Combo with "Med SURG"

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A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include? (Select all that apply.) 1. Take short, frequent breaths 2. Exhale with the mouth open wide 3. Perform the exercises twice a day 4. Place a hand on the abdomen while feeling it rise 5. Hold the breath for several seconds at the height of inspiration

4. Place a hand on the abdomen while feeling it rise 5. Hold the breath for several seconds at the height of inspiration

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to: 1. Check for bleeding in the lung 2. Monitor the function of the lung 3. Drain fluid from the pleural space 4. Remove air from the pleural space

4. Remove air from the pleural space

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? 1. Alleviate pain 2. Prevent infection 3. Replace blood loss 4. Restore fluid volume

4. Restore fluid volume

On the first day after a thyroidectomy, a client tolerates a full-liquid/fluid diet. When the diet is progressed to a soft diet the next day, the client complains of a sore throat when swallowing. How should the nurse respond?

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from:

A procedure performed at the hospital

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse?

"May I take a look at it?"

A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is:

"Tell me what your primary health care provider said about the graft procedure."

A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary?

"The fingertip is preferred for glucose monitoring if hyperglycemia is suspected."

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question?

"There is no difference between readings."

A health care provider prescribes oral loperamide (Maalox) and intravenous ranitidine (Zantac) for a client with burns and crushing injuries caused by an accident. The client asks how these medications work

"They limit acidity in the gastrointestinal tract."

After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response?

"Tube feedings promote healing by reducing the risk for infection."

A client with recently diagnosed diabetes states, "I feel bad. My spouse and I do not get along. It seems as though my spouse doesn't care about my diabetes." The nurse's most appropriate response is:

"You are unhappy. I wonder—have you tried to talk to your spouse?"

A client in thyroid storm tells the nurse, "I know I'm going to die. I'm very sick." What is the nurse's best response?

-"You must feel very sick and frightened."

A client is scheduled for an adrenalectomy. Which nursing intervention should the nurse anticipate will be prescribed for this client?

-Administer intravenous (IV) steroids.

-Administer prescribed analgesics before meals

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

-Apply a precut dressing around the insertion site with the flaps pointing upward. To prevent unraveling and potential aspiration into the airway, only a precut dressing should be used around the site. It should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula.

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other client has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes:

-Complications are not present at the time of diagnosis.

A client's respiratory status may be affected after abdominal surgery. The nurse documents the behavioral objective for this client. What statement is a behavioral objective?

-Demonstrates the technique of coughing and deep breathing

-Despite steroid therapy, the ability to cope with stress will be decreased

A client newly diagnosed as having type 1 diabetes is taught to exercise on a regular basis primarily because exercise has been shown to:

-Improve the cellular uptake of glucose Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise.

A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight?

-Obesity leads to insulin resistance

A client with type 1 diabetes self-administers NPH insulin (Novolin N) every morning at 8:00 AM. The nurse concludes that the client understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between:

A female client who is scheduled for a thyroidectomy is concerned that the surgery will interfere with her ability to become pregnant. The nurse should base a response on the understanding that:

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?

A nurse is caring for a client who has a 20-year history of type 2 diabetes. The nurse should assess for what physiological changes that are associated with a long history of diabetes?

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? 1 Checking the client's serum glucose level 2 Assisting the client out of bed into a chair 3 Placing the client in the high-Fowler position 4 Ensuring the client's residual limb is elevated

1 Checking the client's serum glucose level

Which client statement indicates to the nurse that a client who is receiving cyanocobalamin (vitamin B12) therapy for an intrinsic factor deficiency understands the treatment? 1 "I should have a vitamin B12 injection every month." 2 "I'll take my B12 vitamin every morning with my breakfast." 3 "I'll have a salad every day because Vitamin B12 is in green vegetables." 4 "I should feel better because my vitamin B12 treatments will improve my aplastic anemia."

1 "I should have a vitamin B12 injection every month." Vitamin B12 is administered via injection on a weekly or monthly basis. Vitamin B12 is destroyed by stomach acid and therefore cannot be taken in pill form. Green vegetables are not an important source of vitamin B12. Vitamin B12 is found primarily in meat, fish, poultry, and eggs. Vitamin B12 is prescribed for pernicious, not aplastic, anemia.

A client hospitalized with a severe myocardial infarction tells the nurse, "My life is over. I may as well just give up." What is the best response by the nurse? 1 "You feel your life is over?" 2 "Have you nothing to live for?" 3 "We are not going to let you die." 4 "Everything will be fine. Do not worry."

1 "You feel your life is over?"

Immediately after cataract surgery a client complains of feeling nauseated. The nurse should: 1 Administer the prescribed antiemetic 2 Provide some dry crackers to eat 3 Explain that this is expected after surgery 4 Encourage deep breathing until the nausea subsides

1 Administer the prescribed antiemetic

A client who had a brain attack (CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as: 1 Anomia 2 Apraxia 3 Dysarthria 4 Dysphagia

1 Anomia Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have a speech problem.

A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, the nurse should encourage the client to: 1 Assume a standing position for voiding 2 Void every four hours and attempt to hold urine between set times 3 Attempt to void more frequently in the afternoon than in the morning 4 Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake

1 Assume a standing position for voiding

client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include: 1 Blurred vision along with episodes of vertigo 2 Tremors of the hands when attempting to lift objects 3 Partial improvement of muscle strength with mild exercise 4 Involvement of the distal muscles rather than the proximal muscles

1 Blurred vision along with episodes of vertigo

A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability? 1 Cola drinks 2 Amino acids 3 Rice products 4 Sugar products

1 Cola drinks

A client with rheumatoid arthritis arrives in the clinic stating, "I don't take any medications because they are too expensive." The client reports that family members are arranging for the medications to be obtained from another country. What is the nurse's best response? 1 Discuss alternative solutions with the client 2 Encourage the client to use any method possible to obtain the medications 3 Contact the primary health care provider immediately to discuss the client's plan 4 Explain that medical regimens must be followed to continue to receive care in the clinic

1 Discuss alternative solutions with the client The nurse should discuss alternatives in terms of funding, such as Medicaid, research projects, and special aid.

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? 1 Exercise daily 2 Read in bed before sleeping 3 Avoid naps during the daytime 4 Have a hot cup of tea at bedtime

1 Exercise daily

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? 1 Hemorrhage 2 Gastroparesis 3 Pulmonary embolism 4 Tension pneumothorax

1 Hemorrhage

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. The nurse concludes that the most likely cause of this client's ascites is: 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion

1 Impaired portal venous return

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. A nursing priority is to: 1 Institute fall prevention/safety measures 2 Monitor respiratory status 3 Measure abdominal girth daily 4 Test stool specimens for blood

1 Institute fall prevention/safety measures

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? 1 Panic 2 Coma 3 Euphoria 4 Depression

1 Panic

A client who recently has had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." The nurse identifies that the client is using the defense mechanism known as: 1 Projection 2 Sublimation 3 Compensation 4 Intellectualization

1 Projection

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of: 1 Pruritus 2 Diarrhea 3 Blurred vision 4 Bleeding gums

1 Pruritus Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.

A client has surgery to repair a bladder laceration. The nursing intervention that takes priority in the postoperative care of this client is: 1 Repositioning frequently 2 Giving lower back care 3 Implementing range-of-motion (ROM) exercises 4 Providing teaching related to incision care

1 Repositioning frequently

A client with cholecystitis is placed on a low fat, high protein diet. What nutrient should the nurse teach the client is included with this diet? 1 Skim milk 2 Boiled beef 3 Poached eggs 4 Steamed broccoli

1 Skim milk During acute cholecystitis, low-fat liquids are permitted; skim milk is low in fat and contains protein, which eventually will promote healing. Beef, even if it is lean, contains fat. Egg yolks contain fat. Although low in fat, broccoli does not contain protein; in addition, it is a gas-producing vegetable that should be avoided at this time.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? 1 Use standard precautions. 2 Employ airborne precautions. 3 Plan interventions to limit direct contact. 4 Discourage long visits from family members.

1 Use standard precautions.

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? (Select all that apply.) 1 Anemia 2 Dyspnea 3 Jaundice 4 Anasarca 5 Hyperexcitability

1 Anemia 2 Dyspnea 4 Anasarca (extreme generalized edema)

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? (Select all that apply.) 1 Avoid intramuscular injections. 2 Institute neutropenic precautions. 3 Monitor the white blood cell count. 4 administer prescribed anticoagulants. 5 Examine the skin for ecchymotic areas

1 Avoid intramuscular injections 5 Examine the skin for ecchymotic Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrompbocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? (Select all that apply.) 1 Celery sticks 2 Ground beef 3 Fresh salmon 4 Luncheon meat 5 Cooked broccoli

1 Celery sticks 4 Luncheon meat Celery sticks are high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Beef is lower in sodium than are preserved meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Broccoli does not have significant sodium levels.

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? (Select all that apply.) 1 Decreased urine 2 Hypotension 3 Dyspnea 4 Dry mucous membranes 5 Pulmonary edema 6 Poor skin turgor

1 Decreased urine 2 Hypotension 4 Dry mucous membranes 6 Poor skin turgor Lowered urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and pulmonary edema may be caused by fluid overload.

A client with acute renal failure moves into the diuretic phase after one week of therapy. For which signs during this phase should the nurse assess the client? (Select all that apply.) 1 Dehydration 2 Hypovolemia 3 Hyperkalemia 4 Metabolic acidosis 5 Skin rash

1 Dehydration 2 Hypovolemia In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; dehydration will occur unless fluids are replaced. In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; hypovolemia may occur, and fluids should be replaced.

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? (Select all that apply.) 1 Dependent rubor 2 Warm extremities 3 Ulcers on the toes 4 Thick, hardened skin 5 Delayed capillary refill

1 Dependent rubor 3 Ulcers on the toes 5 Delayed capillary refill Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill greater than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease. 26%of students nationwide answered this question correctly.

A nurse is assessing a client for dehydration, The client has had diarrhea and vomiting for 48 hours. What are indicators of dehydration? (Select all that apply.) 1 Headache 2 Protruding eyeballs 3 The client reporting drinking an average of two glasses of water daily 4 The skin on the client's forehead remains tented after being pinched 5 Within four days, the client lost two pounds of weight

1 Headache 4 The skin on the client's forehead remains tented after being pinched Headache is an indicator of dehydration. To determine dehydration in the adult the nurse should test for decreased skin turgor . To assess for dehydration, pinch the skin over a bone with little or no underlying fat, such as the sternum, forehead, or pelvis. If the skin remains tented after it is released, the client is dehydrated. The eyeballs may be sunken, not protruding, in the presence of dehydration. Asking the client how many glasses of fluid are ingested daily does not evaluate the client's physical status in relation to dehydration. A weight loss of two pounds does not indicate dehydration.

When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client: 1 Passes flatus 2 Has a large formed bowel movement 3 Tolerates clear liquids 4 Has a bowel movement of any size and consistency

1 Passes flatus Passing flatus is the first sign of peristaltic activity, reflecting that intestinal contents are being propelled through the alimentary tract, causing characteristic sounds. Liquids should not be given until bowel sounds have returned. Passing flatus indicates peristaltic movement, not the formation of bowel movements.

A nurse advises a client receiving furosemide (Lasix) to increase potassium intake. Which fruit should the nurse encourage the client to eat? (Select all that apply.) 1 Prune 2 Apple 3 Banana 4 Pineapple 5 Tangerine

1 Prune 3 Banana

A client had thoracic surgery. The nurse should monitor for what clinical manifestations that may indicate acute pulmonary edema? Select all that apply. 1 . Crackles 2 . Cyanosis 3 . Dyspnea 4 . Bradypnea 5 . Frothy sputum

1 . Crackles 2 . Cyanosis 3 . Dyspnea 5 . Frothy sputum

A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of: 1. Autoimmunity." 2. Ocular motility." 3. Increased amino acid metabolism." 4. Defective sebaceous gland formation."

1 Autoimmunity."

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is: 1. Negligent and can be sued for malpractice 2. Practicing under guidelines of the nurse practice act 3. Protected for these actions, in most states, by Good Samaritan legislation 4. Treating a health problem that can and should be addressed by a primary health care provider

1 Negligent and can be sued for malpractice

During a routine examination, an enlarged thyroid gland is discovered in a client, and hyperthyroidism is suspected. What clinical findings should the nurse expect to identify when completing a nursing admission history and physical for this client? (Select all that apply.)

1,2

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? (Select all that apply.)

1,2, 5

While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? (Select all that apply.)

1,2,4

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? (Select all that apply.)

1. Cool Skin 3. Constipation 4. Periorbital edema 5. Decreased appetite

A client with diabetes states, "I cannot eat big meals; I prefer to snack throughout the day." What information should the nurse include in a response to this client's statement?

1. Regulated food intake is basic to control.

A nurse is preparing to administer insulin to a client with diabetes. In which order should the nurse perform the actions associated with insulin administration?

1. Wash hands with soup and water 2. Rotate the vial of insulin between the palms of the hands. 3. Wipe the top of the insulin vial with an alcohol swab 4. Instill air into the vial of insulin equal to the desired dose 5. Withdraw the correct amount of insulin from the inverted vial

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? (Select all that apply.) 1.Dry cough 2. Chest pain 3. Hemoptysis 4. Shortness of breath 5 . Fever greater than 100.4° F

1.Dry cough 4. Shortness of breath 5 . Fever greater than 100.4° F

12 PM and 8 PM." NPH insulin's onset of action is 1.5 to 4 hours, peak action is 4 to 12 hours, and duration of action is 18 to 24 hours; if hypoglycemia occurs, it will happen most likely between 12 PM and 8 PM.

A client is scheduled for an adrenalectomy. The nurse expects that the plan of care will include:

A client is admitted to the postanesthesia care unit after surgery and electronic blood pressure monitoring is to be performed. The nurse should assess the client's blood pressure every: 1 3 to 5 minutes 2 10 to 15 minutes 3 20 to 30 minutes 4 40 to 60 minutes

2 10 to 15 minutes

Megadoses of vitamin A are taken by a client. Why should the nurse question this practice? 1 Vitamin A is highly toxic, even in small amounts. 2 The liver has a great storage capacity for vitamin A, even to toxic amounts. 3 Vitamin A cannot be stored; therefore excess amounts will saturate the general body tissues. 4 Although the body's requirement for vitamin A is great, the cells can synthesize more as needed.

2 The liver has a great storage capacity for vitamin A, even to toxic amounts.

The nurse determines that which genitourinary factor contributes to urinary incontinence in older adults? 1 Sensory deprivation 2 Urinary tract infection 3 Frequent use of diuretics 4 Inaccessibility of a bathroom

2 Urinary tract infection

A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? (Select all that apply.) 1 Thirst 2 Anorexia 3 Leg cramps 4 Rapid, thready pulse 5 Dry mucous membranes

2 Anorexia 3 Leg cramps

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? (Select all that apply.) 1 Eggs 2 Liver 3 Cheese 4 Salmon 5 Shellfish

2 Liver 5 Shellfish Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are high-purine foods and should be avoided. Eggs have insignificant amounts of purine and are unrestricted. Cheese has insignificant amounts of purine and is unrestricted. Foods that contain a moderate amount of purine (50 to 150 mg/dL), such as salmon, may be eaten four times a week.

A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit? (Select all that apply.) 1 Polyuria 2 Paresthesias 3 Hypertension 4 Metabolic alkalosis 5 Widening pulse pressure

2 Paresthesias 3 Hypertension Paresthesias occur as a result of excess nitrogenous wastes, altered fluid and electrolyte balance, and altered regulatory functions. Nonfunctioning kidneys cause fluid retention that may result in hypervolemia and hypertension.

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? (Select all that apply.) 1 Diabetes insipidus 2 Profuse diaphoresis 3 Excess sodium intake 4 Removal of the parathyroid glands 5 Rapid IV infusion of 5% dextrose in water

2 Profuse diaphoresis 5 Rapid IV infusion of 5% dextrose in water

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? 1 Monitoring vital signs and encouraging a vigorous aerobic exercise program. 2 Taking the apical pulse before drug administration and teaching the client how to count the pulse. 3 Contacting Social Services for a home health nursing consultation. 4 Providing written material on the adverse effects of the medication.

2 Taking the apical pulse before drug administration and teaching the client how to count the pulse.

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1. Oral 2. Topical 3. Intravenous 4. Intramuscular

2 Topical

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if: 1. Blisters appear 2. Urinary output decreases 3. Edema and redness occur 4. Low-grade fever develops

2 Urinary output decreases

A client with type 1 diabetes self-administers Novolin N insulin every morning at 8 AM. The nurse evaluates that the client understands the action of the insulin when the client says, "I should be alert for signs of hypoglycemia between:

2 pm and 8 pm."

A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client? 1. Fluid volume 2. Skin integrity 3. Physical mobility 4. Urinary elimination

2. Skin integrity

A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? (Select all that apply.)

3. Weakness 4. Nervousness 6. Increased perspiration

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force?

30 degrees

A client is scheduled for a bilateral adrenalectomy. Before surgery, steroids are administered to the client. What does the nurse determine is the reason for the steroids?

A client who has type 1 diabetes is admitted to the hospital for major surgery. Before surgery the client's insulin requirements are elevated but well controlled. Postoperatively, the nurse anticipates that the client's insulin requirements will:

A client just had a suprapubic prostatectomy. Which action should the nurse implement to prevent a secondary bladder infection? 1 Observe for signs of uremia 2 Attach the catheter to suction 3 Clamp off the connecting tube 4 Change the dressings frequently

4 Change the dressings frequently After a suprapubic prostatectomy, leakage of urine generally is identified around the suprapubic tube; this creates an environment in which bacteria can flourish if the dressing is not changed frequently

A health care provider prescribes an upper gastrointestinal (GI) series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium: 1 Gives off visible light, illuminating the alimentary tract." 2 Provides fluorescence, thereby lighting up the alimentary tract." 3 Dyes the structures of the alimentary tract, making them more visible." 4 Gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."

4 Gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays." Barium salts used in a GI series and barium enemas coat the inner lining of the GI tract and then absorb x-rays passing through. Thus, they outline the surface features of the tract on a photographic plate. Barium has no light-emitting properties. Barium does not fluoresce. Barium does not have the properties of a dye.

A nurse is collecting a health history from a client who has a diagnosis of cancer of the tongue. For which risk factor commonly associated with cancer of the tongue should the nurse assess when collecting the client's history? 1 Nail biting 2 Poor dental habits 3 Frequent gum chewing 4 Large consumption of alcohol

4 Large consumption of alcohol A large amount of alcohol ingestion predisposes an individual to the development of oral cancer because it is a mucosal irritant. Nail biting, poor dental habits, and frequent gum chewing have no effect on the development of oral cancer.

A client who recently experienced a brain attack (CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? 1 Presence of distention 2 Extent of weight gained 3 Amount of high-fiber food consumed 4 Length of time this problem has existed

4 Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium (Colace) daily. Before discharge, the nurse teaches the client that an intermittent side effect of this medication may be: 1 Rectal bleeding 2 Fecal impaction 3 Nausea and vomiting 4 Mild abdominal cramping

4 Mild abdominal cramping

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused as to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority? 1 Moving the client as little as possible 2 Preparing the client for mannitol administration 3 Stimulating the client to maintain responsiveness 4 Monitoring the client for increasing intracranial pressure

4 Monitoring the client for increasing intracranial pressure

A nurse is providing postoperative care for a client who just had a thyroidectomy. For what response should the nurse assess the client when concerned about the potential risk of thyrotoxic crisis? 1 Elevated serum calcium 2 Sudden drop in pulse rate 3 Hypothermia and dry skin 4 Rapid heartbeat and tremors

4 Rapid heartbeat and tremors

A nurse is caring for a client with glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks? 1 Take showers instead of tub baths. 2 Continue the same restrictions on fluid intake. 3 Avoid situations that involve physical activity. 4 Seek early treatment for respiratory tract infections.

4 Seek early treatment for respiratory tract infections. Hemolytic streptococci, common in throat infections, can initiate an immune reaction that damages the glomeruli.

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1 Froot Loops 2 Corn Flakes 3 Cap'n Crunch 4 Shredded Wheat

4 Shredded Wheat

The nurse should ask the client with secondary syphilis about sexual contacts during the past: 1 21 days 2 30 days 3 Three months 4 Six months

4 Six months The client is in the secondary stage, which begins from six weeks to six months after primary contact; therefore, a six-month history is needed to ensure that all possible contacts are located. Any time less than six months may miss contacts that may have become infected.

A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain most likely will remain contaminated with the hepatitis A virus after being cooked? 1 Canned tuna 2 Broiled shrimp 3 Baked haddock 4 Steamed lobster

4 Steamed lobster The temperature during steaming is never high enough or sustained long enough to kill microorganisms. Processing destroys the virus. Because of the extremely high temperature, broiling sufficiently destroys the virus. Baking will destroy the virus.

The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action? 1 Notify the blood bank 2 Notify the health care provider 3 Reduce the rate of the blood transfusion 4 Stop the blood and infuse normal saline

4 Stop the blood and infuse normal saline

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The health care provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client? 1 Protein enzymes 2 Energy carbohydrates 3 Vitamins and minerals 4 Water and electrolytes

4 Water and electrolytes

A nurse caring for a client who has gastroesophageal reflux disease (GERD) should place the client in what position in the illustration? 1 a 2 b 3 c 4 d

4 d The reverse Trendelenburg position uses gravity to help keep gastric contents in the stomach, thereby minimizing reflux of gastric contents into the esophagus. The high-Fowler position promotes lung expansion; it is used when the client eats in bed and when the nurse suctions secretions from the client's respiratory tract. The client can slide down lower in bed while in the semi-Fowler position, which puts undue stress on the stomach, contributing to reflux. The flat position may permit the flow of gastric contents through the cardiac sphincter into the esophagus, contributing to GERD and increasing the risk of aspiration.

