Test 2

A nurse is teaching a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include in the teaching? A. Contact provider if heart rate is less than 60/min B. Check pulse rate for 30 seconds and multiply results by 2 C. Increase intake of sodium D. Take with food if nausea occurs

A Rationale: Take pulse for a full minute; reduce sodium intake; nausea is indication of toxicity

A nurse is reviewing the health record of a client who asks about using propranolol (beta-blocker) to treat hypertension. The nurse should recognize which of the following conditions is a contraindication for taking propranolol? A. asthma B. glaucoma C. hypertension D. Tachycardia

A Rationale: causes bronchoconstriction

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statements is appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2L bottle to keep track of how much you drink." B. "Each glass contains 8 oz. There are 30 mL/oz, so you can have a total of 8 glasses or cups of fluid each day." C. This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."

A Rationale: visual guide for patient for amount to be consumed and how to plan daily intake

A nurse is admitting an older adult client who is experiencing SOB, weakness, weight gain of 2 lbs, and 1+ bilateral edema of the lower extremities. The client has a temperature of 99*F, pulse 96/min, respirations 26/min, O2 of 94% on 3L of O2 via nasal cannula, and BP of 152/96 mm Hg. Which of the following manifestations of FVE should the nurse expect? (Select all that apply) A. Dsypnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A, B, D, E

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (Select all that apply.) A. 1 slice of cheddar cheese B. 1 medium beef hot dog C. 3 oz Atlantic salamon D. 3 oz roasted chicken breast E. 2 oz lean baked ham

A, C, D

A nurse providing teaching to a client who has a new prescription for digoxin. The nurse should instruct the client to monitor and report which of the following adverse effects that is a manifestation of digoxin toxicity? (select all that apply) A. Fatigue B. Constipation C. Anorexia D. Rash E. Diplopia

A, C, E Rationale: Diplopia (visual changes), fatigue (early CNS detection of toxicity), Anorexia are all manifestations of toxicity

A client has a urinary catheter and continuous bladder irrigation after a transurethral resection of the prostate this morning. The amount of bladder irrigating solution that has infused over the past 12 hours is 1000 mL. The amount of fluid in the urinary drainage bag is 1725 mL. The nurse records that the client had ____ mL urinary output in the past 12 hours.

Answer: 725 Rationale: The client has had 1000 mL of bladder irrigating solution infused, and there is 1725 mL of fluid in the urinary drainage bag. 1725 mL - 1000 mL = 725 mL, which represents the amount of urinary output that the client has produced.

A 65-year old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. Smoking B. Urine with a high specific gravity C. Recurrent urinary tract infections D. History of cancer in another organ or tissue

Answer: A Rationale: Many compounds in tobacco enter the bloodstream and affect other organs, such as the bladder. Concentrated urine is associated with kidney stones and UTIs. The urinary bladder is not a common site for metastases.

An 84-year-old male client is being admitted after surgery to remove a section of his bowel (colectomy) following a diagnosis of colon cancer. His urine output from an indwelling urinary catheter after 3 hours in the postanesthesia care unit plus the amount in the bag on admission to the medical-surgical unit totals 100 mL. The urine is cloudy and dark yellow. He also has a history of hypertension. After evaluating the patency of the collection device, what is the most appropriate action for the nurse to perform? A. Notify the health care provider of the low urine output. B. Increase the rate of intravenous fluids until urine output is 0.5 mL/kg/hr. C. Continue to assess the client and re-evaluate urine output in 4 hours. D. Ask about his typical voiding patterns and about any previous episodes of urinary problems.

Answer: A Rationale: The lowest acceptable urine output to avoid acute kidney injury (AKI) is 0.5 mL/kg/hr, which, in this 70-kg man, is about 35 mL/hr or a total of at least 105 mL. Surgery places clients at risk for both hypo- and hypervolemia. Waiting an additional 4 hours to obtain 6-hour trend data delays the prompt assessment and intervention necessary to avoid AKI. It is not appropriate to increase fluid rate, and it is unlikely the client is ready to take oral fluid this soon after surgery on the gastrointestinal tract. Voiding is not an issue with a urinary collection device.

