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A client is scheduled for knee replacement surgery and expresses a desire to make an autologous blood donation. Which client statement about autologous blood donation is most important for the nurse to follow up on? 1."I will make the first donation this week since my surgery is scheduled in 8 weeks." 2."I may have to start taking oral iron supplements." 3."I am glad that I can give up to 6 units of blood." 4."I have to make the last donation at least 1 week before surgery."

1) CORRECT - Blood for the autologous donation is collected 6 weeks before the scheduled surgery. This statement would require additional follow up by the nurse. 2) INCORRECT - The client may start taking an oral iron supplement 1 week before starting the donation process and continue until surgery. This statement does not require follow up by the nurse. 3) INCORRECT - The client can give 1 unit of blood per week for a total of 6 units. This statement does not require additional follow up by the nurse. 4) INCORRECT - This is a correct statement and does not require follow up by the nurse.

The nurse provides care to a client who underwent abdominal surgery. Assessment of the client's abdominal incision reveals that three staples have dislodged and the wound edges are separating. The nurse will implement which action? (Select all that apply.) 1.Place a sterile saline dressing over the wound. 2.Apply sterile tape to secure the wound edges in a closed position. 3.Place the client in a semi-Fowler's position with knees bent. 4.Explain to the client that wound edge separation is easily treated. 5.Apply an abdominal binder to stabilize the incision. 6.Advise the client to breathe deeply to decrease anxiety.

1) CORRECT - Following abdominal surgery, in the event of wound dehiscence, the wound should be covered with a sterile towel or a sterile dressing that has been moistened with saline. 2) INCORRECT - Application of sterile tape is not an effective means by which to close an abdominal wound and may lead to contamination of the wound. In many cases, abdominal wound dehiscence requires surgical repair. 3) CORRECT - To prevent further separation of the wound closure, the client should be positioned to decrease abdominal muscle strain. Knee flexion decreases abdominal muscle strain. 4) INCORRECT - Telling the client wound dehiscence is easily treated represents providing false reassurance. In many cases, surgical wound closure is needed. 5) INCORRECT - An abdominal binder may be used to help prevent wound dehiscence from occurring. However, in the event of wound dehiscence, surgical closure of the wound is often required. 6) INCORRECT - Deep breathing, coughing, and other activities that may increase intra-abdominal pressure are to be avoided, as additional strain on the abdominal muscles may lead to evisceration, which involves protrusion of a portion of the bowel through the open wound.

The nurse provides education to a client who is newly diagnosed with systemic lupus erythematosus (SLE). Which client statement indicates to the nurse a need for further instruction? (Select all that apply.) 1."I will wear SPF 15 sunscreen when I am outside." 2."Nonsteroidal anti-inflammatory medications may help decrease my joint pain." 3."The rash on my face will go away in time." 4."I may need to take a medication that will boost my immune system." 5."I will wear a long-sleeved shirt while gardening."

1) CORRECT - Individuals with SLE should wear sunscreen with a minimum SPF of 30 when exposed to direct sunlight. 2) INCORRECT - With SLE, bone and joint pain is a common manifestation. Regular use of nonsteroidal anti-inflammatory medication may help with pain control. 3) CORRECT - The characteristic "butterfly" pattern rash associated with SLE is permanent and does not resolve with time. 4) CORRECT - Treatment of SLE may include the use of immunosuppressive medications in order to prevent a systemic response to the illness. 5) INCORRECT - To protect skin integrity, the individual with SLE should wear a long-sleeved shirt, full pants, and a broad-brimmed hat when exposed to direct sunlight.

The nurse teaches a client newly diagnosed with diabetes mellitus about proper foot care. Which instructions will the nurse include in the teaching plan? (Select all that apply.) 1.Wash and dry feet every day. 2.Soak feet in hot water twice daily. 3.Have a podiatrist cut the toenails. 4.Check the feet daily for injuries. 5.Never walk barefoot.

1) CORRECT - Those diagnosed with diabetes mellitus should wash their feet daily and dry them carefully, especially between the toes. 2) INCORRECT - This could cause burns and blisters to the feet. 3) CORRECT - A client with diabetes mellitus should have a podiatrist cut their toenails. 4) CORRECT - Individuals with diabetes mellitus should inspect their feet for red spots, cuts, swelling, and blisters. 5) CORRECT - This will protect the feet from injury.

The nurse provides care for a client after surgery. Which intervention does the nurse include in the client's plan of care? 1.Begin oral fluids when bowel sounds are present. 2.Maintain nothing by mouth status until passing flatus. 3.Insert catheter if unable to void 4 hours after surgery. 4.Insert nasogastric tube as needed every 4 hours.

1) CORRECT - To prevent abdominal distension, do not offer oral fluids until bowel sounds are heard. 2) INCORRECT - Early ambulation helps the client pass flatus, but it is not necessary to maintain an NPO status until the client passes flatus. 3) INCORRECT - Do not catheterize unless absolutely necessary. The client has 6 to 8 hours after surgery to void. 4) INCORRECT - Abdominal distention is not treated with a nasogastric tube (NG) PRN. If an NG tube is required, it is left in place for a period of time.

The nurse provides care for a client with a history of type 2 diabetes mellitus (DM). The client had an acute MI and is prescribed IV metoprolol. Which nursing interventions are required with IV metoprolol administration? (Select all that apply.) 1.Connect client to ECG. 2.Monitor for tachycardia. 3.Assess blood glucose level. 4.Administration with morphine is to be avoided. 5.Monitor for heart block. 6.Administer undiluted by direct intravenous infusion.

1) CORRECT — Clients receiving IV metoprolol should be monitored with an ECG to observe for dysrhythmias. 2) INCORRECT - Tachycardia is not associated with IV metoprolol, but bradycardia is a possible dysrhythmia. 3) CORRECT — Metoprolol is a beta-blocker and masks the symptoms of hypoglycemia and shock. The blood glucose is closely monitored. Watch for other symptoms of hypoglycemia, such as sweating, fatigue, hunger, or the inability to concentrate. 4) INCORRECT - Metoprolol is compatible with morphine. 5) CORRECT — Heart block is a possible adverse effect resulting from metoprolol, and ECG monitoring is required. 6) CORRECT— Metoprolol is administered undiluted by direct IV infusion at a rate of 5 mg over 60 seconds every 2 minutes for three doses after a myocardial infarction.