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. The nurse evaluates that the teaching was effective when the client says, "I should: 1 Massage my feet and legs with oil or lotion." 2 Apply heat intermittently to my feet and legs." 3 Eat foods high in protein and carbohydrate kilocalories." 4 Control my blood glucose with diet, exercise, and medication."

4 Control my blood glucose with diet, exercise, and medication."

The nurse is providing immediate postoperative care to a client who had a thyroidectomy. The nurse should monitor the client for which clinical manifestation? 1 Urinary retention 2 Signs of restlessness 3 Decreased blood pressure 4 Signs of respiratory obstruction

4 Signs of respiratory obstruction

A client has been receiving digoxin (Lanoxin). The client calls the clinic and complains of "yellow vision." What is the nurse's best response? 1 "This is related to your illness rather than to your medication." 2 "Take the medication because this is not a serious side effect." 3 "This side effect is only temporary. You should continue the medication." 4 "The medication should be discontinued. Come to the clinic this afternoon."

4 "The medication should be discontinued. Come to the clinic this afternoon."

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? 1 Levin 2 Salem sump 3 Miller-Abbott 4 Blakemore-Sengstaken

4 Blakemore-Sengstaken Blakemore-Sengstaken includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. A Miller-Abbott tube is used for intestinal decompression.

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. For what clinical manifestations should the nurse assess this client? (Select all that apply.)

4 Cardiac dysrhythmias 5 Hypoactive bowel sounds

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? (Select all that apply.) 1 Obesity 2 Smoking 3 Hypertension 4 Diabetes mellitus 5 Low levels of high-density lipoprotein (HDL) cholesterol

4 Diabetes mellitus 5 Low levels of high-density lipoprotein (HDL) cholesterol Diabetes is twice as strong a predictor of coronary heart disease in women as in men; diabetes cancels the cardiac protection that estrogen provides to premenopausal women. A low level of HDL-C (less than 35 mg/dL) has a greater bearing on coronary heart disease in women than in men and is the most important lipid factor in women; the significance of this is unclear. Obesity, smoking, and hypertension are risk factors common to both women and men

A client expresses concern about insomnia and asks, "What I can do to get better sleep?" What activities should the nurse recommend? (Select all that apply.) 1 Drink a glass of wine 2 Engage in mild exercise before bedtime 3 Eat foods containing lysine 4 Follow the same bedtime ritual each night 5 Perform deep-breathing exercises

4 Follow the same bedtime ritual each night 5 Perform deep-breathing exercises

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client?

4 Hypernatremia

4,5

A nurse is preparing to insert a nasogastric tube. During insertion, which response indicates that the client is experiencing difficulty? 1. Gagging 2. Discomfort 3. Flushed face 4. Inability to speak

4. Inability to speak

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. The nurse concludes that the altered blood levels are caused by: 1. Increased leukocyte development in response to infection 2. Decreased extracellular fluid volume secondary to infection 3. Decreased red blood cell proliferation because of hypercapnia 4. Increased erythrocyte production as a result of chronic hypoxia

4. Increased erythrocyte production as a result of chronic hypoxia *Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit.

On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first?

Administer analgesics as prescribed before meals. Analgesics as prescribed will reduce soreness during meals. Reordering the full-fluid diet is not within the legal role of the nurse. Soreness is to be expected;

A client with burns is to receive the exposure method of treatment with application of mafenide (Sulfamylon) twice a day. With this type of treatment the nurse plans to:

Administer prescribed pain medication

A client had a thyroidectomy. The nurse monitors for thyrotoxic crisis, which is evidenced by:

An increased temperature and pulse rate

A client is scheduled for surgery. Legally, the client may not sign the operative consent if:

Any sedative type of medication has been given recently

A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. The first nursing action is to:

Assess the client's injury, vital signs, and past history

During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to:

Assess the person's breathing

A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of:

Autoimmunity.

A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of

Autoimmunity."

The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?

Blistered and wet

For which client response should the nurse monitor when assessing for complications of hyperparathyroidism?

Bone pain

A nurse is planning to teach facts about hyperglycemia to a client with the diagnosis of diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?

Breakdown of fat stores for energy; In the absence of insulin , which facilitates the transport of glucose into cells, the body breaks down proteins and fats to supply energy; ketones, a by-product of fat metabolism, accumulate, causing metabolic acidosis (pH below 7.35)

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe?

Calcium

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? Correct 1 Cardiac problems 2 Joint inflammation Incorrect 3 Kidney dysfunction 4 Peripheral neuropathy

Cardiac problems

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to:

Clean the mouth with a soft toothbrush or a gentle spray

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the:

Client is able to self-administer pain-relieving drugs as necessary

Cool, moist towels

A health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do?

Correct 2 Schedule the client for an appointment

A client with hyperthyroidism refuses radioactive iodine therapy and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription?

Drugs to increase the blood pressure

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled?

Enucleation

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). The nurse includes measures to increase arterial blood flow to the extremities, including:

Exercises that promote muscular activity

Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

A client has a glycosylated hemoglobin measurement of 6%. What should the nurse conclude about this client when planning a teaching plan based on the results of this laboratory test?

Has followed the treatment plan as prescribed; The expected range of glycosylated hemoglobin (HbA1c ) is 4.4% to 6.4%. A value of 6% is within the expected range. Glycosylated hemoglobin measures the average blood glucose level for the 90- to 120-day period before the blood sample is collected; thus, it is a reliable way to measure adherence to a therapy plan of insulin, diet, and exercise

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?

Highly contagious

When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is:

Hoarse quality to the voice

During the first 48 hours after a client has sustained a thermal injury, the nurse should assess for:

Hyperkalemia and hyponatremia

During the first 48 hours after a thermal injury, the nurse should assess the client for

Hyperkalemia and hyponatremia

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client?

Hypernatremia

A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses?

Hyperplasia of the adrenal cortex

At 4:30 PM, a client who is receiving human insulin (Humulin N) every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?

Hypoglycemia

A nurse is caring for a client who was admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

Hypoglycemia and hypotension

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse expects that manifestations of excessive levels of antidiuretic hormone are:

Hyponatremia and decreased urine output

A client is diagnosed as having type 2 diabetes. A priority teaching goal is, "The client will be able to:

Identify pending hypoglycemia or hyperglycemia. Knowledge of the signs and treatment for hypoglycemia or hyperglycemia is critical to client health and well-being and essential for survival.

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

Increased serum lipids; With diabetic ketoacidosis serum lipid levels are high because of the increased breakdown of fat. Serum lipid levels can go so high that the serum appears opalescent and creamy.

A client with diabetes asks how exercise will affect insulin and dietary needs. The nurse should respond, "Exercise:

Increases the need for carbohydrates and decreases the need for insulin."

An client who is obese must self-administer insulin using an insulin syringe. The technique that the nurse teaches the client to use is to:

Inject at a 90-degree angle

Inspect the incision for healing when I change the dressing."

A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends

Meatloaf and strawberries

A client with type 2 diabetes develops gout, and allopurinol (Zyloprim) is prescribed. The client is also taking metformin (Glucophage) and an over-the-counter nonsteroidal anti-inflammatory drug (NSAID). When teaching about the administration of allopurinol, what should the nurse instruct the client to do?

Monitor blood glucose levels more frequently.

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client?

NPH insulin (Novolin N)

Negligent and can be sued for malpractice

A client weighed 210 pounds on admission to the hospital. After two days of diuretic therapy, the client weighs 205.5 pounds. How many liters of fluid has the client excreted? Record the answer using a whole number. Record your answer using a whole number. __________ liters

One liter of fluid weighs approximately 2.2 pounds; therefore, a 4.5-pound weight loss equals approximately 2 liters.

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. The nurse concludes that the most probable reason for the noncompliance is that during the exercises:

Pain at the incision site increases

A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. The primary cause of the client's ascites is a decrease in:

Plasma protein to maintain adequate capillary-tissue circulation -Malnutrition and liver damage lead to a reduced serum albumin level and failure of the capillary fluid shift mechanism, resulting in ascites.

A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the:

Plasma proteins moving out of the intravascular compartment

A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? (Select all that apply.)

Polyuria and Polydipsia

Clients are encouraged to perform deep-breathing exercises after most types of surgery. The nurse teaches clients that the reason for these exercises is to help:

Prevent the buildup of carbon dioxide in the body Retention of carbon dioxide in the blood lowers the pH, causing respiratory acidosis; deep breathing maximizes gaseous exchange, ridding the body of excess carbon dioxide. Deep breathing improves oxygenation of the blood, but it does not stimulate red blood cell production. Although regular deep breathing improves the vital capacity of the lungs, residual volume is unaffected. Deep breathing increases, not decreases, the partial pressure of oxygen.

A nurse is providing postoperative care for a client who just had a thyroidectomy. For what response should the nurse assess the client when concerned about the potential risk of thyrotoxic crisis?

Rapid heartbeat and tremors; Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition.

After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to:

Reduce inflammation at the surgical site

A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, the nurse should teach the client to:

Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone

The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1 Drink 8 ounces of water 2 Take a walk for 30 minutes 3 Lie down for at least 20 minutes 4 Rest in a sitting position for one hour

Rest in a sitting position for one hour

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?

Retention of sodium and water

The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because the:

Second client's incision will take longer to heal

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). The nurse determines that this concept is understood when the client chooses eight ounces of:

Skim milk Skim milk contains about 12 grams of CHO per cup. There are about 30 grams CHO in 1 cup of apple juice. There are about 16 grams CHO in 1 cup of nonfat yogurt. There are about 25 grams CHO in 1 cup of orange juice

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances?

Spinach and mangoes

An obese client must self-administer insulin at home. The nurse should teach the client to use what technique?

Spread the tissue and inject at a 90-degree angle

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery?

Stable vital signs

A client newly diagnosed with type 2 diabetes is receiving glyburide (Micronase) and asks the nurse how this drug works. The nurse explains that glyburide:

Stimulates the pancreas to produce insulin

A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first?

Stop infusion

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infectious processes does the nurse conclude is impaired as a result of this disease?

Stress response; Because of diminished glucocorticoid production, there is a decreased response to stress, reducing the ability to fight an infectious process.

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking?

Suggest that the client limit smoking to one pack of cigarettes a day

Tell me what your primary health care provider said about the graft procedure."

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. What is an appropriate nursing response?

The epidermis is damaged

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines. Record your answer using one decimal place. ________%

The front of the head is 4.5%, and the anterior torso is 18%, for a total of 22.5%.

A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for an aneurysm in the left femoral artery. Mark the site of the pulse that should be assessed to determine maximum arterial perfusion distal to the operative site.

The pulse most distal to the graft should be assessed first to determine adequacy of circulation. The pedal pulse is located on the top of the foot and is the most distal peripheral pulse.

A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma asks the nurse what will happen if surgery is not performed. On what information should the nurse base a response?

The tumor must be removed to prevent heart and kidney damage.

A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?

Topical application of steroids

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?

Before administering preoperative medication to a client, the nurse plans to:

Verify the consent

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

Yellow

A client with diabetes asks how exercise will affect insulin and dietary needs. The nurse should respond, "Exercise:

What should the nurse do when collecting a 24-hour urine specimen?

The nurse identifies that the dietary teaching provided for a client with diabetes is understood when the client states, "My diet:

Can be planned around a wide variety of commonly used foods."

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. The nurse evaluates that the teaching was effective when the client says, "I should:

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe?

Scaly lesions, Pruritic lesions, Reddened papules

A nurse is caring for a postoperative client who has diabetes. Which is the most common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client?

Presence of infection

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which plan reported by the client supports the nurse's conclusion that the teaching was effective?

"Avoid using a sleeping mask at night.

"Can you tell me why you decided to refuse the procedure?"

A client with type 2 diabetes travels frequently and asks how to plan meals during trips. The nurse's most appropriate response is:

"Choose the foods you normally do and follow your food plan wherever you are."

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever" The nurse's best initial response is:

"I know you're worried, but it is too early to tell how much scarring will occur."

What should the nurse do when collecting a 24-hour urine specimen?

-Check to verify if a preservative is needed. Depending on the purpose of the collection, a preservative to prevent breakdown of the specimen may be necessary. Weighing the client is not necessary.

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply?

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?

Using a back-and-forth motion while cleaning the wound

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? (Select all that apply.)

Wear shoes when out of bed; and Dry between the toes after bathing

Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes?

Wear synthetic fiber socks when exercising

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply?

-"I don't know if you do; let's talk about it." The nurse has demonstrated recognition of the verbalized concern and a willingness to listen. The client did not state cancer as the diagnosis; this response puts the client on the defensive.

A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior? 1 Hyperkalemia 2 Hypernatremia 3 A limited fluid intake 4 An increased blood urea nitrogen level

4 An increased blood urea nitrogen level

The health care provider prescribes propylthiouracil (PTU) for a client with the diagnosis of Graves' disease. What should the nurse teach the client when discussing the self-administration of this medication?

-Observe for signs of infection PTU may lower the white blood cell count, making the client prone to infection. Propylthiouracil does not cause hypocalcemia.

The major nursing concern when caring for a client with the diagnosis of hyperthyroidism is:

-Arranging for sufficient rest periods Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism . With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.

After multiple bee stings a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by:

-Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs.

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? (Select all that apply.)

-Dyspnea -Hemoptysis -Feeling of impending doom

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for:

-Elevated hemoglobin The body attempts to compensate for decreased oxygen to tissues by increasing the number of blood cells, the oxygen-carrying component of the blood. With polycythemia, the skin, especially the face, appears flushed, not pale. Dyspnea on exertion is not specific to polycythemia; there is more than one cause of dyspnea on exertion. The hematocrit is increased with polycythemia

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client?

-Expectoration of blood Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax or hemothorax may occur. It is too soon after a thoracentesis for an infection to develop. Signs of infection are important for the client to assess for several days after the procedure. Increased breath sounds are anticipated because the lung is closer to the chest wall after the fluid in the pleural space is removed. A decreased rate may indicate improved gaseous exchange and is not evidence that the client is in danger.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

-Give prescribed drugs to promote bronchiolar dilation.

-Has a productive cough A productive cough indicates that mucus is being raised from the lungs, which is an expected outcome. Crackles are unaffected by postural drainage or coughing. Saliva comes from the mouth; it does not indicate that the lungs are clear. Depth of respirations may not be altered by postural drainage.

Postoperatively a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect the client is experiencing?

-Hypocalcemia The signs and symptoms presented in the question indicate hypocalcemia. Injury to the parathyroid glands during a thyroidectomy results in a deficiency of parathormone, which decreases calcium levels in the blood. Hypokalemia is characterized by generalized weakness, a decrease in reflexes, shallow respirations, and cardiac dysrhythmias. Thyrotoxic crisis is characterized by tachycardia, hyperpyrexia, and an exacerbation of hyperthyroid symptoms. Hypovolemic shock is characterized by a weak, thready pulse and hypotension.

A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early clinical manifestations?

-Increased intracranial pressure

A client is diagnosed with type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. For what side effect should the nurse teach this client to monitor?

-Low blood sugar

A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon?

-Measure the blood glucose level between 2 AM and 4 AM.

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease?

-Mineralocorticoids

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?

-Muscle spasms Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia. Hypoactive reflexes are signs of hypercalcemia. Increased specific gravity is a sign of fluid volume deficit.

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The priority nursing intervention is to:

-Notify the health care provider immediately Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system;

-Observe for fluctuations of the fluid in the water-seal chamber Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber is expected and should be continuous. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication?

-Palpating the neck or face. Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis?

-Receives long-term steroid therapy Increased levels of steroids will accelerate bone demineralization.

A client tells the nurse during the admission history that an oral hypoglycemic agent is taken daily. For which condition does the nurse conclude that an oral hypoglycemic agent may be prescribed by the health care provider?

-Reduced insulin production Oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type 2 diabetes. Rapid-acting regular insulin is needed to reverse ketoacidosis. Obesity does not offer enough information to determine the status of beta cell function. Clients with type 1 diabetes have no functioning beta cells; the necessary treatment is insulin, not an oral hypoglycemic.

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

A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing?

-Somogyi effect The Somogyi effect is a response to hypoglycemia induced by too much insulin; the body responds to the hypoglycemia by counterregulatory hormones stimulating lipolysis, gluconeogenesis, and glycogenolysis, resulting in rebound hyperglycemia. The Dawn phenomenon is hyperglycemia that is present on awakening in the morning because of the release of counterregulatory hormones in the predawn hours; it is thought that growth hormone or cortisol is related to this phenomenon. Diabetic ketoacidosis (diabetic coma) is a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. Hyperosmolar nonketotic syndrome occurs in clients with type 2 diabetes. It is a condition in which the client produces enough insulin to prevent diabetic ketoacidosis but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.

-Suction as needed After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery.

A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. The nurse bases a response on the fact that:

-There may not be enough thyroid tissue to supply adequate thyroid hormone

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?

-Urine negative for ketones and hyperglycemia In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia.

Following surgery, a client received a prescription for 8 mg of morphine sulfate to be given by injection. The vial on hand is labeled 1 mL = 10 mg. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal point. __________ mL

0.8

A client has a glycosylated hemoglobin measurement of 6%. What should the nurse conclude about this client when planning a teaching plan based on the results of this laboratory test?

A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment? 1 Dry 2 Moist 3 Flushed 4 Smooth

A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for:

A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient?

A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. In addition to these changes, the nurse further assesses this client for:

A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care?

A nurse is caring for a newly admitted client with a diagnosis of Graves disease. In preparing a teaching plan, the nurse anticipates which diet will be prescribed for this client?

A nurse is planning to teach facts about hyperglycemia to a client with the diagnosis of diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?

A nurse is providing postoperative care for a client one hour after the client had an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication?

Hydrocortisone (Cortef) is prescribed for a client with Addison disease. Before discharge, the nurse teaches the client about this medication. What did the nurse include as a therapeutic effect of the drug?

The nurse is caring for a client diagnosed with Cushing syndrome. The nurse expects that the client will exhibit:

A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in two years. When can I stop taking my anti-seizure medications?" What is the nurse's best response? 1 "A gradual reduction in seizure medication may be considered." 2 "You will require medication for the rest of your life." 3 "Enough time has passed since the last seizure. The medication probably will be discontinued at this visit." 4 "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered."

1 "A gradual reduction in seizure medication may be considered."

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching was effective? 1 "I should call the clinic if my eye begins to hurt." 2 "I am so glad that I can take a shower tomorrow." 3 "There will be bright flashes of light for a few days." 4 "My vision should show some improvement by tomorrow."

1 "I should call the clinic if my eye begins to hurt." Pain after a cataract extraction and intraocular lens implant may indicate infection or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed, usually from several days to two weeks. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.

A client who is receiving a 2-gram sodium diet asks for juice. How should the nurse respond? 1 "I suggest you have either apple juice or pear nectar." 2 "I suggest you have tomato juice." 3 "Juice is not permitted on a low-sodium diet." 4 "Juice between meals is not calculated into your diet."

1 "I suggest you have either apple juice or pear nectar."

A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. The statement by the client that indicates a need for further teaching is: 1 "I wanted another child, and now pregnancy is not an option for me." 2 "I must allow extra time for irrigating my colostomy when traveling." 3 "It is good to know that I can swim every day after my incision heals." 4 "I'm glad I won't have to have special clothing and I can wear what I have."

1 "I wanted another child, and now pregnancy is not an option for me."

Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching? 1 "I will drink two to three quarts of fluid a day." 2 "Any reconstituted solution must be discarded in one week." 3 "I can continue driving my car as long as I have the stamina." 4 "While taking this medicine I should be able to continue my usual activity."

1 "I will drink two to three quarts of fluid a day." Adequate fluid intake helps to flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution may be stored in the refrigerator for one month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flu-like symptoms are common with this drug.

A client who has had a transurethral prostatectomy (TURP) experiences dribbling after the indwelling catheter is removed. To address this problem, an appropriate nursing response is: 1 "Increase your fluid intake and urinate at regular intervals." 2 "I know you're worried, but it will go away in a few days." 3 "Limit your fluid intake and urinate when you first feel the urge." 4 "The catheter will have to be reinserted until your bladder regains its tone."

1 "Increase your fluid intake and urinate at regular intervals." Increasing fluid intake and urinating at regular intervals will improve bladder tone, which should alleviate dribbling.

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? 1 "Increase your intake of fiber and fluid." 2 "Take the medication before you go to bed." 3 "Check your pulse before taking the medication." 4 "Contact your health care provider if your skin or sclera turn yellow."

1 "Increase your intake of fiber and fluid." Fiber and fluids help prevent the most common adverse effect of constipation and its complication, fecal impaction. The medication should be taken with meals. The pulse is not affected. Cholestyramine binds bile in the intestine; therefore, it reduces the incidence of jaundice.

A spouse spends most of the day with a client who is receiving chemotherapy for inoperable cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse support the client's spouse? 1 Assist the couple to maintain open communication. 2 Offer the couple a description of the disease process. 3 Instruct the spouse about the action of the medications. 4 Meet privately with the spouse to explore personal feelings.

1 Assist the couple to maintain open communication.

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How should the nurse respond? 1 "It is contraindicated because bleeding will increase." 2 "If necessary it will be started to enhance circulation." 3 "If necessary it will be stated to prevent pulmonary thrombosis." 4 "It is inadvisable because it masks the effects of the hemorrhage."

1 "It is contraindicated because bleeding will increase." An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response "It is inadvisable because it masks the effects of the hemorrhage" is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage.

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. The best reply by the nurse is: 1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." 2 "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." 3 "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." 4 "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag."

1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours."

A client with a parotid tumor expresses anxiety about the surgery to remove the tumor. The client states that perhaps surgery should be performed soon, even if the preoperative radiotherapy is not completed. The best response by the nurse is: 1 "You are concerned about the delay of surgery?" 2 "You are anxious about the effects of radiotherapy?" 3 "I think you do not have confidence in your health care provider's decisions." 4 "I can understand your anxiety concerning the delay of your surgery."

1 "You are concerned about the delay of surgery?"

