique to prevent peritonitis." Peritonitis is a potentially fatal complication of peritoneal dialysis.

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response?

"It is okay to cry; mourning the loss of your breast is important for getting past this." Cancer surgery can involve the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy response in adapting or adjusting to a new image.

The nurse is caring for an obese 67-yr-old woman after a right mastectomy with axillary lymph node dissection. Which discharge instruction should the nurse include?

"Special massage therapy can decrease swelling in your arm."

A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. What information does the nurse include when teaching the client about the addition of insulin?

"With insulin, dosage can be adjusted to your changing needs during recovery from surgery." There is better control of blood glucose levels with short-acting (regular) insulin.

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse?

"You don't feel able to make a decision at this time? The response "You don't feel able to make a decision at this time?" reflects the client's concern and provides an opportunity for further verbalization while indicating the nurse's understanding.

A client who experiences anorexia and fatigue develops jaundice. A diagnosis of hepatitis A is made. The client's spouse and adult

"You should call your primary health care provider immediately about getting gamma globulin."

A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest?

10:00 AM to 1:00 PM. Regular insulin peaks in 2 to 5 hours; therefore the greatest risk is between 10:00 AM and 1:00 PM.

The nurse is volunteering at a community center to teach women about breast cancer. What should the nurse include when discussing risk factors?

50 +years, family history of breast cancer; E T O H, personal history of breast, colon, endometrial, or ovarian cancer; early menarche, late menopause; nulliparous or primi after 30.

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin?

Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants.

Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis?

Administration of intravenous insulin

A client returns from surgery after an abdominal cholecystectomy for a gangrenous gallbladder. For which postoperative complication, associated with the location of the surgical site, should the nurse assess the client?

Atelectasis. Subcostal incisional pain causes the client to splint and avoid deep breathing, which impedes air exchange in the alveoli.

Which subjective statement made by the client helps in distinguishing bacterial vaginosis from other vaginal infections?

Bacterial vaginosis (BV) is manifested by a vaginal discharge characteristic fishy odor, which occurs due to the replacement of hydrogen peroxide producing lactobacillus with anaerobic bacteria.

Fourteen months after the traumatic death of a spouse, a client comes to the mental health clinic complaining of continuing depression and states, "I haven't been seeing any of my friends or attending any of the activities I previously enjoyed. What does the nurse determine that the client is experiencing?

Difficulty grieving. The client's grieving process is severe and extended, indicating dysfunction.

A patient is in contact isolation for a bacterial infection. The nurse is going to implement which of the following interventions for this patient?

Help to ensure adequate social interaction and support. Frequently, patients in contact isolation do experience a decrease in social interaction because of the isolation. The nurse must help provide adequate social stimulation for the patient.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find?

Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation.

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care?

Increasing oral fluids, Observation for muscle weakness. Serious complications of hypercalcemia include severe muscle weakness, dehydration, loss of deep tendon reflexes, paralytic ileus, and electrocardiographic changes.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate?

Obtain a physician's order for supplemental oxygen. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen.

A nurse is caring for several extremely depressed clients. What type of setting does the nurse recognize these clients do best in?

Simple daily routines. Depression is usually both emotional and physical, so a simple daily routine is the least stressful and least anxiety producing.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action?

Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations.

A client newly diagnosed with tuberculosis has a productive cough. Which is the most appropriate nursing intervention to teach the client?

Sputum can be contained within disposable paper tissues that can then be discarded in fluid-impervious bags.

Lamictal (lemotrigine) can cause

Steven Johnson's Syndrome. Therefore dosage should start low and work up.

When applying wet compresses or dressings to the skin, the nurse should:

The desired solution should be applied to Kerlix gauze; soft cotton cloths; or strips from cloth diapers, sheets, handkerchiefs, or pillowcase material.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse?

The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution.

The nurse caring for patients in a primary care clinic identifies which patient as being the most at risk for the development of breast cancer?

The risk factors most associated with breast cancer are female gender, advancing age, and family history.