The nurse reviews the blood-test results of four adult clients. Which result indicates to the nurse that the client has a high risk of falling? 1.Blood urea nitrogen (BUN) of 28 mg/dL (10 mmol/L). 2.Serum sodium (Na) of 140 mEq/L (140 mmol/L) and potassium (K) of 4.2 mEq/L (4.2 mmol/L). 3.Erythrocyte sedimentation rate (ESR) of 30 mm/hr (30 mm/hr). 4.Serum calcium (Ca) of 9 mg/dL (2.25 mmol/L) and magnesium (Mg) of 1.8 mEq/L (0.9 mmol/L).

1) CORRECT — The BUN is elevated in salt and water depletion and can cause confusion, disorientation, and convulsions, which could easily lead to falls. Water depletion could also result in falls due to orthostatic hypotension. 2) INCORRECT— The sodium and potassium levels are within normal limits. 3) INCORRECT— The ESR indicates inflammatory or degenerative tissue destruction. A client may have acute febrile disease and may therefore be somewhat lethargic, confused, and weak, but not at the highest fall risk. A normal ESR range is 0 to 20 mm per hour. 4) INCORRECT— The calcium and magnesium results are within normal limits.

After insertion of a central venous catheter (CVC), a client suddenly starts coughing. The nurse observes that the client is pale and dyspneic, and has tachycardia. Which action does the nurse take first? 1.Turn the client to the left side and lower the head of the bed. 2.Notify the health care provider. 3.Administer oxygen. 4.Instruct the client to do the Valsalva maneuver.

1) CORRECT — The client's symptoms are consistent with an air embolism, which can occur with CVC insertion. Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20-30 minutes. 2) INCORRECT — The nurse should notify the health care provider after repositioning the client and administering oxygen. The nurse should first administer emergent treatment to keep the client alive. 3) INCORRECT — The nurse should first turn the client to the left side before administering oxygen. If the nurse administers oxygen first, the client will die from a right ventricular outflow obstruction. 4) INCORRECT — This is an incorrect action. It prevents air embolism, but does not treat it. The Valsalva maneuver is used during insertion and removal of the catheter and during tubing changes.

The nurse instructs a client diagnosed with pyelonephritis about the disease process. Which client statements indicate to the nurse a need for additional teaching? (Select all that apply.) 1."I could have avoided this if I had kept my blood pressure under better control." 2."I don't enjoy drinking water, but if I notice my urine has an odor, I'll try to drink more." 3."Since I'm allergic to sulfa medications, the health care provider will give me intravenous antibiotics." 4."When I have a fever, I will take acetaminophen as prescribed." 5."I can tell I'm getting better when the pain in my back goes away." 6."After the antibiotics are finished, I will need to schedule a visit to the clinic."

1) CORRECT — There is no correlation between pyelonephritis and hypertension. 2) CORRECT — The client needs to be instructed to drink six to eight 8-oz glasses of fluid, but not necessarily water. The client's urine may or may not have odor. 3) CORRECT — Although trimethoprim/sulfamethoxazole is a common treatment for pyelonephritis, there are other oral antibiotics that may be prescribed. 4) INCORRECT— Taking an over-the-counter antipyretic for a fever is an appropriate client statement and indicates teaching has been effective. 5) INCORRECT— Elimination of back pain occurs when the health problem improves. Clients with pyelonephritis often have flank pain. 6) INCORRECT— A follow-up urine culture is required after the client completes the prescribed course of antibiotics.

The nurse provides teaching to a client receiving ferrous sulfate 300 mg per day. Which client statement indicates that teaching is effective? 1."I will have to eat more fresh fruits and whole-grain bread." 2."This medication may cause fine motor tremors." 3."My bowel movements may become light in color." 4."I may have problems with blurred vision."

1) CORRECT— A side effect of ferrous sulfate is constipation. The client should increase intake of fruits, fiber, and fluids. Other side effects include gastric irritation, nausea, abdominal cramps, anorexia, vomiting, diarrhea, and dark-colored stools. 2) INCORRECT— Fine motor tremors are not a side effect of ferrous sulfate. 3) INCORRECT— While taking ferrous sulfate, the client's stools may become dark green or black. 4) INCORRECT— Blurred vision is not a side effect of ferrous sulfate.

he nurse provides teaching to a client receiving ferrous sulfate 300 mg per day. Which client statement indicates that teaching is effective? 1."I will have to eat more fresh fruits and whole-grain bread." 2."This medication may cause fine motor tremors." 3."My bowel movements may become light in color." 4."I may have problems with blurred vision."

1) CORRECT— A side effect of ferrous sulfate is constipation. The client should increase intake of fruits, fiber, and fluids. Other side effects include gastric irritation, nausea, abdominal cramps, anorexia, vomiting, diarrhea, and dark-colored stools. 2) INCORRECT— Fine motor tremors are not a side effect of ferrous sulfate. 3) INCORRECT— While taking ferrous sulfate, the client's stools may become dark green or black. 4) INCORRECT— Blurred vision is not a side effect of ferrous sulfate.

The nurse conducts a health history and physical examination for a school-age client whose parent believes has attention deficit hyperactivity disorder (ADHD). Which behaviors does the nurse observe that support this diagnosis? (Select all that apply.) 1.Wandering when asked to sit in the waiting room. 2.Looking at a book quietly while the parent talks with the nurse. 3.Staring out the window when the nurse is talking. 4.Demanding to leave during the visit with the nurse. 5.Completing homework independently. 6.Moving constantly when a toddler.

1) CORRECT— Not following directions and walking around when asked to sit is a behavior associated with ADHD. 2) INCORRECT— Looking at a book quietly indicates that the client is able to attend and follow directions. 3) CORRECT— The client diagnosed with ADHD often does not seem to listen when being directly spoken to. 4) CORRECT— Interrupting or intruding on others is a behavior associated with ADHD. 5) INCORRECT— A client diagnosed with ADHD has difficulty following through on instructions or finishing schoolwork. 6) CORRECT— Being "on the go" or acting as if driven "by a motor" is a behavior associated with ADHD.