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, which diet can the nurse expect will be prescribed for this client? 1 20 g of protein, 2000 calories 2 70 g of protein, 1200 calories 3 80 g of protein, 2500 calories 4 100 g of protein, 1500 calories

1 20 g of protein, 2000 calories Because the liver is unable to detoxify ammonia to urea, protein intake should be further restricted when coma is inevitable. 70 g of protein, 1200 calories, 80 g of protein, 2500 calories, and 100 g of protein, 1500 calories are relatively high intakes of protein that will increase blood ammonia levels.

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes and withdraws appropriately, but has no verbal response to the stimulus. Using the Glasgow Coma Scale, the nurse determines the client's score is: 1 7 2 9 3 12 4 15

1 7 The Glasgow Coma Scale is a three-part neurological assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: 1 Addressing the pain 2 Reversing feelings of hopelessness 3 Promoting mobility in the residual limb 4 Acknowledging the grieving for the lost limb

1 Addressing the pain

A client is scheduled for an adrenalectomy. Which nursing intervention should the nurse anticipate will be prescribed for this client? 1 Administer intravenous (IV) steroids. 2 Provide a high protein diet. 3 Collect a 24-hour urine specimen. 4 Withhold all medications for 48 hours.

1 Administer intravenous (IV) steroids. Steroid therapy usually is instituted preoperatively and continued intraoperatively to prepare for the acute adrenal insufficiency that follows surgery. The diet must supply ample, not high, protein and potassium; however, it must be low in calories, carbohydrates, and sodium to promote weight loss and reduce fluid retention. A 24-hour urine specimen is unnecessary. Glucocorticoids must be administered preoperatively to prevent adrenal insufficiency during surgery.

After cataract surgery, a client reports feeling nauseated. How can the nurse help to relieve the nausea? 1 Administer the prescribed antiemetic drug. 2 Provide some dry crackers for the client to eat. 3 Explain that this is expected following surgery. 4 Teach how to breathe deeply until the nausea subsides

1 Administer the prescribed antiemetic drug.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." The nurse teaches the client that the most appropriate type of juice to select is: 1 Apple 2 Orange 3 Tomato 4 Grapefruit

1 Apple

Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. What should the nurse do to best evaluate whether the feeding is being absorbed? 1 Aspirate for a residual volume. 2 Evaluate the intake in relation to the output. 3 Instill air into the client's stomach while auscultating. 4 Compare the client's body weight with the baseline data.

1 Aspirate for a residual volume.

Despite receiving 2900 mL intake for two days, the client's urine output has progressively diminished. The nurse identifies that the urinary output is less than 40 mL/hr over the past three hours. What action should the nurse take? 1 Assess breath sounds and obtain vital signs 2 Decrease the intravenous (IV) flow rate and increase oral fluids 3 Insert an indwelling catheter to facilitate emptying of the bladder 4 Check for dependent edema by assessing the lower extremities

1 Assess breath sounds and obtain vital signs The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications.

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. What is an appropriate postoperative nursing intervention on the day after surgery? 1 Assist the client with walking. 2 Help the client to sit in a chair. 3 Maintain the client on bed rest. 4 Encourage the client to keep the legs elevated.

1 Assist the client with walking. Mobility reduces venous stasis and edema and enhances arterial perfusion and healing. Sitting in a chair is contraindicated; it constricts circulation at the hips and knees. Bed rest is contraindicated because it promotes the development of thrombophlebitis and pulmonary emboli. Elevating the legs will limit arterial perfusion.

A primary health care provider prescribes three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in one month. To ensure valid test results, the nurse should instruct the client to: 1 Avoid eating red meat before testing 2 Test the specimen while it is still warm 3 Discard the day's first stool and use the next three stools 4 Take three specimens from different sections of the fecal sample

1 Avoid eating red meat before testing Red meat can react with reagents used in the test to cause false-positive results. Testing the specimen while it is still warm may apply for testing for ova and parasites, not for occult blood. If the correct procedure is followed, discarding the first specimen is unnecessary. Random stool testing can be done but must be on three different bowel movements during the screening period.

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is most important for the nurse to assess this client for: 1 Blood in the stool 2 Food intolerances 3 Complaints of nausea 4 Hourly urinary output

1 Blood in the stool Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, the nurse suspects the tumor is located in the: 1 Cerebellum 2 Parietal lobe 3 Basal ganglia 4 Occipital lobe

1 Cerebellum The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement. The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss. Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease. The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? 1 Cervical 2 Axillary 3 Inguinal 4 Mediastinal

1 Cervical Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows after the disease progresses.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for: 1 Control of pain 2 Immobilization of joints 3 Motivation and teaching 4 Bladder training and control

1 Control of pain

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate: 1 Corneal sensation 2 Facial expressions 3 Ocular muscle movement 4 Shrugging of the shoulders

1 Corneal sensation The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea. Facial expressions (e.g., smiling, frowning) reflect the functioning of cranial nerve VII. The ocular muscle movement tests the function of cranial nerves III, IV, and VI. Shrugging of the shoulders tests the function of cranial nerve XI.

A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client? 1 Decreased white blood cells 2 Increased C-reactive protein 3 Increased sedimentation rate 4 Decreased serum glucose levels

1 Decreased white blood cells Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. Increased C-reactive protein and sedimentation rate elevate in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

A client comes to the emergency department complaining of weakness and dizziness. The blood pressure is 90/60, pulse is 92 and weak, and body weight reflects a 3-pound loss in two days. The weather has been hot. The nurse concludes that the biggest concern for this client is: 1 Deficient fluid volume 2 Impaired skin integrity 3 Inadequate nutritional intake 4 Decreased participation in activities

1 Deficient fluid volume The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid.

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1 Dependent edema in the evening 2 Chest pain that decreases with rest 3 Palpitations in the chest when resting 4 Frequent coughing with yellow sputum

1 Dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

When assessing a client with Graves disease (hyperthyroidism) the nurse expects to identify a history of: 1 Diaphoresis 2 Menorrhagia 3 Dry, brittle hair 4 Sensitivity to cold

1 Diaphoresis Increased basal metabolic rate, increased circulation, and vasodilation result in warm, moist skin. Menorrhagia, dry, brittle hair, and sensitivity to cold are associated with hypothyroidism.

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of: 1 Digoxin (Lanoxin) 2 Captopril (Capoten) 3 Morphine sulfate (MS Contin) 4 Furosemide (Lasix )

1 Digoxin (Lanoxin)

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion? 1 Diuretic therapy 2 Sodium restriction 3 Continuous dyspnea 4 Inadequate oral intake

1 Diuretic therapy Diuretic therapy that affects the loop of Henle generally involves the use of drugs (e.g., bumetanide) that directly or indirectly increase urinary sodium, chloride, and potassium excretion. Sodium restriction does not necessarily accompany administration of bumetanide. Dyspnea does not directly result in a depletion of electrolytes. Unless otherwise prescribed, oral intake is unaffected.

What instructions should the nurse provide to a client after a long leg cast is removed? 1 Elevate the extremity when sitting. 2 Report discomfort or stiffness of the ankle. 3 Perform full range of motion of the leg once daily. 4 Cleanse the leg by scrubbing with long, brisk motions

1 Elevate the extremity when sitting. Elevation will help to control swelling that occurs after a leg cast is removed. Because the ankle has been immobilized, discomfort and stiffness are expected after cast removal. The leg should be put through full range of motion more often than once daily. Because the skin was not exposed, it needs gentle washing to prevent skin trauma.

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? 1 Encourage the client to rest for short periods 2 Continue the bath while supporting the client's arms 3 Gradually increase the client's activity level each day 4 Administer a dose of pyridostigmine bromide (Mestinon)

1 Encourage the client to rest for short periods Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins.

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? 1 Encouraging expression of concerns 2 Administering antibiotics as prescribed 3 Teaching the importance of getting rest 4 Explaining that everything will be all right

1 Encouraging expression of concerns

Which action should be included in the plan of care for a client who has had pelvic surgery? 1 Encouraging the client to ambulate in the hallway. 2 Elevating the client's legs by raising the bed's knee support. 3 Assisting the client to dangle the legs over the side of the bed. 4 Maintaining the client on bed rest until the bandages are removed.

1 Encouraging the client to ambulate in the hallway. Muscle contractions during ambulation improves venous return, preventing venous stasis and thrombus formation.

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease? 1 Esophageal pain may imitate the symptoms of a heart attack. 2 GERD may predispose to heart disease. 3 Strenuous exercise may exacerbate both cardiac and reflux problems. 4 Similar changes in laboratory studies may occur in both cardiac and reflux problems.

1 Esophageal pain may imitate the symptoms of a heart attack. Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. GERD does not predispose to heart disease. Exercise tends to aggravate cardiovascular problems to a much greater extent than esophageal problems. Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is prescribed. After the liver biopsy, the nurse should take the client's vital signs every: 1 Every 15 minutes for two hours 2 Every 30 minutes for four hours 3 Every hour for 8 hours 4 Every 2 hours for 12 hours

1 Every 15 minutes for two hours Every 15 minutes for two hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; two hours after the procedure the vital signs can be taken every 30 minutes instead of every 15 minutes if they are stable. Every hour for eight hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? 1 Feeling of heaviness in both legs. 2 Intermittent claudication of the legs. 3 Calf pain on dorsiflexion of the foot. 4 Hematomas of the lower extremities

1 Feeling of heaviness in both legs. Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homan sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

A client develops iron deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased? 1 Ferritin level 2 Platelet count 3 White blood cell count 4 Total iron-binding capacity

1 Ferritin level Ferritin, a form of stored iron, is reduced with iron deficiency anemia. Platelets will be within the expected range or increased with iron deficiency anemia. Red, not white, blood cells are decreased with iron deficiency anemia. Total iron-binding capacity will be increased with iron deficiency anemia.

A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for possible situations in which exposure may have occurred. Which event does the nurse determine is the most likely source of this infection? 1 Had a small tattoo on the arm three months ago 2 Assisted in the emergency birth of a baby two weeks ago 3 Worked for a month in an undeveloped area in Mexico four months ago 4 Attended an ecologic conference in a large urban center two months ago

1 Had a small tattoo on the arm three months ago

In the postanesthesia care unit after a below-the-knee amputation, a client begins crying after feeling for the affected lower leg. How should the nurse respond? 1 Administer medication to induce sleep. 2 Allow the client to ventilate feelings of loss. 3 Provide time for privacy by leaving the room. 4 Do not address the behavior until the client is more alert.

2 Allow the client to ventilate feelings of loss.

A female client with the diagnosis of Crohn's disease tells the nurse that her boyfriend dates other women. She believes that this behavior causes an increase in her symptoms. What should the nurse do first when counseling this client? 1 Help the client explore attitudes about herself. 2 Educate the client's boyfriend about her illness. 3 Suggest the client should not see her boyfriend for a while. 4 Schedule the client and her boyfriend for a counseling session.

1 Help the client explore attitudes about herself.

A client arrives on the nursing unit unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe: 1 Hyperextension of both the upper and lower extremities 2 Spastic paralysis of both the upper and lower extremities 3 Hyperflexion of the upper extremities and hyperextension of the lower extremities 4 Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

1 Hyperextension of both the upper and lower extremities Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. Spastic paralysis of both the upper and lower extremities is associated with an upper motor neuron disease or lesion. Hyperflexion of the upper extremities and hyperextension of the lower extremities is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities is associated with a lower motor neuron disease or lesion.

A client is diagnosed as having kidney failure. During the oliguric phase the nurse should assess the client for: 1 Hyperkalemia 2 Hypocalcemia 3 Hypernatremia 4 Hypoproteinemia

1 Hyperkalemia The kidneys retain potassium during the oliguric phase of kidney failure; an elevated potassium level is one of the main indicators of the need for dialysis. Hypercalcemia occurs, not hypocalcemia. Hyponatremia occurs, not hypernatremia. Hyperproteinemia occurs, not hypoproteinemia.

A client who is suspected of having Cushing syndrome is admitted to the hospital. The nurse plans to monitor this client for: 1 Hypokalemia 2 Hypovolemia 3 Hypocalcemia 4 Hyponatremia

1 Hypokalemia With glucocorticoid excess, aldosterone hypersecretion occurs and sodium is retained; therefore, potassium is excreted, leading to hypokalemia

A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. The nurse concludes that the probable cause of ascites is: 1 Impaired portal venous return 2 Inadequate secretion of bile salts 3 Excess production of serum albumin 4 Decreased interstitial osmotic pressure

1 Impaired portal venous return An enlarged liver impairs venous return, leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.

A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client? 1 Increase the intake of fluids. 2 Strain the urine for crystals and stones. 3 Stop the drug if urinary output increases. 4 Maintain the exact time schedule for taking the drug

1 Increase the intake of fluids.

After being hospitalized for a transient ischemic attack (TIA) related to hypertension, a client is discharged with a prescription of hydrochlorothiazide (HCTZ). What should the nurse instruct the client to do when taking this medication? 1 Increase the intake of potassium 2 Drink a protein supplement daily 3 Avoid eating foods high in insoluble fiber 4 Resume regular eating habits

1 Increase the intake of potassium The client must increase the dietary intake of potassium because of potassium loss associated with HCTZ.

The nurse considers that sensory restriction in a client who is blind can: 1 Increase the use of daydreaming and fantasy 2 Heighten the client's ability to make decisions 3 Decrease the client's restlessness and lethargy 4 Lead to the use of permanent neurotic behaviors

1 Increase the use of daydreaming and fantasy Internal self-stimulation increases as external stimuli decrease. Blindness is an added stress that can increase anxiety, which impairs decision-making; lack of visual stimuli limits data for decision-making. Lack of visual stimuli can increase restlessness, lethargy, and apathy.

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? 1 Interview the client without the presence of family members. 2 Report the abuse to the appropriate state agency for investigation. 3 Accept the adult child's explanation until more data can be collected. 4 Refer the client's clinical record to the hospital ethics committee for review

1 Interview the client without the presence of family members. Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse. Reporting the abuse to the appropriate state agency for investigation is premature; further assessment is needed to determine if it is necessary to notify the appropriate agency.

A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client: 1 Is contraindicated because it will increase bleeding 2 May be necessary to prevent pulmonary thrombosis 3 Is inadvisable because it may mask signs and symptoms 4 Will be started if necessary to enhance cerebral circulation

1 Is contraindicated because it will increase bleeding Administration of an anticoagulant to a client who is bleeding will interfere with clotting and increase bleeding. Anticoagulants are not used in this situation because they will increase bleeding; they may be used for a client with a cerebral thrombosis.

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1 Lactase 2 Sucrase 3 Maltase 4 Amylase

1 Lactase

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first? 1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help. 2 Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3 Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4 Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution

1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help.

A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee chest 4 Mid-Fowler

1 Left Sims

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological responses to this disease? 1 Levodopa (l-Dopa) 2 Isocarboxazid (Marplan) 3 Dopamine (Intropin) 4 Pyridoxine (vitamin B6

1 Levodopa (l-Dopa)

A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively? 1 Location of the surgical incision 2 Increased anxiety about the prognosis 3 Inflammatory process associated with surgery 4 Pulmonary congestion from preoperative medications

1 Location of the surgical incision

X-ray films reveal that a client has sustained an intracapsular fracture of the left hip as a result of a fall. The client is placed temporarily in Buck's traction. When providing care, the nurse should: 1 Monitor for tenderness in the left calf area 2 Turn the client from side to side every two hours 3 Raise the head of the bed to a semi-Fowler position 4 Put the client's lower extremities through passive range-of-motion exercises

1 Monitor for tenderness in the left calf area

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: 1 Monitor the client's vital signs 2 Increase the client's fluid intake 3 Improve the client's nutritional status 4 Determine the client's reasons for drinking

1 Monitor the client's vital signs

Which medication should the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema? 1 Morphine 2 Phenobarbital 3 Hydroxyzine (Atarax) 4 Chloral hydrate

1 Morphine Morphine binds with the same receptors as natural opioids. However, it has a rapid onset, lowers the blood pressure, decreases pulmonary reflexes, and produces sedation. Phenobarbital has a slower onset than morphine and does not affect respirations and blood pressure to the same extent as morphine.

Thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? 1 Neuronal activity 2 Bowel elimination 3 Efficient circulation 4 Prothrombin development

1 Neuronal activity Thiamine and niacin help convert glucose for energy, and therefore influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. What recommendation by the nurse will help the client maintain blood vessel patency? 1 Practice relaxation techniques 2 Lead a more sedentary lifestyle 3 Decrease the amount of exercise 4 Increase saturated fats in the diet

1 Practice relaxation techniques

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? 1 Receives long-term steroid therapy 2 Has a history of hypoparathyroidism 3 Engages in strenuous physical activity 4 Consumes high doses of the hormone estrogen

1 Receives long-term steroid therapy Increased levels of steroids will accelerate bone demineralization. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization.

The nurse is caring for a client four days after the client had a cystectomy and formation of a continent diversion. After observing mucous threads in the client's urine, the nurse should: 1 Recognize that this is an expected response 2 Report this to the health care provider immediately 3 Obtain a specimen for culture and sensitivity 4 Increase the client's fluid intake for the next 12 hours

1 Recognize that this is an expected response Expecting this response after the diversion response is expected because mucus continually is secreted by the intestinal mucosa. Reporting this to the health care provider immediately is not necessary; mucus is expected with an ileal conduit

The nurse is caring for a client with ascites who is scheduled for a paracentesis. The client teaching will include: 1 The need to empty the bladder immediately before the procedure 2 The importance of a low fat diet after the procedure to aid in healing 3 The importance of staying in a supine position throughout the procedure 4 The need to consume only liquids for 24 hours after the procedure

1 The need to empty the bladder immediately before the procedure

A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. The nurse should assess the client for: 1 Melena 2 Anal itching 3 Constipation 4 Ribbon-shaped stools

2 Anal itching

How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction? 1 Replace the top linen and only the necessary bottom linen. 2 Lift the client from side to side while changing the bed linen. 3 Change the linen from top to bottom without lowering the head of the bed. 4 Slide the client onto a stretcher to remake the bed and then slide the client back to the bed.

1 Replace the top linen and only the necessary bottom linen. Until a client's condition has reached some degree of stability after a myocardial infarction, routine activities such as changing sheets are avoided so that the client's movements will be minimized and the cardiac workload reduced. Lifting the client from side to side while changing the bed linen is contraindicated because it increases oxygen consumption and cardiac workload; also, it may strain the health team members who are lifting the client. Changing all the linen causes unnecessary movement, which increases oxygen demand and makes the heart work harder. Any activity is counterproductive to rest; rest must take precedence so that the cardiac workload is reduced.

The nurse is providing dietary teaching to a 40-year-old client who is receiving hemodialysis. The nurse should encourage the client to include what in the client's dietary plan? 1 Rice 2 Potatoes 3 Canned salmon 4 Barbecued beef

1 Rice Foods high in carbohydrates and low in protein, sodium, and potassium are encouraged for these clients.

An older client with dementia of the Alzheimer's type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter

1 Sacrum

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing? 1 Salicylate toxicity 2 Anaphylactic reaction 3 Withdrawal symptoms 4 Acetaminophen overdose

1 Salicylate toxicity

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. The nurse expects the client to describe the chest pain as: 1 Severe, intense 2 Burning and of short duration 3 Mild, radiating toward the abdomen 4 Squeezing, relieved by Maalox

1 Severe, intense

A client is admitted to the ambulatory surgery unit for a liver biopsy. The nurse recalls that which assessment finding will be a cause for the biopsy to be postponed? 1 Signs of bruising 2 Visible hyperactivity 3 Lethargy on the morning of the test 4 Foods high in vitamin K consumed on the day before the test

1 Signs of bruising If the client has numerous bruises and petechiae, they may indicate deficient thrombocytes or prolonged clotting; both are contraindications for a percutaneous liver biopsy. The client may need support and the health care provider may need assistance, but the test can be done. The client's activity level is unrelated to contraindications for performing a liver biopsy. The amount of foods high in vitamin K consumed the day before the test is unrelated to contraindications for performing a liver biopsy. Although vitamin K is needed for the production of prothrombin, the ingestion of foods high in vitamin K does not guarantee adequate clotting activity.

A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be the result of surgery-related trauma, the nurse assesses the client's ability to: 1 Speak 2 Swallow 3 Purse the lips 4 Turn the head

1 Speak The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: 1 Stop the transfusion 2 Obtain the vital signs 3 Assess the pain further 4 Monitor the hourly urinary output

1 Stop the transfusion

A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response? 1 Streptomycin 2 Pyrazinamide 3 Isoniazid (INH) 4 Ethambutol (Myambutol)

1 Streptomycin

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1 Syncope 2 Headache 3 Tachycardia 4 Hemiparesis

1 Syncope With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node. Hemiparesis is not related to heart block unless decreased cerebral perfusion causes a brain attack.

The nurse provides discharge medication education to a client who has been switched from a prescription for heparin to a prescription for warfarin sodium (Coumadin). The nurse concludes that the teaching was effective when the client states, "I will: 1 Take acetaminophen (Tylenol) for my occasional headaches." 2 Spend most of the day working at my desk." 3 Ask my health care provider for antibiotics before going to the dentist." 4 Make an appointment to have a complete blood count drawn."

1 Take acetaminophen (Tylenol) for my occasional headaches." Acetaminophen should be used when an analgesic is required because it does not interfere with platelet aggregation. Acetylsalicylic acid (aspirin) should be avoided because it interferes with platelet aggregation. Immobility causes venous pooling and can predispose the client to deep vein thrombosis. Antibiotics are not necessary when going to the dentist; this is done when clients have cardiac problems, such as rheumatic fever or cardiac surgery. A prothrombin time (PT) or international normalized ratio (INR), not a complete blood count, needs to be done periodically.

The nurse considers that a 70-year-old female can best limit further progression of osteoporosis by: 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk and milk products

1 Taking supplemental calcium and vitamin D

The nurse is caring for a client with acute renal failure. The most serious complication for this client is: 1 Anemia 2 Infection 3 Weight loss 4 Platelet dysfunction

2 Infection Infection is responsible for one third of the traumatic or surgically induced deaths of clients with acute renal failure, as well as for medically induced acute renal failure.