A nurse practitioner prescribes doxycycline for a sexually active woman with a history of mucopurulent discharge and bleeding associated with cervical dysplasia, dysuria, and dyspareunia. With which sexually transmitted infection are these clinical findings and medication therapy commonly associated?

The signs and symptoms listed and the treatment ordered (doxycycline or azithromycin) indicate that the client has a chlamydial infection

What information about nipple discharge should the nurse teach?

Unexpected nipple discharge of any type warrants medical follow-up

A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique?

While changing the bed the nurse wears gloves but no gown. Organisms spread by contact could be present on linen and furniture. Because the nurse will likely come in contact with the bed or the sheets, a gown should be worn.

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include?

Withholding oral fluid intake. Withholding oral intake of fluids is part of the preparation for a cesarean birth.

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions?

"The medicine will be prescribed for 10 days." Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots.

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection for what reason?

Exposed tissue and blood in an area that is moist, warm, and dark make an excellent culture medium, so it is important to keep the umbilical area clean and dry. The stump should be cleaned with water, using soap sparingly

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion?

Extension of cancerous lesions. Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space.

A nurse is planning care for a client who gave birth to a preterm male infant. Which response does the nurse anticipate that this mother may experience?

Feelings of failure and loss of control. Attachment theory states that the experience of the birth of a preterm infant carries with it feelings of loss of control for the mother.

A child is admitted with a diagnosis of acute poststreptococcal glomerulonephritis. While performing a physical assessment and reviewing the child's laboratory reports, what clinical findings does the nurse expect?

The inflammatory process in the kidney allows red blood cells to enter the urine, which manifests as hematuria. Capillary permeability in the kidney allows protein to pass into the urine. The glomerular filtration rate is reduced, resulting in sodium retention; fluid accumulation is evidenced by periorbital edema in the morning that spreads to the rest of the body as the day progresses. When the glomerular filtration rate is reduced, fluid is retained as evidenced by a decreased urinary output; with a decreased urinary output the specific gravity will increase (1.030). The retention of fluid causes an increase in the intravascular volume, resulting in an increased blood pressure.

A nurse is teaching a group of parents about communicable diseases. What information about chickenpox should the nurse include?

When all vesicles are dried, chickenpox is no longer transmissible; dried vesicles do not harbor the varicella virus. Dry scabs do not transmit the virus.

A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's best initial response?

"I can't, because the weights are needed to keep the bone aligned." The response "I can't, because the weights are needed to keep the bone aligned" explains why the traction may not be released; a continuous pull must be maintained.

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement?

"I get a sharp, stabbing pain when I take a deep breath

The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse?

"The fluid draining from the catheter is cloudy." The primary clinical manifestation of peritonitis is a cloudy peritoneal effluent.

The nurse is caring for a group of patients. Which patient is at risk of aspiration?

A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer?

A sudden massive hemorrhage. Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage;

A client with type 1 diabetes mellitus has a finger stick glucose level of 258 mg/dL (14.3 mmol/L) at bedtime. A prescription for sliding-scale regular insulin exists. What should the nurse do?

A value of 258 mg/dL (14.3 mmol/L) is above the expected range of 70 to 100 mg/dL (3.6 to 5.6 mmol/L); the nurse should administer the regular insulin as prescribed.

Which client is at the greatest risk for a postpartum infection?

A woman who required catheterization after voiding less than 75 milliLiters. Repeated catheterizations for residual urine increase the chance that bacteria will be introduced and their growth fostered.

The nurse teaches a high school sex education class that herpes genitalis infection cannot be cured, but the disease is marked by remissions and exacerbations. What else should the students be taught about this infection?

Although exacerbations occur, they are not as severe as the initial episode. The initial infection is both local and systemic; exacerbations are milder and localized.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess?

An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

A frail 72-yr-old woman with stage 3 chronic kidney disease. Which over-the-counter medications should the nurse teach the patient to avoid?

Antacids (that contain magnesium and aluminum hydroxide) should be avoided because patients with kidney disease are unable to excrete these substances.

A 24-yr-old patient had breast augmentation surgery and will be discharged the same day. What instructions should the nurse provide to minimize the risk of complications in the immediate recovery period?