The nurse observes prominent U waves on a client's electrocardiogram (ECG) rhythm strip. Based on this abnormality, for which condition will the nurse assess the client? 1.Hypokalemia. 2.Hyperkalemia. 3.Hypocalcemia. 4.Hypercalcemia.

1) CORRECT— Prominent U waves on a client's ECG strip signal hypokalemia, an abnormally low serum potassium level. 2) INCORRECT - Hyperkalemia, an abnormally high serum potassium level, causes P-wave flattening, QRS complex widening, and peaking of the T waves. 3) INCORRECT - The QT interval and ST segment may be prolonged with hypocalcemia, an abnormally low calcium level. Torsades de pointe, a lethal ventricular arrhythmia, also may occur with hypocalcemia. 4) INCORRECT - Shortening of the QT interval and ST segment may occur with hypercalcemia, an abnormally high serum calcium level.

The nurse provides care for a client diagnosed with chronic venous insufficiency. Which findings does the nurse note as being consistent with this diagnosis? (Select all that apply.) 1.Thick, dark skin on bilateral lower extremities. 2.Varicose veins in the right leg. 3.Pain in the lower extremities while sitting. 4.A tender, red area on one lower extremity. 5.Crater-like lesions on the lower extremities.

1) CORRECT— Thick, dark skin on the lower extremities is consistent with the diagnosis of chronic venous insufficiency. Chronic edema causes changes in consistency and color of the skin. 2) CORRECT— Varicose veins are consistent with the diagnosis of chronic venous insufficiency. 3) CORRECT— Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions. 4) INCORRECT— A tender area describes phlebitis, not venous insufficiency. This finding is inconsistent with the diagnosis of chronic venous insufficiency. 5) CORRECT — This finding is consistent with the diagnosis of chronic venous insufficiency. Crater-like lesions on the lower legs describes venous stasis ulcers.

The nurse obtains a history from a client who is prescribed rosuvastatin. Which client report is most important for the nurse to report to the health care provider? 1.Rash. 2.Headache. 3.Abdominal pain. 4.Muscle tenderness.

1) INCORRECT - A client who takes rosuvastatin (Crestor) can develop a rash, which the nurse should report to the health care provider in case the provider wants to prescribe treatment. However, this side effect does not place the client at greatest risk for injury. 2) INCORRECT - A client who takes rosuvastatin (Crestor) can develop a headache, which the nurse should report to the health care provider in case the provider wants to prescribe an analgesic. However, this side effect does not place the client at greatest risk for injury. 3) INCORRECT - A client who takes rosuvastatin (Crestor) can develop abdominal pain and other gastrointestinal distress, which the nurse should report to the health care provider in case the provider wants to prescribe treatment. However, this side effect does not place the client at greatest risk for injury. 4) CORRECT- Even though it is rare, one of the greatest risks to a client who is taking rosuvastatin (Crestor) is myositis, or muscle inflammation, that can progress to rhabdomyolysis. Therefore, a client report of muscle tenderness is the priority for the nurse to report to the health care provider.

A university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which action should the nurse take first? 1.Ask if the student has experienced this problem previously. 2.Obtain the student 's temperature. 3.Encourage the student to drink large volumes of fluid. 4.Insist that the police override the curfew and allow travel.

1) INCORRECT - A health history is relevant but not the first action. It does nothing to relieve the client's discomfort. 2) INCORRECT - The student is exhibiting the symptoms of a urinary tract infection (UTI). Fever is a rare manifestation of UTI. 3) CORRECT— The client's symptoms are consistent with a urinary tract infection (UTI), and fluids will help flush the system and may relieve some discomfort. A warm sitz bath may also help relieve discomfort. Antibiotics, the treatment of choice for a UTI, can be obtained after curfew. 4) INCORRECT - The client has reported symptoms consistent with a urinary tract infection, which is not life threatening.

The nurse in the outpatient clinic receives a phone call from a client with type 1 diabetes mellitus. The client reports a blood glucose level of 200 mg/dL (11.1 mmol/L) at 0700. Which instruction to the client is most appropriate? 1.Obtain a blood sugar at 0900 and report the results to the clinic. 2.Increase the morning dose of regular insulin according to health care provider instructions. 3.Obtain a blood sugar at 0300 and report the results to the clinic. 4.Decrease the evening dose of NPH insulin according to health care provider instructions.

1) INCORRECT - A postprandial glucose reading will not supply the needed information about the client's problem. 2) INCORRECT - The client may need to increase the breakfast dose of regular insulin, but first the Somogyi effect should be ruled out. 3) CORRECT— Assess the blood glucose level to determine if the hyperglycemia is caused by the Somogyi effect, which is characterized by a normal or elevated blood glucose at bedtime, hypoglycemia between 0200 and 0300, and a rebound hyperglycemia in the morning. 4) INCORRECT - Decreasing the evening dose is an appropriate action if the Somogyi effect is identified. The nurse must rule out insulin waning and dawn phenomenon before taking action.

A client comes to the clinic reporting muscle weakness, breathlessness, and bone pain. The nurse notes that the client takes phenytoin 100 mg three times a day. When providing nutritional counseling, which food grouping best meets this client's needs? 1.Bananas, mushrooms, yams. 2.Oranges, broccoli, papayas. 3.Milk, cantaloupe, kale. 4.Soybeans, spinach, pumpkin seeds.