A client who is scheduled to have surgery to remove an aldosterone-secreting adenoma asks the nurse what will happen if surgery is not performed. On what information should the nurse base a response? 1 The tumor must be removed to prevent heart and kidney damage. 2 Surgery will prevent the tumor from metastasizing to other organs. 3 Radiation therapy can be just as effective as surgery if the tumor is small. 4 Chemotherapy is as reliable as surgery for the treatment of adenomas of this type in some people

1 The tumor must be removed to prevent heart and kidney damage.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1 They help the venous blood return to the heart. 2 They will not cause discomfort, but gently massage the legs. 3 They are used instead of anticoagulant therapy. 4 They must be worn until the first time the client gets out of bed

1 They help the venous blood return to the heart. Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than 30 minutes. The purpose of pneumatic compression devices is to increase venous return. Clients often complain about pneumatic compression devices being hot and itchy. In addition to the pneumatic compression devices, a mechanical form of DVT prophylaxis, pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.

After a nephrectomy a client arrives in the post-anesthesia care unit in the supine position. Which action should be employed by the nurse to assess the client for signs of hemorrhage? 1 Turn the client to observe the dressings. 2 Press the client's nail beds to assess capillary refill. 3 Observe the client for hemoptysis when suctioning. 4 Monitor the client's blood pressure for a rapid increase

1 Turn the client to observe the dressings.

1 Turn the client to observe the dressings. Because of the anatomic position of the incision, drainage will flow by gravity and accumulate under the client lying in the supine position.

The nurse provides discharge instructions to a male client that had a ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). The teaching should include that indicators of a UTI are: 1 Urgency or frequency of urination 2 The inability to maintain an erection 3 Pain radiating to the external genitalia 4 An increase in the alkalinity of the urine

1 Urgency or frequency of urination

A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? 1 Urinary output of 30 mL in an hour 2 Central venous pressure reading of 2 mm Hg 3 Baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period 4 Baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period

1 Urinary output of 30 mL in an hour A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain.

What should transmission-based precautions for a client with salmonellosis include? 1 Wearing a gown if soiling is likely. 2 Providing isolation in a private room. 3 Wearing a mask when emptying the bedpan. 4 Limiting visiting hours during the acute phase

1 Wearing a gown if soiling is likely. Wearing a gown if soiling is likely, in addition to gloves, reduces the possibility that the organisms may be transmitted to others. Providing isolation in a private room is not necessary as long as fecally contaminated articles are handled and disposed of appropriately. The organism is not transmitted via the airborne route. The type of exposure, not the length of exposure, increases the risk for transmission; visitors are allowed as long as appropriate precautions are implemented.

What is the most objective way that a nurse can assess the extent of edema in a client? 1 Weighing the client 2 Monitoring the intake and output 3 Performing the Trendelenburg test 4 Assessing the extent of pitting edema

1 Weighing the client One liter of fluid weighs approximately 2.2 pounds; weight reflects subtle changes in fluid balance. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. The Trendelenburg test facilitates assessment of venous peripheral vascular disease, not the extent of edema. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client.

A female client who is scheduled for a thyroidectomy is concerned that the surgery will interfere with her ability to become pregnant. The nurse should base a response on the understanding that:

1 As long as medication is continued, ovulation will occur

1 1 Decreased white blood cells Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. Increased C-reactive protein and sedimentation rate elevate in acute inflammatory diseases; steroids help decrease it. Serum glucose levels increase with steroid use.

A client on a low-residue diet asks the nurse about foods that must be avoided. Which foods should the nurse instruct the client to avoid? (Select all that apply.) 1 1. Fresh fruit 2 Broiled fish 3 Poached eggs 4 Buttered white rice 5 Whole wheat bread

1 1. Fresh fruit 5 Whole wheat bread Fresh fruit contains fiber and should be avoided on a low-residue diet. Whole wheat bread contains fiber and should be avoided on a low-residue diet. Broiled fish, poached eggs, and buttered white rice are permitted on a low-residue diet

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg

1 72 mm Hg

Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? (Select all that apply.) 1 Abdominal cramps 2 Fecal liquid seepage 3 Hyperactive bowel sounds 4 Bright red blood in the stool 5 Decreased number of bowel movements

1 Abdominal cramps 2 Fecal liquid seepage 3 Hyperactive bowel sounds Peristalsis increases in an attempt to evacuate the hardened feces; spasms of the intestine may occur. When the bowel is impacted with hardened feces, there often is seepage of liquid feces around the obstruction and thus uncontrolled diarrhea. Intestinal gas builds up behind the obstruction; peristaltic waves initiate movement of intestinal contents that cause gurgling sounds in the intestine (borborygmi). Bright red blood in the stool is indicative of lower gastrointestinal (GI) bleeding. There are often frequent liquid bowel movements in the presence of an impaction.

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.) 1 Absence of hair on the toes 2 Superficial ulcer with irregular edges 3 Pitting edema of the lower extremities 4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area

1 Absence of hair on the toes 4 Reports of pain associated with exercising The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when arterial flow is impaired. A superficial ulcer with irregular edges is associated with venous insufficiency; the ulcer associated with arterial insufficiency is deep, well demarcated, and may be gangrenous. Pitting edema of the lower extremities is associated with venous insufficiency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insufficiency and occurs as a result of degeneration of red blood cells (RBCs) that leak into surrounding tissue.

Which medications are associated commonly with upper gastrointestinal (GI) bleeding? (Select all that apply.) 1 Acetylsalicylic acid (Aspirin) 2 Methylprednisolone (Solu-Medrol) 3 Acetaminophen (Tylenol) 4 Ibuprofen (Advil) 5 Ciprofloxacin (Cipro)

1 Acetylsalicylic acid (Aspirin) 2 Methylprednisolone (Solu-Medrol) 4 Ibuprofen (Advil) Nonsteroidal anti-inflammatory agents (NSAIDs), including acetylsalicylic acid and ibuprofen, and corticosteroids such as methylprednisolone, are known causes of drug-induced gastrointestinal bleeding by causing irritation and erosion of the gastric mucosal barrier. Acetaminophen is a safe alternative to NSAIDS to reduce the risk of GI bleeding. Ciprofloxacin, an antibiotic, has not been associated with GI bleeding.

A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet? 1 Add extra salt to food 2 Limit intake to 1200 calories 3 Omit protein foods at each meal 4 Restrict the daily intake of fluids to 1 L

1 Add extra salt to food Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to develop hyponatremia. Therefore, the addition of salt to the diet is advised.

1 Anemia 2 Dyspnea 4 Anasarca

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? (Select all that apply.) 1 Anxiety 2 Chest pain 3 Irregular pulse 4 Fear of losing control 5 Feelings of depersonalization

1 Anxiety 2 Chest pain 3 Irregular pulse Anxiety is associated with both myocardial infarctions and panic attacks. The overwhelming chest pain that usually accompanies a myocardial infarction, due to myocardial ischemia, precipitates a feeling of impending death. Most people who have panic attacks eventually recognize that they are not going to die as a result of the attack. Chest pain is associated with both myocardial infarctions and panic attacks. Chest pain is associated with a myocardial infarction because of myocardial ischemia. It is often described as "vice-like" or "crushing" in nature. The chest discomfort during a panic attack usually is not as severe as the pain associated with a myocardial infarction. Dysrhythmias often accompany a myocardial infarction because the functioning of the electrical pathways and cardiac muscles in the heart is impaired. Clients having a panic attack may have palpitations and tachycardia. Fear of losing control usually is not a characteristic associated with a myocardial infarction. Fear of losing control or going crazy is among the criteria of the DSM-IV-TR for the diagnosis of panic attacks. A feeling of depersonalization is not a characteristic associated with a myocardial infarction. Depersonalization (feeling detached from the self) and derealization (feelings of unreality) are among the criteria of the DSM-IV-TR for the diagnosis of panic attacks.

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What nursing care should be included in the client's plan of care? (Select all that apply.) 1 Auscultate for a bruit. 2 Palpate the site to identify a thrill. 3 Irrigate with saline to maintain patency. 4 Avoid drawing blood from the affected extremity. 5 Keep the fistula clamped until ready to perform dialysis.

1 Auscultate for a bruit. 2 Palpate the site to identify a thrill. 4 Avoid drawing blood from the affected extremity.

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? (Select all that apply.) 1 Avoid heavy lifting. 2 Lie down after eating. 3 Avoid drinking alcohol. 4 Eat small, frequent meals. 5 Increase fluid intake with meals. 6 Wear an abdominal binder or girdle

1 Avoid heavy lifting. 3 Avoid drinking alcohol. 4 Eat small, frequent meals. Heavy lifting increases intraabdominal pressure, allowing gastric contents to move up through the lower esophageal sphincter (regurgitation), causing heartburn (pyrosis). Alcohol, in addition to peppermints, caffeine, and chocolate, decreases lower esophageal sphincter (LES) pressure, which permits gastric contents to move from the stomach into the esophagus. Eating small, frequent meals limits the amount of food in the stomach, which limits gastroesophageal reflux. Lying down after eating promotes reflux and should be avoided. Increasing fluids with meals increases gastric volume, causing distention and reflux. Constrictive garments, such as belts, binders, and girdles, increase intraabdominal pressure and may lead to reflux.

A nurse is caring for a client who is having difficulty digesting fatty foods. To what deficiency does the nurse attribute this difficulty? 1 Bile 2 Lipase 3 Amylase 4 Cholesterol

1 Bile Fatty acids are insoluble and must combine with bile to form water-soluble substances. Lipase is a pancreatic enzyme. Amylase, which digests starch, is found in saliva and pancreatic juice. Although cholesterol is produced in the liver and stored in the gallbladder, it is not the component of bile that emulsifies fats.

Which clinical manifestations does a nurse expect that a client with renal calculi might report? (Select all that apply.) 1 Blood in the urine 2 Irritability and twitching 3 Dry, itchy skin and pyuria 4 Frequency and urgency of urination 5 Pain radiating from the kidney to a shoulder

1 Blood in the urine 4 Frequency and urgency of urination Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain.

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? (Select all that apply.) 1 Carrots 2 Oranges 3 Tomatoes 4 Skim milk 5 Leafy greens

1 Carrots 5 Leafy greens Yellow/orange vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin A. Dark green leafy vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Broccoli, cabbage, spinach, and collards also are high in vitamin A. Oranges are considered a good source of both vitamin C and potassium. Tomatoes are a good source of vitamin C. Levels of vitamin A are higher in whole milk than in skim milk.

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? 1 Cervical 2 Axillary 3 Inguinal 4 Mediastinal

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? (Select all that apply.) 1 Change positions slowly 2 Take the medication before going to bed 3 Count the pulse before taking the medication 4 Mild weakness and fatigue are common side effects 5 It is safe to take concurrent over-the-counter (OTC) medications

1 Change positions slowly 3 Count the pulse before taking the medication 4 Mild weakness and fatigue are common side effects

A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids? (Select all that apply.) 1 Constipation 2 Hypertension 3 Eating spicy foods 4 Bowel incontinence 5 Numerous pregnancies

1 Constipation 5 Numerous pregnancies

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? (Select all that apply.) 1 Coughing 2 Orthopnea 3 Diaphoresis 4 Yellow sputum 5 Dependent edema

1 Coughing 2 Orthopnea 3 Diaphoresis Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Cold, clammy skin occurs from vasoconstriction caused by stimulation of the sympathetic nervous system. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.

1 Decreased urine 2 Hypotension 4 Dry mucous membranes 6 Poor skin turgor

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? (Select all that apply.) 1 Dependent edema 2 Distended abdomen 3 Polyuria at night 4 Collapsed neck veins 5 Cool extremities

1 Dependent edema 2 Distended abdomen 3 Polyuria at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by dependent edema, a distended abdomen, and polyuria at night. With left ventricular systolic dysfunction, cardiac output is diminished, leading to impaired tissue perfusion. Collapsed neck veins and cool extremities are key features of left-sided heart failure.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should: 1 Give the vaccine 2 Administer aspirin with the vaccine 3 Hold the vaccine and notify the health care provider 4 Reschedule administration of the vaccine for the next month

4 Reschedule administration of the vaccine for the next month

To help prevent long-term complications associated with gastric bypass surgery, the nurse needs to educate the client. Identify the factors that should be included in the nurse's teaching plan for this client. (Select all that apply.) 1 Eat foods rich in calcium. 2 Ingest three small feedings daily. 3 Limit fluids to 1500 mL daily. 4 Consume a diet high in protein. 5 Receive vitamin B12 injections routinely.

1 Eat foods rich in calcium. 4 Consume a diet high in protein. 5 Receive vitamin B12 injections routinely. Calcium deficiency is a late complication of bariatric surgery because of inadequate absorption, even with an intake of calcium-rich foods; calcium supplementation may be necessary. Foods high in protein exit the stomach more slowly than foods high in carbohydrates, which minimize the dumping syndrome. Vitamin B12 deficiency is a late complication of bariatric surgery because of a lack of intrinsic factor; gastric secretion is necessary for the absorption of vitamin B12 . Lifelong supplementation may be necessary. Three small feedings daily will not provide adequate calories and nutrients; six small feedings with a total of 600 to 800 calories a day is routine once the client is eating. Clients need to increase, not limit, fluid intake; the dumping syndrome contributes to diarrhea, which can cause dehydration and electrolyte imbalance.

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? (Select all that apply.) 1 Eat more citrus fruits 2 Take protein supplements 3 Return to previous eating habits 4 Increase intake of dairy products 5 Increase intake of dried cooked beans

1 Eat more citrus fruits 5 Increase intake of dried cooked beans The client should increase the dietary intake of potassium because of potassium loss associated with chlorothiazide. Citrus fruits are high in potassium and should be encouraged. Legumes, such as dried beans, are high in potassium and low in saturated fats.

A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? (Select all that apply.) 1 Ecchymosis 2 Yellow sclera 3 Dark brown stool 4 Straw-colored urine 5 Pain in right upper quadrant

1 Ecchymosis 2 Yellow sclera 5 Pain in right upper quadrant

What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.) 1 Edema 2 Vertigo 3 Polyuria 4 Dyspnea 5 Palpitations

1 Edema 4 Dyspnea Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system. Clinical manifestations include edema, ascites, hepatomegaly, tachycardia, dyspnea, and fatigue. Dyspnea occurs because of pulmonary congestion and inadequate delivery of oxygen to all body cells. Vertigo generally is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output. Palpitations may indicate coronary insufficiency or infarction.

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? (Select all that apply.)

1 Emotional lability 2 Dyspnea on exertion 5 Hyperactive deep tendon reflexes

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. Why is it important to explain these nutritional interventions to the family? 1 Enhance the quality of the client's life 2 Reduce the likelihood of a respiratory infection 3 Prevent the malabsorption syndrome from occurring 4 Decrease the consequences of impaired glucose metabolism

1 Enhance the quality of the client's life Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. They may promote enjoyment of eating and may limit nausea and fatigue.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? (Select all that apply.) 1 Examining the feet daily 2 Wearing well-fitting shoes 3 Performing regular exercise 4 Powdering the feet after showering 5 Visiting the health care provider weekly 6 Testing bathwater with the toes before bathing

1 Examining the feet daily 2 Wearing well-fitting shoes 3 Performing regular exercise

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? (Select all that apply.) 1 Extract peritoneal fluid 2 Improve respiratory status 3 Decrease intrapleural fluid 4 Increase intraabdominal tension 5 Obtain peritoneal fluid for culture

1 Extract peritoneal fluid 2 Improve respiratory status 5 Obtain peritoneal fluid for culture

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? (Select all that apply.) 1 Fatigue 2 Alopecia 3 Vomiting 4 Leukopenia 5 Altered taste sensations

1 Fatigue 5 Altered taste sensations Fatigue and altered taste sensations are major systemic problems caused by radiation therapy. Fatigue may be caused by the increased energy demands needed to repair damaged cells; taste changes are thought to be caused by metabolites released from dead and dying cells. Alopecia can occur when the hair on the head is in the field of radiation, but it is not a major side effect. Vomiting is not common unless the stomach or intestine receives radiation. Leukopenia is not a problem unless 25% or more of the bone marrow is in the treatment field.

A client has a kidney transplant. The nurse should monitor for which signs associated with rejection of the transplant? (Select all that apply.) 1 Fever 2 Oliguria 3 Jaundice 4 Moon face 5 Weight gain

1 Fever 2 Oliguria 5 Weight gain Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria (100 to 400 mL daily) or anuria (less than 100 mL daily) occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy. This response must be assessed further. Jaundice is unrelated to rejection. Moon face is a side effect of steroid therapy; it is not a sign of rejection.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? (Select all that apply.) 1 Fever 2 Tachypnea 3 Hypertension 4 Abdominal rigidity 5 Increased bowel sounds

1 Fever 2 Tachypnea 4 Abdominal rigidity The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intraabdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and therefore hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intraabdominal pressure.

An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? (Select all that apply.) 1 Football 2 Swimming 3 Ice hockey 4 Track events 5 Cross-country skiing

1 Football 3 Ice hockey Trauma to the abdominal wall and to the stoma should be avoided; contact sports, such as football and ice hockey, are contraindicated . Trauma to the abdominal wall is a minimal risk when swimming. Track events are not associated with trauma to the abdominal wall. Cross-country skiing is not associated with trauma to the abdominal wall.

Which factors should the nurse identify that can precipitate hyponatremia? (Select all that apply.) 1 Gastrointestinal (GI) suction 2 Diuretic therapy 3 Inadequate antidiuretic hormone (ADH) secretion 4 Continuous bladder irrigation 5 Parenteral infusion of 0.9% sodium chloride

1 Gastrointestinal (GI) suction 2 Diuretic therapy 4 Continuous bladder irrigation

Which food selections by a client with malabsorption syndrome indicate that the nurse's dietary teaching was successful? (Select all that apply.) 1 Green beans 2 Baked potato 3 Noodle pudding 4 Turkey sandwich 5 Whole wheat cereal

1 Green beans 2 Baked potato Green beans are a vegetable; fresh fruits and vegetables are permitted on a gluten-free diet. A baked potato is permitted on a gluten-free diet. Noodles are made of flour high in gluten and should be avoided. Bread is made with flour high in gluten and should be avoided. Whole wheat cereal is high in gluten and should be avoided.

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? (Select all that apply.) 1 Iced tea 2 Red meat 3 Club soda 4 Hot cocoa 5 Chocolate pudding

1 Iced tea 4 Hot cocoa 5 Chocolate pudding Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition.

A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? (Select all that apply.)

1 Irritability 4 Heart palpitations

A client has cholelithiasis with possible obstruction of the common bile duct. What should be determined about the client's nutritional status before surgery is scheduled? 1 Is the client deficient in vitamins A, D, and K? 2 Does the client eat adequate amounts of dietary fiber? 3 Does the client consume excessive amounts of protein? 4 Are the client's levels of potassium and folic acid increased?

1 Is the client deficient in vitamins A, D, and K? Bile promotes the absorption of fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum. Knowing if the client eats adequate amounts of dietary fiber is not relevant to the situation. Knowing if the client consumes excessive amounts of protein is unnecessary; however, protein is desirable for wound healing. An increase in potassium and folic acid are not expected.

A client has a brain attack (cerebrovascular accident [CVA]) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? (Select all that apply.) 1 Left leg 2 Left arm 3 Right leg 4 Right arm 5 Left side of face

1 Left leg 2 Left arm

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What signs of common complications of diabetes might the nurse expect to identify when assessing this client? (Select all that apply.)

1 Leg ulcers 2 Loss of visual acuity 3 Thick, yellow toenails 5 Decreased sensation in the feet

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? (Select all that apply.) 1 Liver 2 Apples 3 Carrots 4 Raisins 5 Spinach

1 Liver 4 Raisins 5 Spinach

A client who recently had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." Which defense mechanism does the nurse conclude the client is using as a form of self-protection? 1 Projection 2 Sublimation 3 Intellectualization 4 Reaction formation

1 Projection Projection is the attribution of unacceptable feelings and emotions to others. Sublimation is the substitution of socially acceptable feelings or instincts that, if expressed, will be threatening to the self. Intellectualization is the use of mental reasoning processes to deny facing emotions and feelings involved in a situation. Reaction formation is the unconscious reversal of feelings or behavior unacceptable to the self-image and the assumption of opposite feelings or behavior.

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? (Select all that apply.) 1 Psychotic behaviors 2 Jacksonian seizures 3 Nausea and vomiting 4 Rapid pulse 5 Hypotension

1 Psychotic behaviors 2 Jacksonian seizures 3 Nausea and vomiting

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? (Select all that apply.) 1 Malaise 2 Confusion 3 Constipation 4 Swollen lymph glands 5 Oropharyngeal candidiasis

1 Malaise 4 Swollen lymph glands Development of HIV-specific antibodies (seroconversion) is accompanied by a flulike syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs one to three weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flulike syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or opportunistic infection that affects the neurological system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? (Select all that apply.) 1 Muscle weakness 2 Metabolic alkalosis 3 Cardiac dysrhythmias 4 Serum potassium of 5.5 mEq/L 5 Respiratory rate of 24 or higher

1 Muscle weakness 3 Cardiac dysrhythmias Potassium is a component of the sodium-potassium pump that is essential for cellular functioning, especially muscle contraction; a deficiency of either potassium or sodium results in weakness. Potassium is important for muscle contraction; the heart is a muscle and hypokalemia causes dysrhythmias. Decreased functioning of respiratory muscles may result in respiratory acidosis. A serum potassium level of 5.5 is within the upper range of normal. A low respiratory rate, not a rapid one, would be expected because of the weakened respiratory muscles.