Ask the patient to avoid strenuous exercise during her recovery period.

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance?

Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions.

A patient with end-stage renal disease (ESRD) secondary to DM 2 has arrived for hemodialysis. Which assessments should the nurse perform as a priority before, during, and after the treatment?

Blood pressure and fluid balance

The nurse teaches a 53-yr-old patient about screening for early detection of breast cancer. Which statement by the patient requires clarification by the nurse?

Breast self-examination (BSE) has benefits and limitations and may not be a reliable method for early detection of breast cancer.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient?

Bronchiolitis obliterans (BOS) BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions?

Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed.

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation.

Which patient diagnosis or treatment is most consistent with prerenal acute kidney injury (AKI)?

Dissecting abdominal aortic aneurysm A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate.

A 29-yr-old primiparous patient is breastfeeding a 3-wk-old infant. She complains of recent breast tenderness, redness, and fever.

Ensure patient adheres to antibiotic regimen. Mastitis normally requires antibiotic therapy.

Two siblings who live in a camp for migrant workers have contracted measles. The nurse, trying to determine which individuals had contact with the children, identifies those with immunity and assesses the probability of containing the measles to the camp. What technique has the nurse used in managing this situation?

Epidemiological process is a term given to the set pattern of procedures followed in the community when the health of the public is threatened by a communicable disease.

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of these diseases?

Hepatitis A and E most commonly are spread through the fecal-oral route.

A 10-year-old child with recently diagnosed type 2 diabetes attends the Center for Diabetic Teaching with the parents. The nurse interviews the child before the class begins. What is the priority concern diabetic children usually have?

How much school might be missed. School-aged children are most concerned about school—if not for the academics, for the social aspects

An adolescent with type 1 diabetes who has a history of inadequate adherence to therapy is admitted to the hospital with a blood glucose level of 700 mg/dL (38.9 mmol/L). A continuous insulin infusion is started. What complication should the nurse make a priority of detecting while the adolescent is receiving the infusion?

Hypokalemia. Insulin causes potassium to move into the cells along with glucose, thereby reducing the serum potassium level. Hypokalemia can lead to lethal cardiac dysrhythmias.

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of what condition?

Infection. The concentration of glucose in the solution (20% to 25%) is a rich culture medium for bacterial and fungal growth.

A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect to encounter during a physical assessment?

Meningococcal meningitis is identified by its epidemic nature and purpuric skin rash.

When caring for female patients, the nurse should be aware that most cancers occur where on the breast?

Most (50%) breast cancers are diagnosed in the upper outer quadrant of the breast.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient?

Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair the lip is scheduled for later in the week. Which assessment finding requires notification of the surgeon and will probably result in cancellation of the surgery?

Oral candidiasis (thrush) is a fungal infection of the mouth that can be acquired from the maternal vagina during the birth process. Surgery involving the mouth would be delayed until the infection has cleared.

When caring for a patient during the oliguric phase of acute kidney injury (AKI), which nursing action is appropriate?

Patients in the oliguric phase of AKI will have fluid volume excess with potassium and sodium retention. Therefore, they will need to have dietary sodium, potassium, and fluids restricted

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus?

Pink. With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis.

Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism?

Pulmonary angiography is considered the gold standard for diagnosis of pulmonary embolism

What should the nurse expect when assessing a client with pleural effusion?

Reduced or absent breath sounds at the base of the lung. Compression of the lung by fluid that accumulates at its base reduces expansion and air exchange

When assessing a client with pleural effusion, what does the nurse expect to identify?

Reduced or absent breath sounds at the base of the lung. Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange.

The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what?

Replace the catheter on a routine basis. A biofilm made up of bacteria develops on long-term indwelling catheters. The only way to eliminate this biofilm is to replace the catheter.

Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted?

The Glasgow Coma Scale is unchanged from 3 hours ago. Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement.

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient?

Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease.

A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client?

Thin, dark-red vertical lines about 1 to 3 mm long in the nails are associated with trichinosis (parasitic disease) and bacterial endocarditis (infection of the innermost layer of the heart and heart valves).