1) INCORRECT - Bananas, mushrooms, and yams include some folate, but no vitamin D. 2) INCORRECT - These foods are high in vitamin C and potassium. Broccoli is a minor source of calcium. Oranges are a good source of folic acid. The papaya does supply some folic acid. None of these are sources of vitamin D. 3) CORRECT - Anticonvulsants can cause folate and vitamin D deficiencies. The client has symptoms reflective of anemia and bone resorption. Folate deficiency can cause anemia. Good sources of folate are green leafy vegetables, legumes, tomatoes, and various fruits such as oranges and cantaloupe. Good sources of vitamin D include fortified milk. Because vitamin D promotes calcium absorption, foods rich in this vitamin (e.g., kale) are also recommended. 4) INCORRECT - The spinach, soybeans, and pumpkin seeds are a good source of folate, but they do not address the client's vitamin D level

A client diagnosed with lung cancer gains 4.4 lb (2 kg) overnight and has a serum sodium of 122 mEq/L (122 mmol/L) and potassium of 4.5 mEq/L (4.5 mmol/L). Which intervention does the nurse expect to be prescribed for this client? 1.Desmopressin. 2.Furosemide 40 mg IV push. 3.Sodium polystyrene sulfonate. 4.IV normal saline to infuse at 125 mL/hr.

1) INCORRECT - Desmopressin is used to treat diabetes insipidus. 2) CORRECT— Lung cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH), which is an abnormal secretion of antidiuretic hormone. This health problem results in increased water absorption and dilutional hyponatremia. Diuretics are used to promote fluid loss. 3) INCORRECT - Sodium polystyrene sulfonate is used to treat hyperkalemia. The client 's potassium level is within normal limits of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). 4) INCORRECT - Fluids are restricted in the treatment of SIADH.

The nurse provides care for an older adult client diagnosed with type 1 diabetes mellitus and hypertension. The client will receive a CT scan with contrast. Which action does the nurse implement when providing care to this client? 1.Hydrate the client with a 1 L bolus of normal saline. 2.Monitor blood pressure before and after the procedure. 3.Instruct client to increase oral fluids before the procedure. 4.Question whether the scan must be done with the dye.

1) INCORRECT - Fluids are encouraged orally after the procedure. For an older adult client who is not severely dehydrated, 1000 mL of fluid intravenously would likely harm the client. 2) INCORRECT - Blood pressure monitoring is not necessary for a CT scan. 3) INCORRECT - The client's diet is nothing by mouth prior to a CT scan with contrast. 4) CORRECT - An older adult client has a decreased glomerular filtration rate as part of the normal aging process. In addition, hypertension and diabetes cause additional renal compromise. A CT scan with contrast may increase the risk for kidney damage.

he nurse counsels a client diagnosed with glaucoma. Which client statement demonstrates to the nurse that teaching is successful? 1."Because of glaucoma, the correction in my eyeglasses needs to be changed. " 2."I will schedule appointments with my physician early in the morning. " 3."I 'm glad that surgery can reverse the damage caused by the glaucoma. " 4."I will be happy when I don 't have to use the eye drops anymore. "

1) INCORRECT - Glaucoma is an obstruction of the outflow of aqueous humor, causing increased intraocular pressure (IOP) that causes permanent damage to the optic nerve. There is decreased visual acuity, but it cannot be corrected by eyeglasses. 2) CORRECT— Intraocular pressure (IOP) tends to be higher in the early morning hours. An early morning assessment is likely to be more accurate. 3) INCORRECT - Damage resulting from sustained increased pressure cannot be corrected with surgery. 4) INCORRECT - Glaucoma is a chronic health problem. Blindness can be prevented by lifelong treatment with eye drops.

The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take? 1.Assess for glucose in the urine. 2.Increase fluid intake. 3.Assess urine specific gravity. 4.Document the client's concerns.

1) INCORRECT - Glucose in the urine points to diabetes mellitus. Diabetes mellitus is not a complication of this procedure. 2) INCORRECT - Increased fluid intake will not address the problem. 3) CORRECT — After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency. 4) INCORRECT - This records but does not address the complication of the procedure.

The nurse provides care for a client after a renal biopsy. The client reports pain at the biopsy site that radiates to the front of the abdomen. Which complication does the nurse suspect the client is developing? 1.Infection. 2.Bleeding. 3.Renal colic. 4.Hypertension.

1) INCORRECT - It is too early in the postoperative period to see signs of infection. 2) CORRECT - Pain starting at the procedure site and radiating to the flank area and around to the front indicates bleeding. 3) INCORRECT - There is no data to indicate this condition. 4) INCORRECT - Considering the nature of the pain and what it indicates, hypotension is expected.

The nurse provides care for a client who is 24 hours postoperative after a ligation hemorrhoidectomy. Which finding most concerns the nurse? 1.The client reports severe pain in the anorectal area .2.The client experiences dizziness during a sitz bath. 3.The client's lower abdomen is enlarged and sounds dull on percussion. 4.The client states there are laxatives that will prevent further hemorrhoids.

1) INCORRECT - Pain caused by sphincter spasm after a hemorrhoidectomy is the most common postoperative problem. This does not present a physiological danger to the client. The nurse administers pain medication, encourages a side-lying position, places ice packs over the dressing until packing is removed, and assists with sitz baths to decrease pain. 2) INCORRECT - Feelings of faintness can occur as the moist heat of the sitz bath redirects blood to the rectal area. An ice bag on the head during the bath may prevent faintness feelings. Sitz baths should be taken three or four times per day beginning after 12 hours postoperation to manage pain. Since this is common and easily preventable or manageable and is a minor issue, this does not take priority. 3) CORRECT- An enlarged lower abdomen indicates probable urinary retention. After a hemorrhoidectomy, the client is monitored for urinary retention, which occurs because of the proximity of the bladder to the surgical site, which may be swollen. If untreated, an overly distended bladder can create stress on the suture site, resulting in hemorrhage. 4) INCORRECT - Stimulant laxatives are habit-forming and the nurse counsels the client to avoid these. Encourage a high-fiber, high-fluid diet to facilitate regular bowel patterns. Teaching is a lower priority than a physiological alteration, such as urinary retention.

During a home health visit, an older adult Asian American client reports nausea and anorexia since taking isoniazid for 4 months. Which action will the nurse take first? 1.Obtain a sputum specimen. 2.Inspect the hard palate. 3.Assess skin color on the abdomen. 4.Instruct the client to stop the medication.