A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? (Select all that apply.) 1 Nizatidine (Axid) 2 Ranitidine (Zantac) 3 Famotidine (Pepcid) 4 Lansoprazole (Prevacid) 5 Metoclopramide (Reglan)

1 Nizatidine (Axid) 2 Ranitidine (Zantac) 3 Famotidine (Pepcid) Nizatidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Lansoprazole is a proton pump inhibitor that inhibits gastric secretion up to 90% with one dose daily and provides for symptomatic improvement in GERD. Metoclopramide is a prokinetic agent that increases the rate of gastric emptying; it has multiple side effects and is not appropriate for long-term treatment of GERD.

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1 Oliguria 2 Bradypnea 3 Pulse deficit 4 High potassium levels

1 Oliguria A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output. The respirations become rapid and shallow to compensate for decreased cellular oxygenation. The peripheral pulse rate may be rapid and thready, but it is the same rate as the apical rate. Hypokalemia, not hyperkalemia, occurs because as sodium is retained, potassium is excreted.

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? (Select all that apply.) 1 Oliguria 2 Bradypnea 3 Diaphoresis 4 Tachycardia 5 Hypertension

1 Oliguria 3 Diaphoresis 4 Tachycardia Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output . Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred speech

1 Oliguria 3 Irritability 4 Hypotension Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Decreased blood flow to the kidneys leads to oliguria or anuria. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? (Select all that apply.) 1 Pallor 2 Polyuria 3 Bradypnea 4 Tachycardia 5 Hypertension

1 Pallor 4 Tachycardia Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complications? (Select all that apply.) 1 Phlebitis 2 Infection 3 Hepatitis 4 Anorexia 5 Dysrhythmias

1 Phlebitis 2 Infection Phlebitis may occur because the hypertonic nature of the infusion is irritating to the vein. The concentration of glucose in the solution is a culture medium that supports the growth of microorganisms. Hepatitis usually is not associated with total parenteral nutrition. Anorexia often is present before the medical decision is made to begin total parenteral nutrition. Dysrhythmias are not related to total parenteral nutrition but may be a sign of hyperkalemia or hypokalemia.

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? (Select all that apply.) 1 Raisins 2 Squash 3 Carrots 4 Spinach 5 Apricots

1 Raisins 4 Spinach Raisins and spinach are high in iron. Although squash contains some iron, it is not the best source. Although carrots contain some iron, they are not the best source Although apricots contain some iron, they are not the best source.

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? (Select all that apply.) 1 Rapid, thready pulse 2 Increased skin turgor 3 Decreased hematocrit 4 Elevated specific gravity 5 Adventitious breath sounds

1 Rapid, thready pulse 4 Elevated specific gravity The pulse is rapid and thready because of the decreased blood volume associated with dehydration. The specific gravity of urine increases as the body reabsorbs water to correct the fluid deficit; as a result, the urine is concentrated. Skin turgor is decreased with evidence of tenting. The hematocrit is increased because of hemoconcentration. Adventitious breath sounds, such as crackles, occur with fluid volume excess, not with deficit.

A client is admitted to the hospital for surgery for recto-sigmoid colon cancer, and the nurse is obtaining a health history as part of the admission process. What clinical findings associated with recto-sigmoid colon cancer does the nurse expect the client to report? (Select all that apply.) 1 Rectal bleeding 2 Inability to digest fat 3 Change in the shape of stools 4 Feeling of abdominal bloating

1 Rectal bleeding 3 Change in the shape of stools 4 Feeling of abdominal bloating Passage of red blood (hematochezia) is one of the cardinal signs of recto-sigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbon-like or pencil thin. Tumors in the recto-sigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Stool in the descending and sigmoid colon is more formed and thus straining to pass stools, gas pains, cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to recto-sigmoid colon cancer.

A nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels

1 Relief of anginal pain

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.) 1 Restlessness 2 Muscular rigidity 3 Atony of facial muscles 4 Respiratory tract spasms 5 Spastic voluntary muscle contractions

1 Restlessness 2 Muscular rigidity 4 Respiratory tract spasms 5 Spastic voluntary muscle contractions

A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.) 1 Severe fatigue 2 Sense of unease 3 Choking sensation 4 Chest pain relieved by rest

1 Severe fatigue 2 Sense of unease

1 Severe fatigue 2 Sense of unease A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness . A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.

1 Severe, intense

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin? 1 Swallow the capsule whole 2 Take milk with the medication 3 Hold the tablet under the tongue 4 Note a stinging feeling when the drug is under the tongue

1 Swallow the capsule whole The sustained-release capsule should be swallowed whole on an empty stomach. The capsule should not be chewed or crushed because the "beads" within the capsule are activated on a time-release schedule. Taking the capsule on an empty stomach promotes absorption of the drug. The sustained-release capsule is taken on an empty stomach. A sublingual tablet is held under the tongue, not swallowed; sustained release nitroglycerin is a capsule that needs to be swallowed. A stinging feeling when the drug is under the tongue may occur with a sublingual nitroglycerin tablet; sustained-release nitroglycerin is a capsule that should be swallowed whole.

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1 Syncope 2 Headache 3 Tachycardia 4 Hemiparesis

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? (Select all that apply.)

1. Emotional lability 2. Dyspnea on exertion 5. Hyperactive deep tendon reflexes

1 Take acetaminophen (Tylenol) for my occasional headaches."

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? (Select all that apply.) 1 Use a soft toothbrush. 2 Sleep with the head of the bed elevated. 3 Increase activity levels and take frequent walks. 4 Drink more citrus juices and eat more citrus fruits. 5 Read the ingredients in over-the-counter drugs before taking them

1 Use a soft toothbrush. 5 Read the ingredients in over-the-counter drugs before taking them

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? (Select all that apply.) 1 Vomiting relieves pain. 2 Eating food prevents pain. 3 Pain described as gnawing. 4 Flatulence accompanies pain. 5 Pain occurs a half hour after meals.

1 Vomiting relieves pain. 3 Pain described as gnawing. 5 Pain occurs a half hour after meals. Vomiting removes gastric hydrochloric acid (HCl), which irritates the ulcer and causes pain. Typically, gastric ulcer pain is described as burning or gnawing. Eating causes the secretion of HCl, which increases pain. Eating causes the secretion of HCl, which increases, not relieves, pain. Flatulence is not related to a gastric ulcer.

A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? (Select all that apply.) 1 Weight loss 2 Negative nitrogen balance 3 Increased urine specific gravity 4 Excessive loss of potassium ions 5 Pronounced retention of sodium ions

1 Weight loss 4 Excessive loss of potassium ions

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1. "This type of schedule gives noncancerous cells time to recover." 2. "The department only operates from Monday through Friday." 3. "Your energy level will be increased greatly by a five day schedule." 4. "Side effects are eliminated when treatment is administered for five rather than seven days."

1 "This type of schedule gives noncancerous cells time to recover."

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? 1. Cool, moist towels 2. Dry, sterile dressings 3. Analgesic sunburn spray 4. Vitamin A and D ointment

1 Cool, moist towels

A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes? 1. Deep breathing exercises 2. Progressive muscle relaxation 3. Active range-of-motion exercises 4. Important elements of wound care

1 Deep breathing exercises

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? 1. In the preoperative period 2. Two days before discharge 3. On the first postoperative day 4. During the first dressing change

1 In the preoperative period

A client newly diagnosed with type 2 diabetes is receiving glyburide (Micronase) and asks the nurse how this drug works. The nurse explains that glyburide:

1 Stimulates the pancreas to produce insulin

The primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system is to: 1. Ensure maintenance of the closed system 2. Maintain mechanical suction to the system 3. Encourage the client to deep breathe and cough 4. Keep the client in the dorsal recumbent position

1. Ensure maintenance of the closed system

After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations?

Calcium gluconate

A nurse is caring for a client newly admitted with a diagnosis of pheochromocytoma. Which clinical findings does the nurse expect when assessing this client? (Select all that apply.)

1,2,3

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? (Select all that apply.)

1,2,3

1,2,3,5

A client has a hypoglycemic reaction to insulin. Which client responses should the nurse document as clinical manifestations of hypoglycemia? (Select all that apply.)

1,2,5

A nurse teaches a client who has had a thyroidectomy for thyroid cancer to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? (Select all that apply.)

1,2,5

Several hours after administering insulin, the nurse is assessing a client for an adverse response to the insulin. Which client responses are indicative of a hypoglycemic reaction? (Select all that apply.)

1,2,5,

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? (Select all that apply.)

1,3

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? (Select all that apply.)

1,3

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? (Select all that apply.)

1,3,4

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? (Select all that apply.)

1,3,6

A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? (Select all that apply.)

1,4

The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? (Select all that apply.)

1,4,5

A nurse is reviewing a newly admitted client's medication administration record (MAR). The nurse identifies that it is incomplete when the record is lacking information regarding the client's: 1 Height 2 Allergies 3 Body weight 4 Medical diagnosis

2 Allergies

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1. "This type of schedule gives noncancerous cells time to recover." 2. "The department only operates from Monday through Friday." 3. "Your energy level will be increased greatly by a five-day schedule." 4. "Side effects are eliminated when treatment is administered for five rather than seven days."

1. "This type of schedule gives noncancerous cells time to recover."

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? 1. 30 degrees 2. 45 degrees 3. 60 degrees 4. 90 degrees

1. 30 degrees

What nursing action will limit hypoxia when suctioning a client's airway? 1. Apply suction only after catheter is inserted. 2. Limit suctioning with catheter to half a minute. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode.

1. Apply suction only after catheter is inserted.

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. 1. Assess client's vital signs and lung sounds 2. Insert the catheter without applying suction 3. Rotate the catheter while suction is applied 4. Administer oxygen via a ventilation bag

1. Assess client's vital signs and lung sounds, 4. Administer oxygen via a ventilation bag , 2. Insert the catheter without applying suction, 3. Rotate the catheter while suction is applied

A client enters the emergency department reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention 1. Assess vital signs 2. Insert a saline lock 3. Place client on oxygen 4. Draw blood for troponins

1. Assess vital signs

A client has chronic asthma. For which complication should the nurse monitor this client? 1. Atelectasis 2. Pneumothorax 3. Pulmonary edema 4. Respiratory alkalosis

1. Atelectasis

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C&S) are prescribed. Place these interventions in the order in which they should be implemented.

1. Bed rest 2. Oxygen via nasal cannula 3. Specimen C&S 4. Administration of an antibiotic

1. Bed rest 3. Oxygen via nasal cannula 4. Specimens for C&S 2. Administration of an antibiotic

A client is recovering from full-thickness burns and the nurse provides counselling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching? 1. Cheeseburger and a malted 2. Beef barley soup and orange juice 3. Bacon and tomato sandwich and tea 4. Chicken salad sandwich and soft drink

1. Cheeseburger and a malted

1. Cheeseburger and a malted **Of the selections offered, a cheeseburger and a malted have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair.

A client diagnosed with asthma has received a prescription for an inhaler. The nurse teaches the client how to determine when the inhaler is empty, instructing the client to: 1. Count the number of doses taken 2. Taste the medication when sprayed into the air 3. Shake the canister 4. Place the canister in water to see if it floats

1. Count the number of doses taken

1. Dry skin 2. Lethargy 5. Sensitivity to cold

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? (Select all that apply.) 1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. 4. Use a strong soap when washing the skin. 5. Expose the skin to the sun as often as possible.

1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. **Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not necessary.Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? (Select all that apply.)

1. Excessive Thirst 3. Dry Mucous Membrane 6. Decreased urine specific gravity

A nurse is caring for a client recently diagnosed with type 1 diabetes. For what signs and symptoms of an insulin reaction should the nurse assess this client? (Select all that apply.)

1. Headache 2. Diaphoresis 3. Nervousness

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist: 1. Helps health care providers to control infections 2. Decides what antibiotics should be prescribed for infections 3. Works in the laboratory identifying bacteria that cause infection 4. Is responsible for collecting specimens of potentially infectious drainage

1. Helps health care providers to control infections

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? (Select all that apply.)

1. Hirsutism 3. Buffalo hump

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, mild exercise is expected to cause respirations to: 1. Increase to 24 breaths per minute 2. Become progressively more difficult 3. Decrease in rate as their depth increases 4. Become irregular but remain within normal rates

1. Increase to 24 breaths per minute

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? (Select all that apply.)

1. Lability of mood 2. Slow wound healing

A health care provider prescribes bed rest, loperamide (Maalox), and esomeprazole (Nexium) for a client who just had major surgery. After several days of this regimen, the client complains of diarrhea. The nurse concludes that the most likely cause of the diarrhea is: 1. Loperadine 2. Esomeprazole 3. Bed rest 4. Diet alteration

1. Loperadine **Loperadine, a combination antacid, contains magnesium hydroxide, which may cause diarrhea; it also contains aluminum hydroxide, which may cause constipation.

There is a fire on an inpatient unit at the hospital. List the actions the nurse should take in the order in which they should be performed

1. Move clients and others away from the immediate vicinity of the fire. 2. Initiate the fire code alarm system. 3. Close the doors to the rooms on the unit. 4. Evacuate clients and others to a safe area off the unit with the fire. 5. Inform the clients' families that a fire is occurring.

A client is admitted to the emergency department with a stab wound of the left thorax. The nurse should position the client: 1. On the left side with the head of the bed elevated 2. In the Trendelenburg position with knees gatched 3. In the high-Fowler position with the left side supported 4. On the right side flat in bed with a pillow supporting the left arm

1. On the left side with the head of the bed elevated

1. Palpitations 2. Tachycardia Hyperthyroidism increases the metabolic rate and the need for oxygen; this results in an increased heart rate and myocardial irritability. Hyperthyroidism increases the metabolic rate and the need for oxygen; this results in an increased heart rate. Thickened skin, An apathetic attitude, and Menstrual disturbances are associated with hypothyroidism and myxedema.

A client with terminal cancer signs a do-not-resuscitate (DNR) order upon admission to the hospital. When the client goes into respiratory arrest a week later, the client is not resuscitated. Which factor does the nurse determine is most relevant to the legal aspects of a DNR order? 1. Policies of the agency establish the status of DNR orders 2. Age is an important factor in the decision not to resuscitate 3. Decisions regarding resuscitation reside with the client's primary health care provider 4. Once a DNR order is signed, it remains in force for the entire hospitalization

1. Policies of the agency establish the status of DNR orders

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, the nurse should: 1. Provide a means for the client to write. 2. Allow the client more time for articulation. 3. Use visual clues, such as gestures and objects. 4. Face the client and speak slowly and distinctly

1. Provide a means for the client to write.

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them.

1. Put air into the intermediate-acting insulin 2. Put air into the short-acting insulin vial 3. Withdraw the prescribed amount of short-acting insulin. 4. Withdraw the prescribed amount of intermediate acting insulin. 5. Don a pair of clean gloves

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.) 1. Restlessness 2. Muscular rigidity 3. Atony of facial muscles 4. Respiratory tract spasms 5. Spastic voluntary muscle contractions

1. Restlessness 2. Muscular rigidity 4. Respiratory tract spasms 5. Spastic voluntary muscle contractions

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? (Select all that apply.) 1. Scaly lesions 2. Pruritic lesions 3. Reddened papules 4. Multiple petechiae 5 . Erythematous macules

1. Scaly lesions 2. Pruritic lesions 3. Reddened papules

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately? 1. Small amount of yellowish green oozing 2. Moderate area of serosanguineous oozing 3. Epithelialization under the nonadherent dressing 4. Separation of the edges of the nonadherent dressing

1. Small amount of yellowish green oozing

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is: 1. Sooty 2. Frothy 3. Yellow 4. Tenacious

1. Sooty

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances? 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes

1. Spinach and mangoes

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery? 1. Stable vital signs 2. Decreased urinary output 3. High serum potassium levels 4. Intravascular fluid volume deficits

1. Stable vital signs

A client admitted to the emergency department has ketones in the blood and urine. Which situation associated with this physiological finding should be the nurse's focus when collecting additional data about this client?

1. Starvation

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency during the first hours after surgery, the nurse should: 1. Suction as needed 2. Apply an ice collar 3. Maintain a high-Fowler position 4. Encourage expectoration of secretions

1. Suction as needed

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? 1. The disease process and breathing exercises 2. How to control or prevent respiratory infections 3. Using aerosol therapy, especially nebulizers 4. Priorities in carrying out everyday activities

1. The disease process and breathing exercises

The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? (Select all that apply.)

1. Thirst 4. Fruity breath odor 5. Excessive urination

A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? (Select all that apply.)

1. Tremors 4. Heat intolerance

1. Use tinted glasses. 3. Elevate the head of the bed 45 degrees. 4. Tape eyelids shut at night if they do not close.

When caring for a client, what clinical indicators should the nurse immediately report to the health care provider? (Select all that apply.) 1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities 5 . Flushed skin tone

1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities

A client who had a subtotal thyroidectomy returns to the unit from the postanesthesia care unit. What is the priority nursing action at this time?

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states, "I know I will:

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery?

A nurse working in the diabetes clinic is evaluating a client's success with managing the medical regimen. Which is the best indication that a client with type 1 diabetes is successfully managing the disease?

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystotomy tube is in place."

2 "An indwelling urinary catheter is required for at least a day."

The mother of a large family asks the home health nurse for inexpensive sources of B vitamins. What suggestion should the nurse make? 1 "Eat more red meat." 2 "Bake with whole-wheat flour." 3 "Include more eggs in the diet." 4 "Sprinkle wheat germ on casseroles.

2 "Bake with whole-wheat flour." Whole grains are the least expensive sources of B vitamins. Red meat is a source of B vitamins, but it is expensive. Eggs contain limited quantities of B vitamins. Wheat germ is a source of B vitamins, but it is expensive.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record? 1 "Has intact plantar reflexes." 2 "Exhibits a positive Babinski sign." 3 "Demonstrates normal sensory function." 4 "Able to perform active range of motion."

2 "Exhibits a positive Babinski sign." This is a positive Babinski sign ; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults.

A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required? 1 "I must touch the shunt several times a day to feel for the bruit." 2 "I have to take his blood pressure every day in the arm with the fistula." 3 "He will have to be very careful at night not to lie on the arm with the fistula." 4 "We really should check the fistula every day for signs of redness and swelling.

2 "I have to take his blood pressure every day in the arm with the fistula." Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus. Exsanguination can occur in a matter of minutes if the cannula is dislodged. Redness and swelling are signs of infection, which is a complication of cannulization.

A client is to be discharged after a laparoscopic cholecystectomy. What statement indicates to the nurse that the client understands the discharge instructions? 1 "The bandages must be changed every day." 2 "I may have mild shoulder pain for about a week." 3 "The surgical sites should not be bathed for a week." 4 "I will remain on a full liquid diet for two more days."

2 "I may have mild shoulder pain for about a week." Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery. The response "The bandages must be changed every day" is not necessary; the bandages are removed on the second postoperative day. The response "The surgical sites should not be bathed for a week" is not necessary; the client may bathe and shower as usual. The response "I will remain on a full liquid diet for two more days" is not necessary; clients generally tolerate food after 24 to 48 hours.

After a cervical neck injury, a client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been resolved successfully is: 1 "I hate having everyone else do things for me." 2 "I've gotten used to the brace. I may even miss it when it's gone." 3 "I've been keeping my daily calories low in an attempt to lose weight." 4 "I can't get to sleep. However, I make up for it in the morning by sleeping later."

2 "I've gotten used to the brace. I may even miss it when it's gone."

A client newly diagnosed with type 1 diabetes receives information about insulin. The client states, "I hate shots. Why can't I take the insulin in pill form?" What is the nurse's best response? 1 "Your diabetic condition is too serious for oral insulin." 2 "Insulin is poorly absorbed and its action is erratic when taken by mouth." 3 "Insulin by mouth causes a high incidence of allergic and adverse reactions." 4 "Once your diabetes is controlled, your physician might consider oral insulin."

2 "Insulin is poorly absorbed and its action is erratic when taken by mouth."

A nurse is teaching a client with type 1 diabetes about assessing for signs and symptoms of hypoglycemia as a result of excessive insulin. For what response should the nurse instruct the client to monitor in addition to nervousness and hunger? 1 Thirst 2 Nausea 3 Anorexia 4 Sweating

4 Sweating

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure? 1 "The procedure will determine the types of treatments that will be prescribed." 2 "It is a direct visualization of the joint to diagnose the extent of your knee injury." 3 "You will not remember anything about the procedure because you will be anesthetized." 4 "It is a radiological procedure that will aid in the diagnosis of the extent of your knee injury."

2 "It is a direct visualization of the joint to diagnose the extent of your knee injury."

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the health care provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? 1 "I'm glad to hear you have felt well enough to stop the medication." 2 "It is important to take your medications daily to achieve optimal results." 3 "You must be quite frightened about having high blood pressure." 4 "You will need to document daily whether you took your medication or not."

2 "It is important to take your medications daily to achieve optimal results."

A nurse is caring for a client who is a victim of trauma and is to receive a blood transfusion. How should the nurse respond when the client expresses fear that acquired immunodeficiency disease (AIDS) may be acquired as a result of the blood transfusion? 1 "The blood is treated with radiation to kill the virus." 2 "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk." 3 "The ability to directly identify HIV has eliminated this concern." 4 "Consideration should be given to donating your own blood for transfusion."

2 "Screening for the human immunodeficiency virus (HIV) antibodies has minimized this risk." Although blood is screened for the antibodies, there is a period between the time a potential donor is infected and the time when antibodies are detectable; there is still a risk, but it is minimal. There is no current method of destroying the virus in a blood transfusion. The screening tests involve identification of the antibody, not the virus itself; the virus can be identified by the polymerase chain reaction test but is not part of routine screening. Although many people consider autotransfusion for elective procedures, a trauma victim does not have this option.

A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" The nurse's best response is: 1 "If I were you, I would explore other acceptable treatments for your cancer." 2 "Surgery is the recommended approach. Why don't you discuss this further with the health care provider?" 3 "Maybe you will be more confident with a second opinion. I think you need a referral to another health care provider." 4 "With your disease your prognosis will improve if you follow the suggestion to have the recommended surgery."