What priority intervention will the nurse employ to prevent injury to the patient with bone cancer?

Using a lift sheet when repositioning the patient The resultant bone destruction from bone cancer can cause pathological fractures by grasping or pulling on a patient by the extremities or trunk of the body during re-positioning. Use of a lift sheet evenly distributes the patient's weight, lessening the chance of fractures occurring.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is what?

When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress.

A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat?

When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low-potassium diet.

Based on the nurse's knowledge of wounds and wound healing, what are factors that can delay or cause dysfunctional wound healing?

being overweight Hypervolemia, Corticosteroid therapy

The nurse performs a breast examination on a 68-yr-old female patient. Which clinical manifestation indicates further evaluation for breast cancer is needed?

breast cancer may include a palpable lump that is hard, irregular, poorly delineated, nonmobile, and nontender, Nipple retraction, peau d'orange, induration, and dimpling.

During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to:

decrease the blood supply to the scar. The goal of the pressure dressing is to improve the appearance of scars. Uniform pressure to the scar decreases blood supply.

A mother of a 12-year-old child informs the phone triage nurse that she has just removed a tick from her daughter's scalp and asks whether she needs to be concerned about Rocky Mountain spotted fever. The nurse's BEST response includes teaching about the clinical manifestations to look out for which include:

fatigue. fever. petechial rash. severe headache.

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery?

it is critical to monitor for stridor, dyspnea, or other symptoms of acute airway obstruction inspect the neck dressing, as well as the sides of the neck and behind the neck, for blood

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

An obese client with leg trauma. An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma.

A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient?

Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics.

A 52-yr-old man with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action should the nurse perform?

Assess skin turgor to determine hydration status. The patient needs to have optimal hydration.

The nurse is caring for a patient who just underwent an axillary lymph node dissection. What intervention should the nurse use to decrease the lymphedema?

Blood pressure readings, venipunctures, and injections should not be done on the affected arm.

A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs?

Collaborate with the primary healthcare provider to alter the insulin prescription. The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. The primary healthcare provider may choose to decrease the insulin dose and then reassess the client.

The physician has decided to use renal replacement therapy to remove large volumes of fluid from a patient who is hemodynamically unstable in the intensive care unit. The nurse should expect which treatment to be used for this patient?

Continuous venovenous hemofiltration (CVVH) CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately?

Cover the chest wound with a nonporous dressing taped on three sides. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration.

A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should respond, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis ___."

Hepatitis C is caused by an RNA virus that is transmitted parenterally. More effective blood screening for hepatitis C was introduced in June 1992; this brought about a dramatic decrease in hepatitis C infection caused by blood transfusions.

The nurse is teaching a diabetic client about the advantages of using an insulin pump. What information should the nurse include? Select all that apply

It can improve A1C levels, Clients can exercise without eating more carbohydrates. Maintaining a consistent acceptable blood glucose level will improve A1C results. Because insulin is administered only as needed, the client will be able to exercise without having to increase the carbohydrate intake.

Levofloxacin is prescribed for a woman who has been experiencing urinary frequency and burning for the past 24 hours. The nurse concludes that the teaching about this medication has been understood when the client says that she will make which change in her routine?

Mineral substances taken within 2 hours of a levofloxacin dose decrease the medication's effectiveness.

A patient is recovering in the intensive care unit (ICU) 24 hours after receiving a kidney transplant. What is an expected assessment finding during the earliest stage of recovery?

Large urine output Patients frequently experience diuresis in the hours and days immediately following

When doing breast self-examination, the female patient should report which findings to her health care provider?

Left nipple deviation Unilateral deviation of a nipple may be a clinical indicator of breast cancer or other problem and should be reported to the health care provider.

The nurse is caring for a 52-yr-old woman is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make?

Monitor cardiac rhythm. Doxorubicin (especially at high doses) may cause cardiotoxicity and heart failure.

The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention?

Monitor the patient's cardiac status. The nurse's priority is to monitor the patient's cardiac status

What is the most important step in the management of cellulitis?