1) INCORRECT - Since the client's complaints are gastrointestinal-related, the nurse must assess for signs of drug-induced hepatitis. 2) CORRECT - Due to biocultural skin variations, signs of early jaundice are best observed on the posterior hard palate in people of Asian descent. Even sclera may contain carotene pigments that mimic jaundice in Asian American clients. 3) INCORRECT - Asian American clients tend to have yellow undertones to the skin, making it difficult to identify early jaundice. 4) INCORRECT - The nurse needs to assess and validate the signs of hepatotoxicity before directing the client to alter the medication regimen.

The arterial blood gas (ABG) results of a client with diabetic ketoacidosis (DKA) are pH 7.2, PaCO2 35 mm Hg, HCO3 17 mEq/L, and PaO2 89 mm Hg. Which health care provider prescription requires the nurse to intervene? 1.Apply oxygen per nasal cannula at 2 L per minute. 2.Assess capillary glucose level every hour. 3.Give sodium bicarbonate, per prescription. 4.Repeat arterial blood gas (ABG) readings in 2 hours. View Explanation

1) INCORRECT - Supplemental oxygen will help improve oxygen saturation. 2) INCORRECT - Hourly capillary glucose measurements are indicated to monitor and trend blood glucose levels. 3) CORRECT- Sodium bicarbonate is only given if the pH is 6.9 or lower. 4) INCORRECT - Serial ABGs are necessary to trend acid-base imbalances.

The office nurse observes a student nurse assess the blood flow in a client with peripheral arterial disease using a Doppler ultrasound device. The nurse intervenes when which action is observed? 1.The student nurse holds the probe at a 45-degree angle to the artery being assessed. 2.The student nurse presses firmly while moving the probe proximal to distal. 3.The student nurse applies lukewarm gel over the vessel to be assessed. 4.The student nurse marks the pulse locations with a waterproof pen.

1) INCORRECT - The probe should be at a 45-degree angle for the best signals. 2) CORRECT - Pressing snugly or excessively can compress the artery, obliterating the blood flow and the signal. Direction of movement, if done, should be distal to proximal. 3) INCORRECT - Conductive gel is applied to the skin to decrease resistance to sound transmission and protect the crystals in the probe used to transmit and receive signals. Warming the gel is important because if the gel is cold, it can promote vasoconstriction, making it difficult to detect a signal. 4) INCORRECT - Marking the pulse location facilitates locating the pulses for repeated assessments.

The home care nurse visits a client diagnosed with Parkinson disease. The spouse reports that the client is losing weight even though it appears that the client has a good appetite at meals. Which action will the nurse first take? 1.Instruct the spouse to offer the client thick milkshakes. 2.Inform the spouse that this is to be expected. 3.Observe as the client feeds self. 4.Refer the client to the dietitian.

1) INCORRECT - The spouse may need to offer the client supplements to assist with weight gain. However, the nurse should first assess the client eating. 2) INCORRECT - This is not an expected finding. Although it may be difficult to maintain weight, the nurse should try to increase the client's caloric intake. 3) CORRECT— A client with Parkinson disease may struggle with feeding. The client may be dropping more food instead of eating it. The nurse should observe the client eat first and record the actual intake. After observing the client, additional interventions may be implemented. 4) INCORRECT - The nurse should observe the client eat first and record the actual intake. After observing the client, the nurse may decide to refer the client to a dietitian.

A client receiving treatment for a head injury requests pain medication for chronic back pain. Which response is the best for the nurse to make to personnel who question the client 's need for pain medication? 1."Your job is to report client requests to nursing personnel. Don 't interpret what the client is saying. " 2."I am surprised as well. There was no evidence of back pain when walking to the bathroom earlier this evening. " 3."Tell me exactly what the client said. In cases like this, careful documentation is important. " 4."Anxiety and fatigue are pain distracters. When they are reduced, the back pain returns. "

1) INCORRECT - There is no need to remind the staff of their role in client care. It is not necessary to admonish the staff for interpreting the client 's request. 2) INCORRECT - The nurse 's knowledge of the pain process should guide comments made to support personnel. Gossiping about clients is prohibited. The nurse should serve as a role model to other staff. 3) INCORRECT - The purpose of documentation is to communicate needs to other health care professionals. The nurse needs to talk directly to the client about the back pain before documenting. Writing down what others say a client says is hearsay. 4) CORRECT— The body does not respond to significant levels of pain in two different areas of the body at one time. Since the client has a head injury, it is likely that the chronic back pain was not acknowledged by the body or the head injury pain was so severe it overrode the amount of chronic back pain.

The home health nurse visits a client who has urinary incontinence following a prostatectomy. The client reports that he is changing incontinence pads every 2 hours. Which action by the nurse is appropriate? 1.Encourage the client to drink 1000 mL per day .2.Instruct the client to use artificial sweetener. 3.Instruct the client to do pelvic muscle strengthening exercises. 4.Administer terazosin 1 mg orally per day.

1) INCORRECT - There is no need to restrict fluids, and doing so will cause additional issues for the client. 2) INCORRECT - Artificial sweetener will irritate the bladder and may increase incontinence. 3) CORRECT - Performing pelvic muscle strengthening exercises several times a day is an appropriate action for incontinence. The exercises will improve bladder control. 4) INCORRECT - Terazosin is an alpha 1-adrenergic blocker that is used for treatment of benign prostatic hyperplasia (BPH). The client has had a prostatectomy. Therefore, this is not an appropriate treatment.

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client is most important for the nurse to pursue during the assessment process? 1."My grandfather had polio when he was young." 2."I have been a vegetarian for several months now." 3."Things have been stressful at work lately." 4."We have been in the final preparations for a trip overseas."

1) INCORRECT - These symptoms are not characteristic of polio. Furthermore, polio is an infectious disease, not an inherited condition. 2) INCORRECT - There may be some deficiencies in the diet if the client is not knowledgeable about how to select appropriate foods. However, vitamin deficiencies are unlikely to cause the symptoms being described. 3) INCORRECT - While a concern, this is not the most important statement for the nurse to evaluate. Stress can cause or exacerbate almost any symptoms, and psychologically, people sometimes develop conversion disorders to keep themselves away from the stressful situation. However, the nurse should first explore a physical cause of the symptoms. 4) CORRECT - This needs immediate further investigation. Immunizations may have been given in preparation for this trip and an immunization could trigger the onset of the neurologic symptoms of Guillain-Barré syndrome. The symptom onset in Guillain-Barré is usually abrupt and can progress rapidly. Symptoms often, but not always, progress in an ascending direction (from feet toward head). It is an emergency condition. The most immediate concern is potential respiratory compromise from respiratory muscle weakness.