2 "Surgery is the recommended approach. Why don't you discuss this further with the health care provider?"

Which statement made by a client after attending a class on nutrition indicates an understanding of the importance of essential amino acids? 1 "Amino acids can be made by the body because they are essential to life." 2 "They come from the diet because they cannot be synthesized in the body." 3 "They are used in key processes essential for growth once they are synthesized by the body." 4 "Essential amino acids are required for metabolism, whereas the other amino acids are not."

2 "They come from the diet because they cannot be synthesized in the body." The body does not synthesize these amino acids ; they must be ingested in the diet. The essential amino acids cannot be made by the body. All amino acids are needed for metabolism; however, arginine and histidine are necessary for growth, but not during adulthood.

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin (Dilantin) for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? 1 "Did you forget to take your medication?" 2 "You are worried about having more seizures?" 3 "You must be under a lot of stress right now." 4 "Don't be too concerned because your medication needs to be increased."

2 "You are worried about having more seizures?"

A client with chronic kidney disease has been on hemodialysis for two years. The client relates to a nurse in the dialysis unit in an angry, critical manner and frequently does not follow the prescribed diet or take prescribed medications. What does the nurse identify as the most likely underlying cause of this behavior? 1 A constructive method of accepting reality 2 A defense against underlying depression and fear 3 An attempt to punish the nurse and the members of the staff 4 An effort to maintain the previous lifestyle as much as possible

2 A defense against underlying depression and fear

A client with a diagnosis of incarcerated hernia asks the nurse for an explanation of the diagnosis. The nurse explains that an incarcerated hernia means that the: 1 Bowel has twisted on itself 2 A piece of the intestine gets stuck in a hole in the abdominal wall 3 Intestinal blood supply has been cut off 4 Involved intestine has developed an erosion

2 A piece of the intestine gets stuck in a hole in the abdominal wall When the intestine cannot be returned manually to the body cavity, the hernia is considered incarcerated. A twisted bowel is called a volvulus. When blood supply is cut off to the intestine, it is called a strangulated hernia. Erosion of intestinal tissue may be caused by a variety of conditions; one condition that can cause erosion of the bowel is a strangulated hernia, not an incarcerated hernia.

A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. What is the priority nursing action? 1 Strain the client's urine. 2 Administer the prescribed morphine. 3 Place in the high-Fowler position. 4 Collect a urine specimen for culture and sensitivity

2 Administer the prescribed morphine. Pain relief is the priority. Clients report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, other medical and nursing interventions can be implemented. Although straining all urine is required, pain relief is the priority. Once the client is medicated for pain, the urine that was set aside can be strained. The high-Fowler position is not necessary. The client can be assisted to assume a position of comfort. The urine was sent for a culture and sensitivity in the emergency department.

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1 Pallor 2 Ankle edema 3 Yellowed toenails 4 Diminished pedal pulses

2 Ankle edema Ankle edema results from venous pooling with increased hydrostatic pressure; fluid moves from intravascular to interstitial spaces. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.

A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. What foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Applesauce, cream of wheat, and milk 3 Tomato juice, raisin bran cereal, and tea 4 Sliced oranges, pancakes with syrup, and coffee

2 Applesauce, cream of wheat, and milk

A client has surgery for an incarcerated hernia. The health care provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? 1 Reduce dietary roughage. 2 Avoid lifting heavy items. 3 Increase dietary potassium intake. 4 Keep the head of the bed elevated.

2 Avoid lifting heavy items.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

2 Babinski

Daily Humulin R insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential insulin reaction? 1 At breakfast 2 Before lunch 3 Before dinner 4 In the early afternoon

2 Before lunch Regular insulin is short acting, and it peaks in two to four hours, which in this case will be at or before lunch. Breakfast is too soon; regular insulin peaks in two to four hours. Before dinner is too late; regular insulin peaks in two to four hours. The early afternoon is too late; regular insulin peaks in two to four hours.

A nurse is caring for a client who reports urinary problems, and the health care provider prescribes a cholinergic medication. Which response is prevented that helps the nurse determine that the medication is effective? 1 Bladder spasticity 2 Bladder flaccidity 3 Urinary tract calculi 4 Urinary tract infections

2 Bladder flaccidity Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder. Cholinergics will not prevent renal calculi. Urinary tract infections are a secondary gain because cholinergics help prevent urinary retention that can lead to urinary tract infection, but this is not the primary purpose for administering a cholinergic.

When a client has gluteal edema, why should the nurse avoid using the gluteus maximus muscle for administration of intramuscular medications? 1 Deposition of an injected drug causes pain. 2 Blood supply is insufficient for adequate absorption. 3 Fluid leaks from the site for a long time after the injection. 4 Tissue fluid dilutes the drug before it enters the circulation.

2 Blood supply is insufficient for adequate absorption. Fluid in interstitial spaces impairs circulation, leading to slowed absorption of drugs, as well as an increased risk for skin breakdown.

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1 Inflammation of the synovial membrane rarely occurs. 2 Bony ankylosis of a joint is irreversible and causes immobility. 3 Complete immobility is desired during the acute phase of inflammation. 4 Redness and swelling of a joint signify that irreversible damage has occurred.

2 Bony ankylosis of a joint is irreversible and causes immobility.

A nurse is caring for a postoperative client who had a gastrectomy. What early client response indicates that peristalsis has returned? 1 Passage of stool occurs 2 Borborygmi are auscultated 3 Nausea and vomiting cease 4 Absence of a rigid and tender abdomen

2 Borborygmi are auscultated The presence of borborygmi indicates the return of peristalsis. The nurse should auscultate the abdomen and listen for bowel sounds, which signify the passage of flatus. The first bowel movement occurs after peristalsis returns and usually after food is ingested. Nausea may be present even though peristalsis has begun. Peristalsis should return before the tenderness of the abdomen subsides.

A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin (Dilantin). The nurse should instruct the client to: 1 Take the medication on an empty stomach 2 Brush the teeth and gums three times daily 3 Stop taking the drug if abdominal pain occurs 4 Note any change in pulse and respiratory rates

2 Brush the teeth and gums three times daily Adequate dental hygiene is essential to control or prevent the common side effect of hypertrophy of the gums. The medication should be taken with food or milk to decrease gastrointestinal side effects. The health care provider should be consulted before the drug is discontinued or the dosage is adjusted; usually in this situation, a gradual dosage reduction is prescribed. Changes in pulse and respiratory rates are unrelated to phenytoin therapy.

2 Calcium gluconate; The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia

A nurse concludes that the anemia that accompanies chronic kidney disease should be treated because it contributes to: 1 Uremic frost 2 Chronic fatigue 3 Tubular necrosis 4 Dependent edema

2 Chronic fatigue

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence? 1 Placement of a T-tube 2 Client being overweight 3 Presence of excessive flatus 4 Client receiving prophylactic antibiotics

2 Client being overweight

A nurse is caring for a client with a history of gastrointestinal (GI) irritability. What should the nurse advise the client to avoid to limit GI irritability? 1 Iodized salt 2 Cola drinks 3 Amino acids 4 Rice products

2 Cola drinks

A low-residue diet is recommended for a client. Which food should the nurse encourage the client to select from a menu? 1 Steamed broccoli 2 Creamed potatoes 3 Raw spinach salad 4 Baked sweet potato

2 Creamed potatoes Creamed potatoes are the only vegetable listed that is included in a low-residue diet; this vegetable is low in fiber. Steamed broccoli, raw spinach salad, and baked sweet potato contain more fiber than creamed potatoes.

A client's leg is placed in Buck's extension to immobilize a fracture until surgery can be performed. When caring for this client, the nurse understands that Buck's extension is a type of: 1 Skeletal traction 2 Cutaneous traction 3 Halter transfixation 4 Balanced suspension

2 Cutaneous traction Buck's extension is an example of traction applied directly to the skin (cutaneous) by tape or by a foam boot. Skeletal traction is applied directly to the bony skeleton. There is no such intervention as halter transfixation. A halter (strap) may be used with cervical or pelvic traction. Balanced suspension traction keeps the affected extremity elevated off the be

A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms? 1 Chronic glomerulonephritis 2 Cystitis 3 Nephrotic syndrome 4 Pyelonephritis

2 Cystitis Cystitis is an inflammation of the bladder that causes frequency and urgency of urination, pain on micturition, and hematuria. Chronic glomerulonephritis is atrophy of the kidney that is associated with manifestations of systemic circulatory overload. Nephrotic syndrome is a condition of increased glomerular permeability characterized by severe proteinuria. Pyelonephritis is a diffuse, pyogenic infection of the pelvis and parenchyma of the kidney that causes flank pain, chills, fever, and weakness.

An 85-year-old client has a three-day history of nausea, vomiting, and diarrhea. The client develops weakness and confusion and is admitted to the hospital. To best monitor the client's rehydration status, the nurse should assess the client's: 1 Skin turgor 2 Daily weight 3 Urinary output 4 Mucous membranes

2 Daily weight A continuous increase in serial weight determinations indicates a movement toward correction in the dehydration; 1 L of fluid weighs 2.2 pounds. The skin in older adults has less fluid and subcutaneous fat than younger adults, which results in a subjective and inaccurate assessment of rehydration. In older adults there can be a 50% decrease in renal blood flow and tubular function; therefore, urinary output does not provide an accurate assessment of rehydration therapy. The mucous membranes in older adults are drier than in younger adults because of the decrease in salivary secretions and therefore do not provide an accurate assessment of rehydration therapy.

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound? 1 Monitoring urinary output 2 Decreasing external stimuli 3 Maintaining body alignment 4 Encouraging high intake of fluid

2 Decreasing external stimuli

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. The nurse notifies the health care provider about the client becoming upset. What is the primary reason the nurse chose to notify the health care provider? 1 With this type of emotion, the dosage of steroids may have to be reduced 2 Despite steroid therapy, the ability to cope with stress will be decreased 3 Mild sedation is needed to assist the client with coping with the loss 4 Feelings of exhaustion with lethargy will occur as a result of stress

2 Despite steroid therapy, the ability to cope with stress will be decreased

A health care provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? 1 Ingest foods while they are hot. 2 Divide food into four to six meals a day. 3 Eat the last of three daily meals by 8 pm. 4 Suck a peppermint candy after each meal.

2 Divide food into four to six meals a day.

A health care provider prescribes psyllium (Metamucil) 3.5 g twice a day for constipation. What is most important for the nurse to teach this client? 1 Urine may be discolored. 2 Each dose should be taken with a full glass of water. 3 Use only when necessary because it can cause dependence. 4 Daily use may inhibit the absorption of some fat-soluble vitamins.

2 Each dose should be taken with a full glass of water.

A client with a history of chronic kidney disease is hospitalized. The nurse assesses the client for signs of related kidney insufficiency, which include: 1 Facial flushing 2 Edema and pruritus 3 Dribbling after voiding 4 Diminished force and caliber of stream

2 Edema and pruritus

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1 History of hypertensive disease 2 Emboli associated with atrial fibrillation 3 Developmental defect of the arterial wall 4 Inappropriate paroxysmal neural discharge

2 Emboli associated with atrial fibrillation

A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instruction should the nurse provide to help prevent leakage of stool from the appliance? 1 Irrigate the colostomy to establish an expected pattern of elimination. 2 Empty the appliance when it is approximately one half full with feces. 3 Use an antiseptic to clean the peristomal skin before applying the appliance. 4 Select an appliance with a pouch opening of at least 5 cm larger than the stoma.

2 Empty the appliance when it is approximately one half full with feces.

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation? 1 Turning the client from side to side 2 Encouraging the client to perform ankle exercises 3 Getting the client up to sit in a chair for as long as tolerated 4 Ambulating the client when the effects of anesthesia subside

2 Encouraging the client to perform ankle exercises

A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery? 1 Describing the specific surgical procedure 2 Ensuring the bowel preparation is initiated 3 Encouraging the client to socialize with other clients 4 Providing the client's food preferences for the evening meal

2 Ensuring the bowel preparation is initiated

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: 1 Iliac area 2 Epigastric area 3 Hypogastric area 4 Suprasternal area

2 Epigastric area

A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours? 1 Taking the client's temperature. 2 Evaluating the client's motor status. 3 Obtaining the client's urine for a urinalysis. 4 Monitoring the client's blood pressure for hypertension.

2 Evaluating the client's motor status. Evaluating the client's motor status will indicate whether symptoms progress or improve and assist the health care provider in determining the diagnosis. An elevation in temperature is not an early sign of an extension of a brain attack (cerebrovascular accident [CVA]). Obtaining a urine specimen for a urinalysis is not the priority. The data indicate that vital signs are within expected limits and do not reflect hypertension; although the vital signs should be monitored, the client's motor status in this instance is most significant.

A nurse is caring for a client who has a prescription for a diuretic, 2-gram sodium diet, and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) level 42 mg/dL and creatinine 1.1 mg/dL. Considering the assessment findings, what is the most appropriate intervention by the nurse? 1 Sending the client's urine for analysis 2 Expecting an increase in the oral fluid intake 3 Placing the client on strict intake and output measurements 4 Notifying a nutritionist/dietitian so that sodium can be restricted further

2 Expecting an increase in the oral fluid intake

A client is receiving furosemide (Lasix). For which sign of hypokalemia should the nurse monitor the client? 1 Chvostek sign 2 Flabby muscles 3 Anxious behavior 4 Abdominal cramping

2 Flabby muscles With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue, muscle weakness, and soft, flabby muscles. Chvostek sign, the contraction of the facial muscles in response to a light tap over the facial nerve in front of the ear, is associated with hypocalcemia; low calcium levels allow sodium to move into excitable cells, increasing depolarization and nerve excitability. Anxiety and irritability are associated with hyperkalemia. Hyperkalemia affects the nervous and muscular systems; fatigue, weakness, and lethargy are associated with hypokalemia. Decreased gastrointestinal motility occurs with hypokalemia; abdominal cramping is associated with hyperkalemia and is caused by hyperactivity of smooth muscles.

The nurse reviews a client's medication history, which includes a cholinergic medication. The client states, "I take that for some kind of urinary problem." The nurse recalls that cholinergic medications are prescribed primarily for what type of urinary condition? 1 Kidney stones 2 Flaccid bladder 3 Spastic bladder 4 Urinary tract infections

2 Flaccid bladder Cholinergics intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention.

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. The nurse concludes that the element that most likely contributed to the hyponatremia is: 1 Salt intake 2 Fluid intake 3 Sodium absorption 4 Glomerular filtration

2 Fluid intake Hemodilution has occurred because the 1500 mL of intravenous fluid has lowered the serum sodium level. An increase in salt intake is not the cause of the hyponatremia; in addition, the client has not eaten for several days. A decreased, not increased, reabsorption of sodium occurs in acute renal failure. A decreased, not increased, glomerular filtration rate occurs with renal failure.

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? 1 Urine output 2 Glucose level 3 Serum potassium 4 Immune response

2 Glucose level As a result of increased cortisol levels, glucose metabolism is altered, which may contribute to an increase in blood glucose levels. Increased mineralocorticoids will decrease urine output. Sodium is retained by the kidneys, but potassium is excreted. The immune response is suppressed.

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred? 1 Suddenly 2 Gradually 3 Overnight 4 Irregularly

2 Gradually

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1 Arterial spasm 2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus

2 Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

The nurse is providing care for a client that had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says, "The medication will: 1 Limit inflammation around my incision." 2 Help prevent further clogging of my arteries." 3 Lower the slight fever I have had since surgery." 4 Reduce the discomfort I feel at the surgical incision."

2 Help prevent further clogging of my arteries." Clopidogrel interferes with platelet aggregation, which impedes the formation of thrombi. Clopidogrel is a platelet aggregation inhibitor, not an anti-inflammatory. Clopidogrel is a platelet aggregation inhibitor, not an antipyretic. Clopidogrel is a platelet aggregation inhibitor, not an analgesic.

A client with acute kidney failure is to receive peritoneal dialysis and asks why the procedure is necessary. The nurse's best response is, "It: 1 Prevents the development of serious heart problems." 2 Helps perform some of the work usually done by the kidneys." 3 Removes toxic chemicals from the body so you will not get worse." 4 Speeds recovery because the kidneys are not responding to other therapy."

2 Helps perform some of the work usually done by the kidneys." Dialysis removes chemicals, wastes, and fluids usually removed from the body by the kidneys. The mention of heart problems is a threatening response and may cause increased fear or anxiety. Stating that peritoneal dialysis "removes toxic chemicals from the body so you will not get worse" is threatening and can cause an increase in anxiety. Dialysis helps maintain fluid and electrolyte balance; there are no data to indicate the cause of the acute kidney failure or previous therapy.

A client who had a transurethral resection of the prostate is transferred to the post-anesthesia care unit with an IV and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period? 1 Sepsis 2 Hemorrhage 3 Leakage around the catheter 4 Urinary retention with overflow

2 Hemorrhage After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs it will manifest later in the postoperative course.

An acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy is: 1 Sepsis 2 Hemorrhage 3 Renal failure 4 Paralytic ileus

2 Hemorrhage The kidney, an extremely vascular organ, receives a large percentage of the blood flow, and hemorrhage from the operative site can occur. Sepsis and renal failure may occur later in the postoperative period. Paralytic ileus can occur, but it is not life threatening.

A nurse is caring for a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis. What dietary need should the nurse discuss with the client? 1 Low-calorie foods 2 High-quality protein 3 Increased fluid intake 4 Foods rich in potassium

2 High-quality protein Although proteins may be restricted, those eaten should be high-quality proteins that are used to replace proteins lost during dialysis. A high-caloric intake should be encouraged. Increased fluid intake is inappropriate; fluids usually are restricted moderately because of impaired renal function. Foods rich in potassium are inappropriate; high-potassium foods are restricted because of impaired renal function.

The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client: 1 Slides toward the edge of the seat before standing 2 Holds both handles of the walker while rising to the standing position 3 Moves forward into the walker after transferring from sitting to standing 4 Stands in place holding on to the walker for at least 30 seconds before walking

2 Holds both handles of the walker while rising to the standing position Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position

2 Hypocalcemia The signs and symptoms presented in the question indicate hypocalcemia. Injury to the parathyroid glands during a thyroidectomy results in a deficiency of parathormone, which decreases calcium levels in the blood.

A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for: 1 Hypertensive crisis 2 Hypovolemic shock 3 Abdominal distention 4 Tenting of the integument

2 Hypovolemic shock

A client with jaundice associated with hepatitis expresses concern over the change in skin color. The nurse explains that this color change is a result of: 1 Stimulation of the liver to produce an excess quantity of bile pigments 2 Inability of the liver to remove normal amounts of bilirubin from the blood 3 Increased destruction of red blood cells during the acute phase of the disease 4 Decreased prothrombin levels, leading to multiple sites of intradermal bleeding

2 Inability of the liver to remove normal amounts of bilirubin from the blood

A client is returned to the surgical unit after an abdominal cholecystectomy. What is the main reason why the nurse should assess for clinical indicators of respiratory complications? 1 Length of time required for surgery is prolonged. 2 Incision is in close proximity to the client's diaphragm. 3 Client's resistance is lowered because of bile in the blood. 4 Bloodstream is invaded by microorganisms from the biliary tract.

2 Incision is in close proximity to the client's diaphragm.

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common? 1 Increased urinary output 2 Increased cardiac workload 3 Decreased oxygen saturation 4 Decreased arterial blood pressure

2 Increased cardiac workload With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system. Urinary output is not increased; it may be decreased to maintain blood volume in anemia and decrease blood viscosity in polycythemia. The percent of hemoglobin molecules saturated with oxygen is not affected. Clients with polycythemia will have increased blood pressure because of increased viscosity of the blood.

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? 1 No further drainage from the incisions 2 Increased edema in the leg that provided the donor graft 3 Mild incisional pain and tenderness for three to four weeks 4 Extreme fatigue and a mild fever occurring for several weeks

2 Increased edema in the leg that provided the donor graft Because the client is out of bed more at home and the leg used for the donor graft is in the dependent position, edema of this extremity usually increases. The internal mammary artery is the graft of choice and was probably used in the first CABG procedure, necessitating retrieval of a vessel from the leg. Serosanguinous drainage may persist after discharge. Mild incisional pain and tenderness may persist longer than 3 to 4 weeks because it takes 6 to 12 weeks for the sternum to heal. Extreme fatigue and a mild fever are not expected; these are associated with post-pericardiotomy syndrome and should be reported to the health care provider immediately.

A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences: 1 Slight stiffness of the fingers 2 Increasing pain at the injury site 3 Small amount of bloody drainage on the cast 4 Bounding radial pulse in the affected extremity

2 Increasing pain at the injury site

A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to: 1 Urate crystals in the synovial tissue 2 Inflammation in the joint's synovial lining 3 Formation of bony spurs on the joint surfaces 4 Escaped fluid from the capillaries that increases interstitial fluids

2 Inflammation in the joint's synovial lining The pathological process involved with rheumatoid arthritis is accompanied by vascular congestion, fibrin exudate, and cellular infiltrate, causing inflammation of the synovium.

A client has had a total gastrectomy. What should the nurse include in the discharge teaching? 1 Daily use of a stool softener. 2 Injections of vitamin B12 for life. 3 Monthly injections of iron dextran. 4 Replacement of pancreatic enzymes.

2 Injections of vitamin B12 for life. Intrinsic factor is lost with removal of the stomach, and vitamin B12 is needed to maintain the hemoglobin level and prevent pernicious anemia. Adequate diet, fluid intake, and exercise should prevent constipation. Iron deficiency anemia is not expected. Secretion of pancreatic enzymes should not be affected because this surgery does not alter this function.