A client with gastroesophageal reflux disease (GERD) is prescribed to start pantoprazole (Protonix) 40 mg every day. Which statement by the client requires further teaching by the nurse? A. "When I feel better, I can stop taking this drug." B. "I'll take this drug at 8 AM every morning." C. "This drug can cause headache and dizziness." D. "I should not crush the drug because it has a delayed release."

Answer: A Rationale: Treatment for GERD should be continued even if a client begins to feel better. Discontinuation of therapy can result in return of original GERD symptoms, which can further damage esophageal tissues. Side effects of pantoprazole (Protonix) can include headache and dizziness, which should immediately be reported to the client's health care provider. This medication should be taken on a regular, predictable schedule because proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion by affecting the proton pump of the gastric parietal cells. This medication should not be crushed because of its delayed release properties.

Over the past 3 months, a client with a history of gastroesophageal reflux disease and obesity has implemented lifestyle changes. What lifestyle changes does the nurse recognize as important for the client to decrease chances of development of cancer of the esophagus? Select all that apply. A. Lost 10 pounds B. Sleeps with two pillows C. Has quit eating processed foods D. Drinks a glass of wine every night E. Uses a nicotine patch instead of smoking

Answer: A, B, C, E Rationale: Losing weight can result in a decrease in intra-abdominal pressure, which can reduce the symptoms of reflux that are associated with an increased risk for development of esophageal cancer. Nocturnal reflux can be reduced by sleeping with the head of the bed elevated or with the use of two pillows. Chemicals used in processed foods, as well as smoking, can contribute to an increased risk for esophageal (and other types of) cancer. Excessive alcohol intake is associated with esophageal cancer.

A client is provided with materials to obtain three fecal occult blood tests (Hemoccult). What health teaching does the nurse provide? Select all that apply. A. "Avoid red meat and raw vegetables for a week before getting the samples." B. "Drink a gallon of GoLYTELY before you collect the first sample." C. "Do not take food or fluids for 24 hours before the test." D. "Do not take ibuprofen for a week before obtaining the samples." E. "Avoid vitamin C tablets, foods, and juices a week before getting the samples."

Answer: A, D, E Rationale: To avoid obtaining false-positive results associated with fecal occult blood tests (Hemoccult), patients must avoid certain foods before the test, such as raw fruits and vegetables and red meat. Vitamin C-rich foods, juices, and tablets must also be avoided. Anticoagulants, such as warfarin (Coumadin), and nonsteroidal antiinflammatory drugs should be discontinued for 7 days before testing begins.

A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (select all that apply) A. Avoid sitting in a wet bathing suit B. Wipe the perineal area back to front following elimination C. Empty the bladder when there is an urge to void D. Wear synthetic fabric E. Take a shower daily

Answer: A,C,E

A nurse is reviewing urinalysis results of four clients. Which of the following urinalysis results indicates a urinary tract infection? A. Positive for hyaline casts B. Positive for leukocyte esterase C. Positive for ketones D. Positive for crystals

Answer: B

A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick. What is the nurse's best action? A. Notify the charge nurse as soon as possible. B. Increase the rate of the bladder irrigation. C. Document the assessment in the medical record. D. Prepare the patient for a blood transfusion.

Answer: B Rationale: After a TURP procedure, the flow of the irrigant should be sufficient to keep the urine clear. Because the client's urinary drainage is bright red and thick, the nurse's initial action should be to increase the rate of bladder irrigation. The nurse will subsequently document the assessment in the medical record, and monitor the client's laboratory work, particularly hemoglobin and hematocrit values.

The client arrives to the primary care clinic with a problem of new abdominal pain and blood in her urine. She is afebrile. Which information is most important for the nurse to obtain from this client's history? A. Kidney cancer in the client's family B. Injury or trauma to the abdomen or pelvis C. Treatment for a urinary tract infection in the past 12 months D. Recent exposure to heavy metals, drugs, or other nephrotoxins

Answer: B Rationale: Bladder trauma or injury should be considered in the patient with abdominal pain. Lack of fever reduces suspicion for infection; pain is not usually associated with kidney cancer or acute and chronic kidney injury from nephrotoxins

The nurse auscultates a client's abdomen and hears a loud bruit near the umbilicus. What is the nurse's best action based on this assessment finding? A. Document the assessment finding in the medical record. B. Palpate the abdomen lightly in all four quadrants. C. Report the finding to the health care provider. D. Place the client in a semi-Fowler's position.