Oral or parenteral antibiotics Oral or parenteral antibiotics are indicated, depending on the extent of the cellulites. The antibiotic needs to be administered systemically.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

Palpitations are of neurogenic origin associated with hypoglycemia. Tachycardia occurs with low serum glucose levels because of sympathetic nervous system activity. Nervousness, anxiety, and shakiness occur as. The client will feel hungry with hypoglycemia

An adolescent approaches a nurse acknowledging sexual orientation towards same-gender relationships. How would a nurse intervene in such a situation?

Provide referral to an agency providing support service or social opportunities. Whenever an adolescent is expressing feelings of sexual orientation for the same gender, it is best advised to refer them to any agency that provides support services or social opportunities to gay, lesbian, and bisexuals.

The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate?

Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider. Because this is new for the client, the nurse should notify the primary healthcare provider.

The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation?

Requirements for intensive therapy with small, frequent insulin doses The pen injector allows greater accuracy with small doses of less than 5 units.

A client reports severe itching, especially at night. On assessment, the nurse finds the presence of burrows in the flexor surfaces of the wrists and in the anterior axillary folds. Which treatment is most appropriate for this client?

Severe itching, especially at night, and the presence of burrows in the flexor surface of the wrists and in the anterior axillary folds indicate scabies, which is caused by the Sarcoptes scabieimite. Treatment involves the use of 5% permethrin topical lotion for one overnight application and a second application 1 week later.

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply.

Sudden chest pain. Abrupt onset of shortness of breath. Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea

A 50-yr-old patient is beginning breast cancer treatment with tamoxifen. What should the nurse teach the patient about her new drug regimen?

Tamoxifen has the potential to cause cataracts and retinopathy. The drug is likely to exacerbate rather than alleviate perimenopausal symptoms.

A primigravida client with type 1 diabetes is attending her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur?

Twenty-fourth and twenty-eighth weeks of gestation. At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin.

The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection?

Use of a wet dressing. Wet dressings may promote the growth of organisms, leading to infection.

Self-care instructions for a woman following a modified radical mastectomy would include that she:

A decrease in sensation and tingling in the affected arm and in the incision are expected for weeks to months after the surgery.

A patient had a hip replacement 3 days ago. The patient states that the right leg is swollen below the knee and is warm to the touch. The patient has the diagnosis of deep vein thrombosis. Which intervention is appropriate for the patient?

Elevate the right lower leg when the patient is in the sitting position. A patient with a deep venous thrombosis elevates the extremity when sitting or lying to enhance venous return to the heart.

A patient presents with complaints of mastalgia. After determining cancer is not present, which strategies may provide relief?

Ice, reduce caffine, BCP's, support bra CONTINUOUSLY

A client who is exposed to pollens reports a runny, stuffy nose and itchy, watery eyes. The nasal examination reveals swollen and pink nasal mucosa. Which finding does the nurse suspect to be present in the client's laboratory reports?

Immunoglobulin E I g E level of 150 I U per milliters.

A 72-yr-old patient had a mastectomy for breast cancer 6 months ago and wants to have breast reconstructive surgery. Which motivation for surgery would be most likely?

Improve the woman's self-image The most likely motivation for this patient to seek reconstructive surgery is to improve self-esteem.

While assisting with developing a plan of care for a patient with multiple myeloma the nurse knows a priority intervention would include which of the following:

Increasing and encouraging oral fluids A patient with multiple myeloma has a priority concern of hypercalcemia secondary to bone destruction. The multiple myeloma patient should have urine output of at least 1.5 to 2 L/day. In order to maintain this urine output they need approximately 3 L of fluids per day.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughing. Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth.

Which health problem is most likely to precipitate acute hypoglycemia in a client?

Liver disease. Clients with liver disease have a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen (glycogenolysis).

A client is diagnosed with tuberculosis associated with human immunodeficiency virus infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started?

Liver function studies. Antitubercular drugs, such as isoniazid and rifampin are hepatotoxic.

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)?

Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

Which information indicates the nurse has a good understanding about the mechanism of action for maraviroc?