A day after surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." Which conflict of Erikson's developmental stages is reflected by this comment? 1 Trust versus mistrust 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

2 Integrity versus despair

A nurse is assessing a client who is scheduled for a liver biopsy. What assessment finding needs to be reported immediately because it warrants a postponement of the liver biopsy? 1 Mental confusion 2 International normalized ratio (INR) of 4.0 3 Presence of an infectious disease 4 Foods high in vitamin K eaten before the biops

2 International normalized ratio (INR) of 4.0 Prolonged INR time indicates that the client has a deficiency in clotting; this should be corrected before the biopsy is performed to prevent hemorrhag

A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea? 1 Cor pulmonale 2 Left heart failure 3 Bronchial spasms 4 Right ventricular failure

2 Left heart failure The failing left ventricle cannot accept blood that is returning from the lungs; this results in increased vascular pressure in the lungs. Cor pulmonale is associated with right ventricular failure. Bronchial spasms are associated with asthma. There is no evidence that the client has asthma. Right ventricular failure is associated with distended neck veins, hepatomegaly, anorexia, diminished urinary output, and respiratory distress.

A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program? 1 Total blindness is inevitable 2 Lost vision cannot be restored 3 Use of both eyes usually is restricted 4 Surgery will help the problem only temporarily

2 Lost vision cannot be restored Retinal damage caused by the increased intraocular pressure of glaucoma is progressive and permanent if the disease is not controlled. Early treatment may prevent blindness. One eye may be affected, and there is no restriction on the use of either eye. Surgery can open up drainage and permanently reduce pressure.

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash

2 Low calcium Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout. Foods high in phosphorus must be avoided.

A client's urine specific gravity is being measured. For what condition should the nurse conduct a focused assessment when a client's specific gravity is increased? 1 Fluid overload 2 Low-grade fever 3 Diabetes insipidus 4 Chronic kidney disease

2 Low-grade fever An elevated temperature can lead to dehydration and an increased urine specific gravity (more than 102.5). When there is edema or fluid overload, the accumulating body fluid will cause a decrease in the specific gravity of the urine

A client with Ménière disease is advised to eat a sodium-restricted diet to reduce endolymphatic fluid. Which food selection provides evidence that the nurse's teaching was effective? 1 Cake 2 Macaroni 3 Baked clams 4 Grilled cheese

2 Macaroni Macaroni, boiled in unsalted water, has the least sodium of the food choices offered.

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? 1 Monitor vital signs. 2 Maintain an open airway. 3 Monitor pupil response and equality. 4 Maintain fluid and electrolyte balance

2 Maintain an open airway.

A client with an ileal conduit is being prepared for discharge. As part of the discharge teaching, the nurse instructs the client to: 1 Abstain from beer and alcohol consumption 2 Maintain fluid intake of at least 2 L daily 3 Notify the health care provider if the stoma size decreases 4 Avoid getting soap and water on the peristomal skin

2 Maintain fluid intake of at least 2 L daily High-fluid intake flushes the ileal conduit and prevents infection and obstruction caused by mucus or uric acid crystals

A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first? 1 Milk the tubing gently. 2 Notify the health care provider. 3 Check the patency of the catheter. 4 Irrigate the catheter with prescribed solutions

2 Notify the health care provider.

A client who had a suprapubic prostatectomy returns from the post-anesthesia care unit and accidentally pulls out the urethral catheter. What should the nurse do first? 1 Reinsert a new catheter. 2 Notify the health care provider. 3 Check for bleeding by irrigating the suprapubic tube. 4 Take no immediate action if the suprapubic tube is draining.

2 Notify the health care provider. The catheter must be reinserted by the health care provider to ensure bladder emptying, maintain pressure at the operative site, and prevent hemorrhage. Because of the danger of further trauma to the urethra and surgical site, the health care provider should insert the catheter.

Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is: 1 Warmth 2 Numbness 3 Skin desquamation 4 Generalized discomfort

2 Numbness

A client is admitted to the hospital for the surgical repair of an incarcerated indirect inguinal hernia. What is the primary preoperative nursing intervention for this client? 1 Placing the client in the supine position 2 Observing the client's bowel movements 3 Monitoring the client's serum enzyme levels 4 Teaching the client about the need to cough postoperatively

2 Observing the client's bowel movements A possible complication of a hernia is intestinal obstruction; if an obstruction occurs, there is no passage of flatus or regular bowel movements. The supine position has no effect on an incarcerated hernia. Monitoring serum enzyme levels is done for all clients; it is not specific for a client with a hernia. Coughing is contraindicated because it places stress on the operative site.

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? 1 Assist the client to ambulate. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Encourage using the incentive spirometer.

2 Obtain the client's vital signs.

A client follows a vegetarian diet and must compensate for the lack of vitamin B12 found in food of animal origin. Which food should the nurse encourage the client to consume each day? 1 One orange 2 One glass of soy milk 3 Two handfuls of nuts 4 Two servings of green vegetables

2 One glass of soy milk One glass of soy milk provides the recommended daily amount of vitamin B12. Soy protein is the only complete plant protein. One orange does not provide vitamin B12. Two handfuls of nuts does not provide vitamin B12. Two servings of green vegetables does not provide vitamin B12.

Which clinical indicator does a nurse identify when assessing a client with hemiplegia? 1 Paresis of both lower extremities 2 Paralysis of one side of the body 3 Paralysis of both lower extremities 4 Paresis of upper and lower extremities

2 Paralysis of one side of the body

A client is scheduled for an adrenalectomy. The nurse expects that the plan of care will include: 1 Low protein diet 2 Parenteral steroids 3 Preoperative 24-hour urine specimen 4 Withholding all medications 48 hours before surgery

2 Parenteral steroids; Steroid therapy usually is given intravenously or intramuscularly preoperatively and continued intraoperatively to prepare for the acute adrenal insufficiency that follows surgery. The diet must supply ample protein and potassium. A 24-hour urine specimen is unnecessary. Glucocorticoids must be administered preoperatively to prevent adrenal insufficiency during surgery.

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to: 1 Cleanse the pin sites with alcohol several times a day 2 Perform a neurovascular assessment of both lower extremities 3 Ambulate the client with partial weight bearing on the affected leg 4 Maintain placement of an abduction pillow between the client's legs

2 Perform a neurovascular assessment of both lower extremities A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse should monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase and the leg will feel hard and firm on palpation. Both legs are assessed for symmetry.

A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, the nurse should: 1 Apply an abdominal binder 2 Place a support under the scrotum 3 Teach the client to cough several times an hour 4 Encourage the client to eat a high carbohydrate diet

2 Place a support under the scrotum After inguinal hernia repair, the scrotum commonly becomes edematous and painful; drainage is facilitated by elevating the scrotum on rolled linen or using a scrotal support

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every one to two hours? 1 Maintain comfort 2 Prevent pressure ulcers 3 Prevent flexion contractures of the extremities 4 Improve venous circulation in the lower extremities

2 Prevent pressure ulcers

A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report? 1 Bloody vomitus 2 Projectile vomiting 3 Bleeding with defecation 4 Pain in the left lower quadrant

2 Projectile vomiting Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material. Hematemesis is associated more closely with peptic ulcer disease. Bleeding with defecation is associated with hemorrhoids and anal fissures. Pain in the left lower quadrant is associated with diverticulitis. Pain associated with a small bowel obstruction usually is more diffuse.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, the nurse should: 1 Hold the client's extremities firmly 2 Protect the client's head from injury 3 Insert an airway between the client's teeth 4 Have several staff members move the client to a soft surface

2 Protect the client's head from injury

A client with Crohn's disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to a major deficiency of: 1 Iron 2 Protein 3 Vitamin C 4 Linoleic acid

2 Protein

A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end stage renal disease (ESRD)? 1 Fluid 2 Protein 3 Sodium 4 Potassium

2 Protein The waste products of protein metabolism are the main cause of uremia. The degree of protein restriction is determined by the severity of the disease.

An 18-year-old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1 Urinary retention 2 Gastric hyperacidity 3 Rebound tenderness 4 Increased lower bowel motility

3 Rebound tenderness -Rebound tenderness is a classic subjective sign of appendicitis .

A client is recuperating from a spinal cord injury at the T4 level and depends on a wheelchair for mobility. What should the nurse teach the client to prepare for use of a wheelchair? 1 Leg lifts to prevent hip contractures 2 Push-ups to strengthen arm muscles 3 Balancing exercises to promote equilibrium 4 Quadriceps-setting exercises to maintain muscle tone

2 Push-ups to strengthen arm muscles Arm strength is necessary for transfers and activities of daily living and for the use of crutches or a wheelchair.

A nurse is providing education to a community group about hospice. The nurse clarifies that the primary goal of hospice is help clients do what? 1 Have the option of assisted suicide 2 Remain comfortable until the end of life 3 Explore the newest treatments for their form of cancer 4 Release family members from participating in care

2 Remain comfortable until the end of life

Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. The nurse's priority action is to: 1 Obtain a prescription for an antibiotic 2 Report the client's concern to the primary health care provider 3 Administer the prescribed medication for pain 4 Explain that this is typical after a cast is applied

2 Report the client's concern to the primary health care provider

A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing intervention? 1 Store urine in lead-lined containers. 2 Restrict visitors to a 10-minute stay. 3 Wear a lead-lined apron when giving care. 4 Avoid giving injections in the gluteal muscle.

2 Restrict visitors to a 10-minute stay.

A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively? 1 Renal scan 2 Serum creatinine 3 24-hour urine output 4 White blood cell (WBC) count

2 Serum creatinine

A nurse is providing postoperative care to a client who had a kidney transplant. What assessment is the best indicator of the functioning of the newly transplanted kidney? 1 Renal scan 2 Serum creatinine 3 White blood cell (WBC) count 4 Intake and output balance daily

2 Serum creatinine Serum creatinine, a test of renal function, measures the kidneys' ability to excrete metabolic wastes; creatinine, a nitrogenous product of protein breakdown, is increased with kidney insufficiency.

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, the nurse documents this gait as: 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric

2 Shuffling

When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? 1 Slide slowly to the floor to prevent a fall and injury. 2 Sit on the edge of the bed while they hold the client upright. 3 Bend forward because this will increase blood flow to the brain. 4 Lie down quickly so the legs can be raised above the heart level.

2 Sit on the edge of the bed while they hold the client upright.

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control? 1 Dry skin 2 Skin pallor 3 Constriction of pupils 4 Pulse rate of 60 beats/min

2 Skin pallor The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor. The sympathetic system stimulates, rather than inhibits, secretion by the sweat glands. Constriction of pupils is not under sympathetic control; the parasympathetic system constricts the pupils. The parasympathetic system (vagus nerve) slows the pulse, and the sympathetic system increases it.

A client who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. The nurse informs the client that one of the substances passing through the membrane is: 1 Blood 2 Sodium 3 Glucose 4 Bacteria

2 Sodium Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. Red blood cells do not pass through the semipermeable membrane during hemodialysis. Glucose does not pass through the semipermeable membrane during hemodialysis. Bacteria do not pass through the semipermeable membrane during hemodialysis.

A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy? 1 Fever of 100° F 2 Sores in the mouth 3 Moderate diarrhea after treatment 4 Nausea for six hours after treatment

2 Sores in the mouth Stomatitis is a common response to chemotherapy and should be brought to the health care provider's attention because a swish-and-swallow anesthetic solution can be prescribed to make the client more comfortable. Although a low-grade fever may occur, it does not require immediate medical attention. Moderate diarrhea is expected and is not a cause for concern unless dehydration results. Nausea is expected but should be reported if it lasts more than 24 hours.

A nurse is providing preoperative teaching for a client who is scheduled for a transurethral resection of the prostate. What should the nurse include in the client's postoperative teaching plan? 1 The urine will be bright red for 24 to 48 hours 2 Spasms of the bladder occur during the first 24 to 48 hours 3 To decrease bladder contractions, the Valsalva maneuver and Kegel exercises will be encouraged 4 To maintain proper fluid balance, oral fluids are restricted during continuous urinary bladder irrigations

2 Spasms of the bladder occur during the first 24 to 48 hours Spasms result from irritation of the bladder during surgery; they decrease in intensity and frequency as healing occurs. Urine that is bright red for 24 to 48 hours is too long; this indicates hemorrhage. Drainage should be dark red and after the first few hours gradually turn pink. The Valsalva maneuver should be avoided because it may initiate prostatic bleeding, not bladder contractions. The presence of continuous bladder irrigation (CBI) is unrelated to the amount of oral fluids that should be consumed; once the continuous bladder irrigation is discontinued, oral fluids should be encouraged.

In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, the most critical concern is: 1. Skin integrity 2. Gas exchange 3. Social isolation 4. Nutritional status

2. Gas exchange *P. jiroveci , now believed to be a fungus, causes pneumonia in immunosuppressed hosts; it can cause death in 60% of the clients. The client's respiratory status is the priority.

A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, the nurse expects: 1 Melena 2 Steatorrhea 3 Hard, dry stool 4 Ribbon-shaped stool

2 Steatorrhea Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon.

A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established by a: 1 Urinalysis 2 Stool culture 3 Febrile agglutinin test 4 Complete blood count

2 Stool culture

Three months after beginning chemotherapy, a client develops severe anorexia, stomatitis, and episodes of diarrhea. The nursing plan includes increasing fluid and caloric intake and measures to relieve discomfort caused by stomatitis. To address the plan, the nurse should recommend that the client: 1 Drink water frequently 2 Suck on an ice pop every two hours 3 Swallow warm tea throughout the day 4 Rinse the mouth with the prescribed nystatin after meals

2 Suck on an ice pop every two hours Ice pops provide calories and fluid, and the cold relieves discomfort associated with the stomatitis. Water does not provide calories, only fluid. Tea has no calories, and warm drinks will increase, not decrease, the discomfort associated with the stomatitis. Although rinsing the mouth with nystatin after meals may prevent infection, it does not provide calories or fluid, or relieve discomfort associated with the stomatitis.

A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I initially should eat: 1 Fruit juice and a lollipop. 2 Sugar and a slice of bread. 3 Chocolate candy and a banana. 4 Peanut butter crackers and a glass of milk.

2 Sugar and a slice of bread. The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); t

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television

2 Swimming Swimming helps keep the muscles supple, without requiring fine motor activity. Hiking might prove too rigorous for the client. Sewing requires fine motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will: 1 Turn off clients' IVs that have infiltrated." 2 Take clients' vital signs after their procedures are over." 3 Use unit written materials to teach clients before surgery." 4 Help by giving medications to clients who are slow in taking pills.

2 Take clients' vital signs after their procedures are over."

A nurse provides instruction when the beta-blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? 1 Move slowly when changing positions. 2 Take the medication before going to bed. 3 Expect to feel drowsy when taking this drug. 4 Count the pulse before taking the medication.

2 Take the medication before going to bed. Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur with BBs.

When planning discharge teaching for a client who had an ileostomy, the nurse places primary emphasis on: 1 Informing the client about the ileostomy association 2 Telling the client whom to contact if assistance is needed 3 Encouraging the client to return to the workplace as soon as possible 4 Teaching the client the importance of irrigations to regulate bowel movements

2 Telling the client whom to contact if assistance is needed The client should know there is help available, even though direct supervision is no longer provided. Informing the client about the ileostomy association and encouraging the client to return to the workplace are not the priorities at this time. Ileostomies are not irrigated because stool is liquid.

An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse recalls that with a comminuted fracture: 1 Bone protrudes through a break in the skin 2 The bone has broken into several fragments and the skin is intact 3 The bone is broken into two parts and the skin may or may not be broken 4 Splintering has occurred on one side of the bone and bending on the other

2 The bone has broken into several fragments and the skin is intact In a comminuted fracture, the bone is splintered or crushed.

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? 1 The signs and symptoms of pericarditis 2 The possible need for prophylactic antibiotic therapy before dental work 3 That cardiac surgery will have to be done eventually for the other valves 4 That pregnancy and childbirth are too stressful when one has this problem

2 The possible need for prophylactic antibiotic therapy before dental work Antibiotic therapy before invasive procedures, such as dental work, is often prescribed to prevent endocarditis because these situations may introduce infectious agents systemically. Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart. There is no evidence of pathology of other valves. Childbirth is not contraindicated; however, prophylactic antibiotic therapy may be administered to prevent endocarditis.

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 health care provider to alter the insulin prescription

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down Syndrome. The nurse can best assess the client's pain level by: 1 Asking the client's parent 2 Using Wong's "Pain Faces" 3 Observing the client's body language 4 Explaining the use of a 0 to 10 pain scale

2 Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A client is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver. The nurse suspects what type of toxicity? 1 Thiamine 2 Vitamin A 3 Vitamin C 4 Pyridoxine

2 Vitamin A These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is relatively nontoxic, and excess amounts are excreted in the urine.

What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose? 1 Heparin 2 Vitamin K 3 Iron dextran (Imferon) 4 Protamine sulfate

2 Vitamin K

When performing a peritoneal dialysis procedure, the nurse should: 1 Place the client in a side-lying position 2 Warm dialysate solution slightly before instillation 3 Infuse the dialysate solution slowly over several hours 4 Withhold the routine medications until after the procedure

2 Warm dialysate solution slightly before instillation The infusion should be warmed to body temperature to lessen abdominal discomfort and promote dilation of peritoneal vessels. The side-lying position may restrict fluid inflow and prevent maximum urea clearance; the client should be placed in the semi-Fowler position. The infusion of dialysate solution should take approximately 5 to 10 minutes. Routine medications should not interfere with the infusion of dialysate solution.

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. The component of the complete blood count that the nurse is concerned about most is: 1 Red blood cells (RBCs) 2 White blood cells (WBCs) 3 Platelets 4 Hematocrit

2 White blood cells (WBCs) Antineoplastic drugs depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life threatening. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells.

The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase (Viokase). The nurse evaluates that teaching is understood when the client states, "I will take them: 1 At bedtime." 2 With meals." 3 One hour before meals." 4 On arising each morning."

2 With meals." The pancreatic enzymes (amylase, trypsin, and lipase) must be present when food is ingested for digestion to take place. At bedtime the food eaten for dinner has passed beyond the duodenum; at bedtime the enzyme is given too late to aid digestion. Taking pancrelipase one hour before meals or on arising each morning will have no chyme in the duodenum on which the enzyme can act.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1 "I am unable to run a mile now." 2 "I wake up at night short of breath." 3 "My shoes seem larger lately." 4 "My wife says I snore very loudly."

2 "I wake up at night short of breath." Increased shortness of breath is often an indicator of fluid overload in the heart failure client

A male client with aortic stenosis is scheduled for a valve replacement in two days. He tells the nurse, "I told my wife all she needs to know if I don't make it." What response is most therapeutic? 1 "Men your age do very well." 2 "You are worried about dying." 3 "I know you are concerned, but your surgeon is excellent." 4 "I'll get you a sleeping pill tonight because I know you will need it."

2 "You are worried about dying."

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? (Select all that apply.) 1 Provide a low fat diet. 2 Administer analgesics. 3 Teach relaxation exercises. 4 Encourage walking in the hall. 5 Monitor cardiac rate and rhythm. 6 Observe for signs of hypercalcemia

2 Administer analgesics. 3 Teach relaxation exercises. 5 Monitor cardiac rate and rhythm.

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? (Select all that apply.) 1 Flatulence 2 Anal itching 3 Blood in stool 4 Rectal pressure 5 Pain when defecating

2 Anal itching 3 Blood in stool 4 Rectal pressure 5 Pain when defecating Pruritus occurs as varicosities enlarge and become inflamed. Blood and mucus in the stool occur as varicosities enlarge and become inflamed. Rectal pressure occurs as portal venous pressure increases and varicosities enlarge. Pain occurs when varicosities enlarge and thromboses occur; pain increases on defecation. Flatulence is unrelated to hemorrhoids.

Which interventions should the nurse anticipate will be prescribed initially for a client who had a hemorrhoidectomy? (Select all that apply.) 1 Giving an enema 2 Applying moist heat 3 Administering stool softeners 4 Encouraging showers as needed 5 Providing occlusive dressings to the area

2 Applying moist heat 3 Administering stool softeners Moist heat dilates the blood vessels, thereby increasing circulation to the area; this is soothing and promotes healing. Stool softeners are prescribed to avoid straining on defecation and constipation. Enemas may be prescribed several days after surgery if the client has not had a bowel movement. Baths, especially sitz baths, are advised to promote healing and cleaning of the area. Occlusive dressings are not used. Light applications of witch hazel may be used to promote drainage and healing.

Discharge instructions for the client diagnosed with cirrhosis with varices should include information about the importance of: (Select all that apply.) 1 Adhering to a low carbohydrate diet 2 Avoiding aspirin and aspirin containing products 3 Limiting alcohol consumption to two drinks weekly 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

2 Avoiding aspirin and aspirin containing products 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? (Select all that apply.) 1 Corn 2 Bananas 3 Strawberries 4 Cucumber salad 5 Mashed sweet potatoes 6 Baked potatoes with skins

2 Bananas 6 Baked potatoes with skins A serving of banana (1 cup sliced, raw) has 594 mg of potassium. A serving of baked potato with the skin (1 potato, ½ lb) has 844 mg of potassium. A serving of corn (1 cup frozen kernels) contains 229 mg of potassium. A serving of strawberries (1 cup raw, capped, whole) has 247 mg of potassium. A serving of cucumber with the peel (six slices ⅛-inch thick by 2⅛ inches in diameter) has 42 mg of potassium. A serving of mashed sweet potatoes (1 cup solid pack, canned) has 125 mg of potassium.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? (Select all that apply.) 1 Raw carrots 2 Boiled spinach 3 Sweet potatoes 4 Brussels sprouts 5 Asparagus spears

2 Boiled spinach 3 Sweet potatoes One cup of boiled spinach contains 6.42 mg of iron. One cup of mashed sweet potatoes contains 3.4 mg of iron. One cup of cut carrots contains 1 mg of iron. One cup of Brussels sprouts contains 1.1 mg of iron. One cup of cut asparagus contains 1.2 mg of iron.

A client had a laproscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? (Select all that apply.) 1 Wash the puncture sites with strong soap and hot water daily. 2 Call the health care provider if you have a fever of 100o F or more for two days. 3 Remove the tape-strips over the puncture sites one week after surgery. 4 Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage. 5 Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the left shoulder.