The nurse instructs a client receiving digoxin and furosemide daily. Which client statement demonstrates to the nurse that teaching was effective? 1."I will eat alfalfa sprouts on my salad. " 2."I will eat more cabbage with my meals. " 3."I will eat half a grapefruit every morning. " 4."I will eat bananas every day. "

1) INCORRECT - This client is vulnerable to develop hypokalemia from digoxin and furosemide, and therefore should increase potassium in the diet. Alfalfa sprouts and lettuce are low in potassium and not good choices. 2) INCORRECT - The client at risk for hypokalemia should eat foods high in potassium. Cabbage is a vegetable low in potassium. High potassium vegetables include broccoli, spinach, and potatoes. 3) INCORRECT - The client at risk for hypokalemia should eat foods high in potassium, such as oranges and bananas. Grapefruits are low in potassium. 4) CORRECT— Bananas are high in potassium. Other fruits high in potassium include cantaloupe and oranges. This is the best client selection at risk for hypokalemia

The nurse prepares to obtain vital signs on a client. The client's previous blood pressure reading was 138/76 mm Hg and the client's pulse rate was 68 beats/minute. How long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? 1.45 to 60 seconds. 2.30 to 45 seconds. 3.10 to 20 seconds. 4.15 to 20 seconds.

1) INCORRECT - This is a longer period of time than is necessary for the client's blood pressure reading and not an appropriate related to the client's previous reading. 2) CORRECT - To ensure that the diastolic has been determined, the cuff shouldbe released slowly until the mid-60s mmHg for someone with the client'sprevious reading. Since the cuff should be deflated at a rate of 2 to 3 mm persecond, a range of 90 mmHg will require 30 to 45 seconds. 3) INCORRECT - This period of time is not enough to get an accurate reading for this client. 4) INCORRECT - This is not an adequate period of time to get an accurate reading for this client.

The nurse provides care for a client diagnosed with an acute episode of pancreatitis. Which observation causes the nurse to intervene? 1.An unlicensed assistive personnel (UAP) obtains daily intake and output. 2.The spouse assists the client to ambulate in the hall. 3.The LPN/LVN maintains nasogastric suctioning. 4.A nurse administers intravenous fentanyl.

1) INCORRECT - This is an appropriate action for the UAP. The nurse should assess intake and output, skin turgor, and mucous membranes to ensure that the client is not experiencing dehydration. 2) CORRECT— For the client with pancreatitis, bed rest is needed to decrease the metabolic rate and the secretion of pancreatic enzymes. 3) INCORRECT - This is an appropriate action. The client is kept NPO to decrease secretions, and nasogastric suctioning is used to remove gastric secretions and decrease abdominal distention. 4) INCORRECT - This is an appropriate action. Opiates are given for pain.

The nurse provides care for a child client with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease? 1.Hemoglobin level. 2.Hematocrit level. 3.White blood cell count. 4.Reticulocyte count.

1) INCORRECT - This value is decreased in sickle cell disease. 2) INCORRECT - This value is decreased in sickle cell disease. 3) INCORRECT - The white blood cell count is not impacted by sickle cell disease. 4) CORRECT - These counts are elevated in children diagnosed with sickle cell disease because the lifespan of their sickled red blood cells is shortened.

The nurse assesses a client receiving treatment for myxedema. Which observation indicates that treatment is effective? 1.Applies multiple layers of clothing. 2.Discusses the family finances with a spouse. 3.Is short of breath after climbing the stairs. 4.Takes medication every day as prescribed.

1) INCORRECT - Wearing multiple layers of clothing indicates the client is feeling excessively cold and hypothyroidism is not being effectively treated. 2) CORRECT— Hypothyroidism causes slowed mental functioning. Discussing financial affairs indicates improved thought processes and improvement in health status. 3) INCORRECT - Shortness of breath with activity is a manifestation of hypothyroidism. Treatment has not yet been effective. 4) INCORRECT - It is vital that the client takes the medication as prescribed, but this does not indicate that the client 's condition is improving.

The nurse reviews the documentation by a student nurse after a routine physical on a healthy adult. The nurse determines that the student nurse properly inspected the client's anterior chest if which entry is found in the client's chart? 1."Diaphragmatic excursion equal bilaterally measuring 4 cm." 2."Smooth, symmetrical chest expansion noted." 3."Vesicular breath sounds present over lung periphery." 4."Ribs with symmetric interspaces and 90-degree costal angle."

1) INCORRECT — Diaphragmatic excursion is percussed on posterior chest wall. 2) INCORRECT — Expansion is palpated over posterior chest wall. 3) INCORRECT — Vesicular breath sounds are auscultated on anterior, posterior, and lateral chest. 4) CORRECT — Inspection of the anterior chest includes shape and configuration of the chest, facial expression, level of consciousness, color and condition of skin, and quality of respirations.

The nurse provides care for a client who needs fluorescein angiography. Which client statement indicates to the nurse that further teaching is required? 1."I'll have to wear dark glasses for a while." 2."I may notice yellow staining of my skin, but it will disappear." 3."I will have to drink more fluids immediately after the test." 4."The test determines the amount of pressure within my eyes."

1) INCORRECT — Fluorescein is a dye administered IV, and fluorescein angiography is a series of photographs that detail the eye's circulation. The eyes are dilated with mydriatic eye drops before the exam. After the exam, the client should avoid direct sunlight until the eyes have returned to normal. 2) INCORRECT — Fluorescein is administered IV, and the dye does cause temporary staining of the skin. 3) INCORRECT — Drinking lots of fluids helps eliminate the dye. 4) CORRECT— Tonometry measures pressure in the eye. Fluorescein angiography measures circulation in the retina.