Answer: C Rationale: A bruit heard over the aorta usually indicates the presence of an aneurysm. The nurse should not percuss or palpate the abdomen and should immediately notify the health care provider of the findings.

The client passes a urinary stone that laboratory analysis indicates is composed of calcium oxalate. Based on this analysis, which instruction does the nurse specifically include for dietary prevention of the problem? A. "Increase your intake of meat, fish, and cranberry juice." B. "Avoid citrus fruits and citrus juices such as oranges." C. "Avoid dark green leafy vegetables such as spinach." D. "Decrease your intake of dairy products, especially milk."

Answer: C Rationale: Calcium oxalate stones form more easily in the presence of oxalate. Sources of oxalate include spinach, black tea, and rhubarb. Avoiding these sources of oxalate may reduce the number of stones formed. Citrus intake is not restricted in this type of stone and is often suggested to be increased. Dietary intake of calcium does not appear to affect calcium-based stone formation, although the client should avoid calcium mineral supplements. Moderation of meat reduces stone formation in general.

A client is admitted to the emergency department in severe pain with a gunshot wound to the right upper abdomen. Admitting vital signs are TPR 98-96-28; BP 118/70; oxygen saturation 94%. What is the nurse's priority when monitoring this client? A. Open the airway to improve breathing. B. Give oxygen via nasal cannula at 2 L/min. C. Monitor vital signs frequently. D. Determine how the client was shot and by whom.

Answer: C Rationale: Penetrating abdominal trauma is caused by GSWs, stabbing, or impalement with an object. The liver is the most commonly injured organ from penetrating abdominal trauma, and trauma is the leading cause of death in adults younger than 40 years in the United States. With what appears to be stable vital signs at this time, the nurse should monitor vital signs for any changes that may indicate complications from the penetrating abdominal trauma. It is not within the nurse's scope to determine who shot the client.

The nurse is completing documentation for a client with acute kidney injury who is being discharged today. The nurse notices that the client has a serum potassium level of 5.8 mEq/L. Which is the priority nursing action? A. Asking the client to drink an extra 500 mL of water to dilute the electrolyte concentration and then re-checking the serum potassium level B. Encouraging the client to eat potassium-binding foods and to contact his or her primary care provider within 24 hours. C. Checking the remaining values on the electrolyte panel and informing the provider of all results before the client is discharged. D. Applying a cardiac monitor and evaluating the client's muscle strength and muscle irritability.

Answer: C Rationale: Repeating the laboratory test is a reasonable option, but the provider must make this decision after being informed about the context, including the results of the entire electrolyte panel, which will also have information about renal function (creatinine and blood urea nitrogen). Although the potassium level is slightly elevated, it is not a value commonly associated with cardiac dysrhythmias or skeletal muscle changes. Although additional fluid intake may dilute some electrolytes, potassium is not generally altered by plasma volume. There are no foods that specifically bind potassium and, depending on the rapidity of the rise in serum potassium, waiting a day may result in harm to the patient.

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. 36-year-old woman who is blind receiving diuretics B. 46-year-old man who has paraplegia and is admitted for asthma management C. 56-year-old woman who is admitted with a vaginal-rectal fistula and diabetes D. 66-year-old man who has severe osteoarthritis and high risk for falling

Answer: C Rationale: This client has a wound that can be irritated by urine and whose urinary tract could become infected by the draining fistula (her diabetes increases her overall risk for infection). All of these other clients could be managed with frequent toileting. The men could also be managed with external urine collection devices.

Which assessments are most important for the nurse to perform when monitoring a client who returns to the medical-surgical unit after a dye-enhanced CT scan? A. Body temperature and urine odor B. Kidney tenderness and flank pain C. Urine volume and color D. Specific gravity and pH

Answer: C Rationale: To prevent dye-induced nephrotoxicity, the nurse should evaluate the urine and ensure a large, dilute output for several hours after the test. Generally, the amount of contrast does not cause dehydration; the concern is that the high osmolar content of some dyes has a direct nephrotoxic affect. Kidney tenderness and flank pain may indicate bleeding, a complication from a kidney biopsy. Body temperature and urine odor may indicate a UTI after manipulation of the urinary tract system and manipulation (e.g., placement of a urinary catheter or instilling of fluid into the bladder) does not occur with a CT scan.