Maraviroc is an antiretroviral drug in the CCR5 receptor antagonist class used in the treatment of HIV infection. It is also classed as an entry inhibitor. It also appeared to reduce graft-versus-host disease in patients treated with allogeneic bone marrow transplantation for leukemia,

A cognitively impaired client's family member requests that the nurse list the benefits of using a respite care service. What information should the nurse provide about respite care services?

Respite care service is offered at home, in day care settings, or in a health care institution that provides overnight care. Currently, Medicare does not cover respite care service and Medicaid has strict requirements for services and eligibility. Respite care services provide short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult.

It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus?

Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.

Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?

Serosanguineous drainage from the wound or on the dressing forewarns about separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration).

What should the mental health nurse keep in mind when preparing to meet with a group of staff nurses who cared for victims of a disaster that occurred in the community?

The usual arrangement for the most effective group interaction is a circular configuration of chairs. Staff involved in the incident need protected time to undergo stress debriefing, which generally lasts from 1 to 3 hours per session. Food should be available so that hunger is not a distraction.

Enteral feedings are ordered for a young child with burns covering 40% of total body surface area. The nurse should know that:

paralytic ileus precludes the use of enteral feedings. Oral feedings are not contraindicated. They are encouraged; however, most children with burns are unable to consume sufficient calories by mouth. Enteral feedings can continue during procedures. Enteral feedings can begin when the paralytic ileus resolves. A high-protein, high-calorie diet is recommended.

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism?

A contrast medium may be given intravenously when performing a spiral-computed tomography (CT). The nurse should make sure that the client is well hydrated before and after the procedure to help flush out the contrast medium. The nurse should instruct the client to lie still on the hard table and that the scanner will revolve around the body with clicking noises.

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)?

A fever is an inflammatory response . A productive cough with discolored sputum. A heart rate of 120 beats/min indicates that there is increased metabolism due to fever.

The patient has stage IIB breast cancer. Which nursing intervention would be most effective in planning care?

Assess the patient's response to the diagnosis of breast cancer.

Which treatment strategies would benefit a client diagnosed with chlamydia? Select all that apply.

Doxycycline and azithromycin are used to treat chlamydia

A preterm newborn is placed in the neonatal intensive care unit. What is the first concern that the nurse anticipates for this infant's mother

Fear of touching the infant. Fear stems from the size and frailty of the newborn and the overwhelming environment of the intensive care area; parents should be encouraged to touch and handle their infants when possible.

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action?

Feeding the infant. A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level.

At 37 weeks' gestation a client's membranes spontaneously rupture; however, she does not have any labor contractions. What action is most important in the nursing plan of care for this client?

Monitoring for the presence of fever. The possibility of an ascending infection increases when membranes have ruptured and birth is not imminent; the client must be monitored for signs of infection.

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?

Put the stockings on before rising in the morning.

A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include?

Rapid removal of large amounts of fluid may precipitate cardiovascular collapse. The mechanism is unclear, but cardiovascular collapse probably is caused by fluid shifts.

A 45-year-old man presents to the emergency department with acute onset of confusion. The client's respiratory rate is 36 breaths/min, blood pressure is 85/62 mmHg, and chest radiography reveals pneumonia. What CURB-65 score will the nurse document in the client's record? Record your answer using a whole number. ____________score

This client will score 1 point for confusion and 1 for the respiratory rate of 36 breaths/min, plus 1 point for systolic blood pressure: 1 + 1 + 1 = a total score of 3. The CURB-65 scale may be used as a supplement to clinical judgment to determine the severity of pneumonia. One point is scored for each indicator, such as confusion, blood urea nitrogen greater than 20 mg/dL, respiratory rate of 30 breaths/min or more, systolic blood pressure less than 90 mm or Hgor diastolic blood pressure of 60 mm Hg or less, and age of 65 years or older.

A 51-yr-old woman has recently had a unilateral, right total mastectomy and axillary node dissection What nursing intervention should included in the patient's care?

Promote gradually increasing mobility as soon as possible following surgery.