The nurse assesses a client, diagnosed with rheumatoid arthritis, for self-care readiness. Which activity does the nurse ask the client to perform? 1.Ascend and descend stairs. 2.Lace and tie both shoes. 3.Comb hair and brush teeth. 4.Walk without assistance.

1) INCORRECT — Stairs can be eliminated in the client's environment by installing a ramp. 2) INCORRECT — Inability to tie shoes is a modifiable problem with the use of slip-on or alternative fastener shoes. 3) CORRECT— Performing basic hygiene and grooming must be done daily to maintain overall health. If the client cannot do this, it indicates the need for daily home assistance. 4) INCORRECT — Though ideal, walking unassisted is not necessary for independence. A walker or wheelchair may be used.

A client receiving continuous enteral feedings is prescribed to receive medications through the NG tube. Which action will the nurse take when administering the medications to the client? 1.Flush the tube with 60 mL of warm sterile water after each medication. 2.Add the three medications directly to the enteral feeding. 3.Aspirate gastric contents to check that the pH value is greater than 6. 4.Clamp the tube for 30 minutes after administering the medications.

1) INCORRECT — The nurse should flush the tube with 15 to 30 mL of warm sterile water between each medication to keep the tube clear. Flushing with 60 mL each time could lead to fluid overload. 2) INCORRECT — The nurse should never add medications directly to the enteral feeding, as this would prevent the nurse from determining the actual time the client received the medication or if the client received all of the medication. 3) INCORRECT — The nurse should check the pH of the gastric contents to ensure it is less than 5, which indicates the tube is in the stomach. 4) CORRECT — The nurse should clamp the tube for 30 minutes after administering the medications to enhance absorption and prevent interactions with the enteral feeding.

The nurse plans care for an older adult client. Which intervention will best promote rest for this client? 1.Place a clock at the bedside. 2.Restrict visitors to reduce stimulation during the evening. 3.Instruct on how to call for help if needed. 4.Delay explaining the purpose of an upcoming diagnostic test.

1) INCORRECT- A clock at the bedside does not promote rest. It may assist with orienting to time. 2) INCORRECT- Restricting visitors does not promote rest. This might exacerbate feelings of isolation. 3) CORRECT- An older adult client who feels isolated and is unable to obtain help if needed cannot rest properly. Instructing on how to call for help will help the client relax. 4) INCORRECT- Delaying the explanation for an upcoming diagnostic test may help promote rest. However, instructing a client on how to call for help would be the priority.

A client with a previous history of transfusion-related acute lung injury (TRALI) requires another transfusion of red blood cells (RBCs). Which intervention will the nurse use to prevent a recurrence of TRALI? 1.Premedicate with intravenous diphenhydramine. 2.Transfuse the red blood cells over 4 hours. 3.Request for leukocyte-reduced red blood cells. 4.Give supplemental oxygen during the transfusion.

1) INCORRECT- Diphenhydramine is indicated for a mild allergic reaction and not for TRALI prevention. 2) INCORRECT- Transfusion over 4 hours will not reduce the risk for TRALI. The maximum transfusion time for RBCs is 4 hours. 3) CORRECT- The reaction of anti-leukocyte antibodies between donor and recipient leads to TRALI. Leukocyte-reduced RBCs reduces the risk of TRALI recurrence. 4) INCORRECT- Supplemental oxygen will not prevent TRALI, nor is it used routinely in a RBC transfusion.

During the nursing assessment, the nurse learns that the client takes garlic capsules daily. After completing the history, it is most important for the nurse to follow-up on which client information? 1.The client was diagnosed with hypertension recently. 2.The client takes regular insulin for type 1 diabetes mellitus. 3.The client is chief executive officer of a real estate company. 4.The client 's father died at age 42 of a myocardial infarction.

1) INCORRECT- Garlic is taken to regulate cholesterol and blood pressure. The side effects include heartburn, flatulence, and gastric irritation. 2) CORRECT- Garlic supplements can have a direct hypoglycemic effect and may potentiate the action of diabetic drugs. This information should be given to the health care provider. 3) INCORRECT- The job may add to the client's stress level. This is a teaching point for health modifications that may control both glucose and blood pressure. 4) INCORRECT- Genetic history is a non-modifiable risk factor for coronary artery disease. The client should control hypertension, maintain appropriate body weight, monitor fats in diet, reduce stress, exercise regularly, and report any shortness of breath, fatigue, or chest pain to the health care provider immediately.

The nurse on the neurology unit prepares a client for discharge after an exacerbation of multiple sclerosis. Which statement from the client to the nurse indicates that teaching is successful? 1."When I exercise, I push beyond feeling tired and then stop." 2."When my muscles are spastic, I will take a hot bath." 3."I will sleep on my stomach as much as I can." 4."I will be firm and steady when I stretch a spastic leg open."

1) INCORRECT- Overexertion must be avoided because it will cause fatigue and exacerbate symptoms. Exercises for muscle strengthening done to the point of fatigue can actually cause further paresis or weakness, numbness, and decreased coordination. 2) INCORRECT- Heat and humidity, whether environmental or from a hot bath or shower, can aggravate the fatigue. Fatigue can precipitate and/or intensify multiple sclerosis symptoms. 3) CORRECT- Sleeping prone may minimize spasm of the flexor muscles of the hips and knees of a person with multiple sclerosis. If these spasms are not relieved, joint contractures may occur. For the client who is unable to effectively reposition, prolonged periods of supine positioning increase the risk for developing pressure injury on the sacrum and hips. 4) INCORRECT- A spastic extremity should not be forced into an extended position. Instead, the spastic extremity should be gently rotated in the direction to which it is being drawn, and then gently rotated in the opposite direction. The rotations are repeated, incrementally increasing the degree of rotation with each repetition.

The nurse notes that a client receiving parenteral nutrition (PN) suddenly is dyspneic, diaphoretic, anxious, restless, coughing, and reporting chest pain. Which action does the nurse take first? 1.Take the client 's vital signs and auscultate heart and lung sounds. 2.Call for the crash cart and notify the health care provider. 3.Slow down the PN solution and administer insulin as prescribed. 4.Turn the client on the left side and lower the head of the bed.