The client's urinalysis shows all of the following abnormal results. Which result does the nurse report to the health care provider immediately? A. pH 7.8 B. Protein 31 mg C. Sodium 15 mEq/L D. Leukoesterase and nitrate positive

Answer: D Rationale: Although the alkaline pH is abnormal, it may be the results of diet or other benign factors; the slight increase in protein is concerning but not urgent and may be explained by diet, strenuous activity, or other benign causes, similar to the slightly elevated sodium, which could be from salty food ingestion. However, the most common cause of positive leukoesterase result is a UTI, and this test is further confirmed with a positive nitrate result.

A client in the community health clinic is prescribed trimethoprim/sulfamethoxazole for cystitis. She reports that she developed hives to "something called Septra." What is the nurse's best action? A. Reassure the client that Septra is not trimethoprim/sulfamethoxazole. B. Highlight this important information in the client's medical record. C. Place an allergy alert band on the client's wrist. D. Notify the prescriber immediately.

Answer: D Rationale: Septra is a brand name for TMP-SMX, a sulfa-based antibiotic with multiple brand names. It is inappropriate to band a wrist in a community health clinic. This information may need to be added to the client's medical record, but simply highlighting the information will not prevent an avoidable adverse drug event. The provider needs the allergy information in order to substitute another effective antibiotic.

The nurse is teaching a client about taking sildenafil (Viagra) for erectile dysfunction. Which statement by the client indicates a need for further teaching? A. "I should have sex within an hour after taking the drug." B. "I should avoid alcohol when on the drug, or it might not work well." C. "I can expect to maybe get a stuffy nose or headache when I take the drug." D. "If I have chest pain during sex, I should take a nitroglycerin tablet."

Answer: D Rationale: Sexual stimulation is needed within ½ to 1 hour after taking sildenafil (Viagra) to promote an erection. Patients should avoid drinking when taking medications such as sildenafil (Viagra). Nasal congestion and/or headache are common side effects associated with this medication. Patients who experience chest pain during sex should discontinue sexual activity and seek emergency care.

A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse? A. Offer a warm sitz bath B. Recommend drinking cranberry juice C. Encourage increased fluids D. Administer an antibiotic

Answer: D Rationale: The greatest risk to the client is injury to the renal system and sepsis from the UTI.

A nurse is caring for a client who has heart failure and reports increased SOB. The nurse increases the clients O2 per protocol. Which of the following actions should the nurse take first? A. Obtain the clients weight B. Assist the client into high-Fowler's position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximeter

B

A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice of toast with 1 tbsp peanut butter D. 1 large scrambled egg

B

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? A. Call the ED physician immediately B. Draw a serum digoxin level C. Assess for signs of hypokalemia D. Establish the client's airway

B Rationale: The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.

A nurse is caring for an older adult client who has a new prescription for digoxin and takes multiple other medications. The nurse should recognize that concurrent use of which of the following medications places the client at risk for digoxin toxicity? A. Phenytoin B. Verapamil C. Warfarin D. Aluminum hydroxide

B Rationale: Verapamil is a calcium-channel blocker and can increase digoxin levels

A client is diagnosed with left-sided HF. Which assessment findings will the nurse expect the client to have? Select ALL that apply. A. peripheral edema B. crackles in both lungs C. breathlessness D. ascites E. tachypnea

B, C, E Rationale: Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.

A nurse in a provider's office is monitoring serum electrolytes for four older adult clients who take digoxin. Which of the following electrolyte values increases a client's risk for digoxin toxicity? A. Ca - 9.2 mg/dL B. Ca - 10.3 mg/dL C. K - 3.4 mEq/L D. K - 4.8 mEq/L

C Rationale: low levels of potassium can lead to digoxin toxicity

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2mEq/L. What is the nurse's best action at this time? A. Assess the client's oxygen saturation level B. Ask the laboratory to retest the potassium level C. Give potassium as an IV infusion D. Check the patient's serum creatinine

D Rationale: Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.