1) INCORRECT- The current observations are sufficient to indicate probable pulmonary embolus, and corrective actions need to be implemented before further assessment. 2) INCORRECT- The crash cart may not be needed, and the health care provider (HCP) usually cannot be reached quickly enough to prevent death or disability in this type of emergency. 3) INCORRECT- The client is not showing symptoms of a hyperglycemic reaction to PN, such as headache, weakness, nausea, vomiting, dehydration, osmotic diuresis, or hypovolemic shock. These signs are similar to those for volume overload, but intravenous nutrition typically infuses at a very slow rate and would not precipitate pulmonary edema. 4) CORRECT- These symptoms indicate an air embolism, a central line -related complication that can occur from catheter insertion, tubing changes, or catheter breaking. The left lateral Trendelenburg position is essential to move air away from the pulmonary artery and into the apex of the heart. After changing the client's position, the nurse will obtain assistance and notify the HCP.

The wound care nurse assesses a group of clients. The nurse determines that which client is receiving appropriate care? (Select all that apply.) 1.The client 1 day post-operative after an appendectomy with a hydrogel dressing over the surgical site. 2.The client with necrotic areas on both heels covered by sterile gauze and tape. 3.The client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly. 4.The client with a spinal cord injury who has a non-blanching reddened area covered by a foam dressing. 5.The client whose poorly healing leg wound is being treated with a negative-pressure wound vacuum system. 6.The client with an infected wound that is covered with an alginate dressing changed every 3 days.

1) INCORRECT— A hydrogel dressing is not absorbent enough for a surgical incision. This client is not receiving appropriate care. 2) INCORRECT— Sterile gauze will not provide the debridement needed for necrotic wounds. This client is not receiving appropriate care. 3) CORRECT — A hydrocolloid dressing will maintain moisture and provide protection for a stage 3 wound. This client is receiving appropriate care. 4) CORRECT — A foam dressing will protect a stage 1 pressure injury. This client is receiving appropriate care. 5) CORRECT — A wound vac will increase blood flow and promote healing for a poorly healing wound. This client is receiving appropriate care. 6) INCORRECT— An infected wound will need to have the dressing changed more frequently than every 3 days. This client is not receiving appropriate care.

The nurse provides care for a client diagnosed with a detached retina. Which post-operative medication prescription does the nurse question? (Select all that apply.) 1.Droperidol .2.Polyethylene glycol 3350. 3.Morphine sulfate. 4.Benzonatate. 5.Hydromorphone. 6.Clonidine.

1) INCORRECT— Droperidol prevents vomiting, and therefore helps prevent increased intraocular pressure. 2) INCORRECT— Polyethylene glycol 3350 prevents constipation, thus preventing increased intraocular pressure. 3) CORRECT — Morphine sulfate can cause constipation, which should be avoided after repair of the retina. Non-narcotic pain relievers are used when possible. 4) INCORRECT— Benzonatate suppresses cough, thus preventing increased intraocular pressure. 5) CORRECT— Hydromorphone can cause constipation, which should be avoided after detached retina repair. 6) CORRECT— Clonidine can cause constipation, which should be avoided after detached retina repair.

A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L) and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.) 1.8 oz of regular soda. 2.Half cup of plain pasta. 3.Half cup of canned fruit. 4.2 teaspoons of sugar. 5.1 cup of whole milk. 6.125 mL of apple juice.

1) INCORRECT— Eight ounces of regular soda contain 26 grams of carbohydrates. 2) CORRECT— One-half cup of plain pasta contains 15 grams of carbohydrates. 3) CORRECT— One-half cup of canned fruit contains 15 grams of carbohydrates. 4) INCORRECT— Two teaspoons of sugar contain 8.5 grams of carbohydrates. 5) INCORRECT— One cup of whole milk contains 11 grams of carbohydrates. 6) CORRECT— Apple juice in the amount of 125 milliliters contains 15 grams of carbohydrates.

The nurse counsels an older client about peripheral vascular disease. Which client statement indicates that further teaching is needed? 1."I should not smoke since it makes my symptoms worse. " 2."I should exercise, even if it causes pain. " 3."I should use warm packs if my hands and feet get cold. " 4."I should stay inside during extreme weather. "

1) INCORRECT— Smoking causes vasoconstriction of extremity vessels. Emotional stress and caffeine also cause vasoconstriction. 2) INCORRECT— Exercise increases collateral circulation. The client should walk until pain begins, rest, and then walk a little farther. 3) CORRECT— Decreased sensitivity may result in burns. The client should be instructed to use gloves and socks to warm the hands and feet. Warm moist packs hold heat longer than warm packs and increase the risk for injury. 4) INCORRECT— In peripheral vascular disease, the body cannot adjust to temperature extremes. The client should be instructed to wear socks or insulated shoes at all times and keep the home warm

The nurse provides care for an African-American client diagnosed with hypertension in a cardiac unit. Which medication prescription does the nurse question for this client? 1.Hydralazine hydrochloride. 2.Atenolol. 3.Chlorothiazide. 4.Nifedipine.

1) INCORRECT— There is no need to question this prescription. Hydralazine is a direct vasodilator. It lowers blood pressure by relaxing the smooth muscles, especially of arteries and arterioles, and decreasing the peripheral resistance. 2) CORRECT — Atenolol is a beta-adrenergic inhibitor (beta blocker) that slows heart rate and decreases cardiac contractility and cardiac output, thereby lowering blood pressure. Beta blockers are less effective in African Americans than they are in Caucasians and should be questioned in an African-American client with hypertension. 3) INCORRECT— There is no need to question this prescription. Chlorothiazide is a thiazide diuretic. It promotes water and sodium excretion, thereby lowering blood pressure. Diuretics are especially effective with African-American clients. 4) INCORRECT— There is no need to question this prescription. Nifedipine is a calcium channel blocker. It stops calcium movement into the cells, thereby relaxing smooth muscle and causing vasodilation. Calcium channel blockers are particularly effective in older clients and in African-American clients.