2 Call the health care provider if you have a fever of 100o F or more for two days. 4 Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? (Select all that apply.) 1 Reduce calcium intake. 2 Change positions slowly. 3 Report peripheral edema. 4 Expect temporary hair loss. 5 Avoid drinking grapefruit juice.

2 Change positions slowly. 3 Report peripheral edema. 5 Avoid drinking grapefruit juice Changing positions slowly helps reduce orthostatic hypotension. Peripheral edema may occur as a result of heart failure and must be reported. Grapefruit juice affects the metabolism of calcium channel blockers and should be avoided. Reducing calcium intake is unnecessary because calcium levels are not affected. Hair loss does not occur.

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. (Select all that apply.) 1 Olive oil 2 Chicken broth 3 Enriched whole milk 4 Red meats, such as beef 5 Vegetables and whole grains 6 Liver and other glandular organ meats

2 Chicken broth 3 Enriched whole milk 4 Red meats, such as beef 6 Liver and other glandular organ meats Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.) 1 Thirst 2 Confusion 3 Tachycardia 4 Pale coloring 5 Poor tissue turgor

2 Confusion 5 Poor tissue turgor

A nurse assesses a client's intravenous site. What clinical finding leads the nurse to conclude that the intravenous (IV) site has been infiltrated? (Select all that apply.) 1 Redness along the vein 2 Coolness of skin near the insertion site 3 Swelling around the insertion site 4 Cessation in flow of solution 5 Vein feels hard and cordlike

2 Coolness of skin near the insertion site 3 Swelling around the insertion site 4 Cessation in flow of solution When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F), whereas body temperature is approximately 98.6° F; therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. In addition, the fluid in the interstitial space causes swelling around the insertion site, and the solution stops flowing. Redness along the vein, with the vein feeling hard and cordlike, is present with phlebitis.

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? (Select all that apply.) 1 Abdominal cramps 2 Decreased heart rate 3 Peripheral paresthesia 4 Decreased bowel sounds 5 Hyperactive deep tendon reflexes

2 Decreased heart rate 4 Decreased bowel sounds Because of potassium's role in the sodium-potassium pump , hypokalemia may cause nerve and muscle weakness, which may precipitate bradycardia and atrial dysrhythmias. On an ECG tracing, the T wave is depressed with hypokalemia. Decreased bowel sounds result from decreased bowel motility associated with hypokalemia. Gastrointestinal hyperactivity and diarrhea are related to hyperkalemia, not hypokalemia. Paresthesia and numbness in the extremities are associated with hyperkalemia, not hypokalemia. Deep tendon reflexes are depressed, not hyperactive, with hypokalemia.

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? (Select all that apply.) 1 Fever 2 Diarrhea 3 Gain in weight 4 Spitting up blood 5 Abdominal cramps

2 Diarrhea 5 Abdominal cramps The inflammatory process tends to increase peristalsis , causing diarrhea. As ulceration occurs, loss of blood leads to anemia. The inflammatory process tends to increase peristalsis, causing spasms of the intestines. Fever may or may not be a sign. The client will lose weight because of anorexia and malabsorption. Hemoptysis (coughing up blood from the respiratory tract) is not a related sign.

A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? (Select all that apply.) 1 Avoid fluid intake after 6 pm 2 Drink 8 to 10 glasses of water each day 3 Urinate immediately after sexual intercourse 4 Increase the daily intake of carbonated beverages 5 Clean the perineal area with an astringent soap twice a day

2 Drink 8 to 10 glasses of water each day 3 Urinate immediately after sexual intercourse

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? (Select all that apply.) 1 Oliguria 2 Dry mouth 3 Palpitations 4 Constipation 5 Urinary retention 6 Orthostatic hypotension

2 Dry mouth 3 Palpitations 4 Constipation 6 Orthostatic hypotension Dry mouth is a side effect of Nalbuphine HCl. Palpitations are a side effect of Nalbuphine HCl. Constipation is a common side effect of Nalbuphine HCl. Orthostatic hypotension may occur with Nalbuphine HCl. The ability to form urine is not affected; an increased urinary output or frequency may occur. Urinary urgency, not retention, is a reaction to Nalbuphine HCl.

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? (Select all that apply.) 1 Irritability 2 Dysrhythmias 3 Muscle weakness 4 Abdominal cramps 5 Tingling of the fingertips

2 Dysrhythmias 3 Muscle weakness Dysrhythmias are a sign of potassium depletion in cardiac muscle. Other cardiovascular effects include irregular, rapid, weak pulse, decreased blood pressure, flattened and inverted T waves, prominent U waves, depressed ST segments, peaked P waves, and prolonged QT intervals. Muscle weakness is a symptom of potassium depletion in skeletal muscles; potassium facilitates the conduction of nerve impulses and muscle activity. Irritability, as a result of heightened neuromuscular activity, is a sign of hyperkalemia. Abdominal cramps, as a result of heightened neuromuscular activity, are symptoms of hyperkalemia. Tingling of the fingertips, as a result of a lowered threshold of excitation of peripheral sensory nerve fibers, is a symptom of hypocalcemia.

A client is admitted with anorexia, weight loss, abdominal distention, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs? 1 Allow the client to eat food preferences. 2 Encourage the consumption of high-protein foods. 3 Institute intravenous (IV) therapy to improve the client's hydration. 4 Maintain nothing by mouth status because food precipitates diarrhea.

2 Encourage the consumption of high-protein foods. The diet should be high in protein and calories, low in fat, and gluten-free for individuals with malabsorption syndrome . Protein is needed for tissue rebuilding. The client may prefer foods high in gluten, which will potentiate malabsorption. IV therapy is a dependent function and does not provide all the necessary nutrients. Diarrhea is caused by malabsorption, which accounts for the depressed nutritional status; once the diarrhea is corrected, it is essential to compensate by providing a nutritious diet.

The nurse is reviewing a teaching plan for a client that has been prescribed a 2-gram sodium diet. The plan should include which foods that are low in sodium? 1 Meat and fish 2 Fruits and juices 3 Milk and cheese 4 Dry cereals and grains

2 Fruits and juices

A nurse provides discharge teaching for a client who had a total hip replacement. Which statements made by the client indicate an understanding of the education? (Select all that apply.) 1 I should not climb any stairs. 2 I should not cross my legs. 3 I should avoid stretching exercises. 4 I should not sit in a low chair. 5 I should avoid lying prone for longer than 30 minutes.

2 I should not cross my legs. 4 I should not sit in a low chair.

A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? (Select all that apply.) 1 Polyuria 2 Lethargy 3 Bradycardia 4 Dilated pupils 5 Slow respirations

2 Lethargy 3 Bradycardia 5 Slow respirations

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? (Select all that apply.) 1 Polyuria 2 Lethargy 3 Hypotension 4 Muscle twitching 5 Respiratory acidosis

2 Lethargy 4 Muscle twitching Lethargy results from anemia, buildup of urea, and vitamin deficiencies. Muscle twitching results from excess nitrogenous wastes.

A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? (Select all that apply.) 1 Halitosis 2 Leukoplakia 3 Bleeding gums 4 Substernal pain 5 Alterations in taste 6 Enlarged cervical lymph nodes

2 Leukoplakia 5 Alterations in taste 6 Enlarged cervical lymph nodes Leukoplakia are white, thickened patches that tend to fissure and become malignant; ulcerations in the mouth or on the tongue may indicate cancer. Taste buds in the tongue may be impaired, resulting in alterations in taste. Regional lymph nodes enlarge as cancer cells begin to metastasize. Halitosis is not an early sign of or specific to cancer of the mouth. Bleeding gums occur in gingival diseases. Pain associated with cancer of the tongue does not radiate to the substernal area.

A nurse is caring for a client with hepatic cirrhosis. Which elements are important to include in this client's diet? (Select all that apply.) 1 High fat 2 Low protein 3 Low sodium 4 High vitamins 5 Low carbohydrates

2 Low protein 3 Low sodium 4 High vitamins A low protein diet reduces formation of ammonia, which must be degraded by the liver. A low sodium intake controls fluid retention, blood pressure, and, consequently, edema. Vitamins help to repair long-standing nutritional deficits associated with cirrhosis of the liver. High fat intake is avoided because of related cardiovascular risks and the demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.

A nurse teaches a client that it is not recommended to take bicarbonate of soda regularly. What effect of bicarbonate of soda is the nurse trying to prevent? 1 Gastric distention 2 Metabolic alkalosis 3 Chronic constipation 4 Cardiac dysrhythmias

2 Metabolic alkalosis Prolonged use of sodium bicarbonate may cause systemic alkalosis, as well as retention of sodium and water.

A nurse teaches a client with gastrointestinal (GI) irritability to minimize the intake of dietary irritants. Which products did the nurse teach the client to avoid? (Select all that apply.) 1 Rice 2 Milk 3 Cheese 4 Table salt 5 Chocolate candy

2 Milk 3 Cheese 5 Chocolate candy

A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin (Lanoxin) is prescribed. When administering the medication, the nurse should: 1 Administer the medication with 8 ounces of orange juice 2 Monitor the client for atrial fibrillation and first-degree heart block 3 Administer the digoxin one hour after the client's morning insulin 4 Withhold the medication if the apical pulse rate is greater than 60 beats/min

2 Monitor the client for atrial fibrillation and first-degree heart block The speed of conduction is decreased when digoxin is given, and this can result in premature beats, atrial fibrillation, and first-degree heart block. Digoxin does not deplete potassium and therefore orange juice does not need to be given; orange juice is high in calories and needs to be calculated in the diet. Insulin and digoxin can be given at the same time. The purpose of the drug is to reduce a rapid heart rate and therefore be administered; it should be withheld when the client's heart rate decreases below a parameter set by the health care provider (e.g., 60 beats per minute).

A nurse is caring for a client with a ureteral calculus. Which are the most important nursing actions? (Select all that apply.) 1 Limiting fluid intake at night 2 Monitoring intake and output 3 Straining the urine at each voiding 4 Recording the client's blood pressure 5 Administering the prescribed analgesic

2 Monitoring intake and output 3 Straining the urine at each voiding 5 Administering the prescribed analgesic

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? (Select all that apply.) 1 Chvostek sign 2 Muscle cramps 3 Extreme fatigue 4 Cardiac dysrhythmias 5 Increased temperature

2 Muscle cramps 3 Extreme fatigue Sodium is the most abundant cation in the extracellular fluid and functions as part of the sodium/potassium pump. In the presence of a deficit, the client will exhibit confusion, lethargy, headache, and muscle cramps. Lethargy results in the presence of a deficit. Spasm of the facial muscles following a tap over the facial nerve (Chvostek sign) indicates hypocalcemia. Cardiac dysrhythmias are associated with increases or decreases in potassium and calcium. An increase in body temperature reflects a possible infection, not an electrolyte imbalance.

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.) 1 Sclera 2 Nail beds 3 Lining of eyelids 4 Palms of hands 5 Bony prominences

2 Nail beds 3 Lining of eyelids 4 Palms of hands Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids. Palms of the hands will become pale because of the decreased hemoglobin. Sclerae are observed for signs of jaundice, not anemia, when they become pale yellow to orange. Bony prominences are not assessed when a client has anemia. Bony prominences are examined for redness caused by pressure that, if prolonged, can lead to a break in the skin and development of pressure ulcers.

A client is diagnosed with calcium oxalate renal calculi. Which nutrients should the nurse teach the client to avoid? (Select all that apply.) 1 Milk 2 Nuts 3 Liver 4 Spinach 5 Rhubarb

2 Nuts 4 Spinach 5 Rhubarb Nuts, especially peanuts, almonds, and pecans, should be avoided. Clients with struvite stones (staghorn stones) also should avoid nuts. Rhubarb and spinach are high in calcium oxalate. Other examples include beets, wheat bran, tea, chocolate, and coffee. Limiting oxalate-rich foods limits oxalate absorption and the formation of calcium oxalate calculi

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.) 1 Pupil response to light 2 Verbal response to speech 3 Eye opening in response to speech 4 Deep tendon reflexes in response to percussion 5 Motor activity in response to a verbal command

2 Verbal response to speech 3 Eye opening in response to speech 5 Motor activity in response to a verbal command

A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective? 1. Is free of crackles 2. Has a productive cough 3. Is able to expectorate saliva 4. Can breathe deeply through the nose

2. Has a productive cough

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. What should the nurse do first? 1 Instill normal saline into the tube to maintain patency. 2 Obtain an x-ray to verify that the tube is in the stomach. 3 Auscultate the epigastric area while instilling 15 mL of air. 4 Withdraw 30 mL of stomach contents to verify tube placement.

2 Obtain an x-ray to verify that the tube is in the stomach X-ray verification of tube placement is required before anything is instilled into the nasogastric tube. Administering a feeding through a misplaced tube can cause the formula to enter the client's lungs. Instilling normal saline into the tube to maintain patency is unsafe. The normal saline will enter the client's lungs if the tube is in the wrong place. Auscultating the epigastric area while instilling 15 mL of air and withdrawing 30 mL of stomach contents to verify tube placement are not definitive ways to ensure correct placement of the nasogastric tube. Once placement is verified by an x-ray, these methods may be used before initiating a feeding.

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? (Select all that apply.) 1 Nausea 2 Palpitations 3 Tachycardia 4 Nervousness 5 Warm, dry skin 6 Increased respirations

2 Palpitations 3 Tachycardia 4 Nervousness Palpitations are of neurogenic origin associated with hypoglycemia; the sympathetic nervous system is stimulated by the decline in blood glucose. Tachycardia occurs with low serum glucose levels because of sympathetic nervous system activity. Nervousness, anxiety, and shakiness occur as a result of sympathetic nervous system stimulation associated with hypoglycemia. Nausea, vomiting, and abdominal cramps are associated with hyperglycemia. The client will feel hungry with hypoglycemia. Warm, dry skin is a sign of hyperglycemia, caused by dehydration associated with osmotic diuresis related to glycosuria. The skin will be cool and moist with hypoglycemia. Increased respirations are signs of ketoacidosis from insufficient insulin to prevent fat breakdown for energy; they are compensatory responses that occur in an attempt to blow off carbon dioxide and raise the serum pH. There is no particular change in respirations with hypoglycemia.

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the health care provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" The best reply by the nurse is, "This test will: 1 Detect your heart sounds." 2 Reflect any heart damage." 3 Help us change your heart's rhythm." 4 Tell us how much stress your heart can tolerate."

2 Reflect any heart damage."

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? (Select all that apply.) 1 Discolored toenails 2 Reports of leg fatigue 3 Localized heat in a calf 4 Reddened areas on a leg 5 Tortuous veins in the legs 6 Pain in lower extremities when standing

2 Reports of leg fatigue 5 Tortuous veins in the legs 6 Pain in lower extremities when standing

2 Reports of leg fatigue 5 Tortuous veins in the legs 6 Pain in lower extremities when standing Leg fatigue is a common clinical manifestation caused by venous stasis and inadequate tissue oxygenation. Vein walls weaken and dilate resulting in distended, protruding veins that appear tortuous and darkened. As vein walls weaken and dilate venous pressure increases and the valves become incompetent; venous stasis and inadequate oxygenation result in leg pain. Discolored toenails result from a fungus under the nail or chronic hypoxia, not varicose veins. Localized heat in a calf is a sign of thrombophlebitis. Reddened areas on a leg are indicative of thrombophlebitis.

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? (Select all that apply.) 1 Preventing constipation 2 Screening of blood donors 3 Avoiding shellfish in the diet 4 Limiting hepatotoxic drug therapy 5 Maintaining a monogamous sexual relationship

2 Screening of blood donors 5 Maintaining a monogamous sexual relationship Contracting hepatitis B through blood transfusions can be prevented by screening donors and testing the blood. Hepatitis B can be transmitted via contaminated body fluids such as semen, saliva, and urine. Multiple sexual partners increase the risk. A monogamous sexual relationship with an infection-free individual eliminates the risk. Preventing constipation is not related to limiting the risk for contracting hepatitis B. Avoiding shellfish in the diet limits the risk for contracting hepatitis A. Limiting hepatotoxic drug therapy does not prevent transmission of hepatitis B.

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? (Select all that apply.) 1 Pulse rate 2 Skin color 3 Presence of edema 4 Movement of the hand 5 Sensations in the extremity

2 Skin color 4 Movement of the hand 5 Sensations in the extremity

A client with a diagnosis of cancer of the stomach expresses a lack of interest in food and eats only small amounts. What should the nurse provide? 1 Nourishment between meals 2 Small portions more frequently 3 Supplementary vitamins to stimulate the client's appetite 4 Only foods the client likes in small portions at mealtimes

2 Small portions more frequently

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? (Select all that apply.) 1 Pruritus of the calf 2 Tender area on the leg 3 Warm area over the calf 4 Pitting edema of the ankle 5 Reddened area at the ankle

2 Tender area on the leg 3 Warm area over the calf

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. (Select all that apply.) 1 Flushing of the face 2 Unilateral chest pain 3 Elevation of temperature 4 Sudden onset of shortness of breath 5 Pain rating increase from 2 to 8 in the hip

2 Unilateral chest pain 4 Sudden onset of shortness of breath

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled? 1. Radiation 2. Enucleation 3. Cryosurgery 4. Chemotherapy

2. Enucleation

2 Verbal response to speech 3 Eye opening in response to speech 5 Motor activity in response to a verbal command Assessing a client's verbal response to the nurse's speech is one of the three criteria for determining level of consciousness with the Glasgow Coma Scale. Assessing eye opening in response to the nurse's speech is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale. Assessing a client's motor response to a verbal command is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale.

2 Vitamin K

A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client? 1 Infection 2 Vomiting 3 Osteomyelitis 4 Bronchospasm

2 Vomiting Vomiting may result in aspiration of vomitus, because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.) 1 Anorexia 2 Vomiting 3 Constipation 4 Muscle weakness 5 Irregular heart rate

2 Vomiting 4 Muscle weakness 5 Irregular heart rate

2 Vomiting 4 Muscle weakness 5 Irregular heart rate Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? (Select all that apply.)

2,3

What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? (Select all that apply.) 1 Dry skin 2 Weight loss 3 Tachycardia 4 Restlessness 5 Constipation 6 Exophthalmos

2,3,4,6

A client is receiving dexamethasone (Decadron) for adrenocortical insufficiency. To monitor for a negative side effect of the medication, the nurse should:

A nurse is planning to transfer a client who is experiencing pain from the bed to a chair. Place the following steps in the order in which they should be implemented. 1. Explain the steps of the transfer. 2. Verify the client's activity prescription. 3. Ensure that the wheels on the bed are locked. 4. Position the client in functional body alignment before transferring. 5. Identify factors that may impact the ability to transfer.

2. Verify the client's activity prescription. 5. Identify factors that may impact the ability to transfer. 1. Explain the steps of the transfer. 3. Ensure that the wheels on the bed are locked. 4. Position the client in functional body alignment before transferring

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is: 1. "Why did you sign the consent?" 2. "Can you tell me why you decided to refuse the procedure?" 3. "You are obviously afraid about something concerning the procedure." 4. "Although the procedure is very important, I understand why you changed your mind."

2. "Can you tell me why you decided to refuse the procedure?"

Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to:

The health care provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of:

2. 70 to 105 mg/dL of blood

The nurse is caring for a 75-year-old client that had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. The nurse should: 1. Notify the health care provider immediately of the findings 2. Administer the prescribed oxygen 3. Record the observations and continue to observe the client 4. Administer the prescribed antianxiety medication

2. Administer the prescribed oxygen

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? (Select all that apply.) 1. Age 2. Anorexia 3. Hemiplegia 4. History of diabetes 5 . Urinary incontinence

2. Anorexia 3. Hemiplegia 5 . Urinary incontinence

2. Anorexia 3. Hemiplegia 5. Urinary incontinence

A client is scheduled for surgery. Legally, the client may not sign the operative consent if: 1. Ambivalent feelings are present and acknowledged 2. Any sedative type of medication has been given recently 3. A discussion of alternatives with two health care providers has not occurred 4. A complete history and physical has not been performed and recorded

2. Any sedative type of medication has been given recently

A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client? 1. Localized tissue necrosis 2. Carbon dioxide retention 3. Increased respiratory rate 4. Saturated hemoglobin molecules

2. Carbon dioxide retention

After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should: 1. Strip the chest tube catheter 2. Check the system for air leaks 3. Decrease the amount of suction pressure 4. Recognize that the system is functioning correctly

2. Check the system for air leaks

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with this autosomal recessive disorder: 1. Cerebral palsy 2. Cystic fibrosis 3. Muscular dystrophy 4. Multiple sclerosis

2. Cystic fibrosis

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? (Select all that apply.) 1. Apathy 2. Dyspnea 3. Hemoptysis 4. Bronchial wheezes 5. Feeling of impending doom

2. Dyspnea 3. Hemoptysis 5. Feeling of impending doom

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? (Select all that apply.)

2. Headache 3. Diaphoresis Hypoglycemia affects the central nervous system, causing headache. Hypoglycemia affects the sympathetic nervous system, causing diaphoresis. Lethargy is associated with hyperglycemia because glucose is not being used for cellular metabolism. Excessive thirst is associated with hyperglycemia because fluid shifts along with the excess glucose being excreted by the kidneys, resulting in polyuria. Deep respirations (Kussmaul respirations) are associated with hyperglycemia because the body is attempting to blow off carbon dioxide to compensate for the metabolic acidosis.

During the first 48 hours after a client has sustained a thermal injury, the nurse should assess for: 1. Hypokalemia and hyponatremia 2. Hyperkalemia and hyponatremia 3. Hypokalemia and hypernatremia 4. Hyperkalemia and hypernatremia

2. Hyperkalemia and hyponatremia

What are expected changes that the nurse might identify when assessing the skin of an older adult? (Select all that apply.) 1. Scaly skin 2. Increased wrinkles 3. Signs of ecchymosis 4. Marked flaking of skin 5 . Hyperpigmented patches

2. Increased wrinkles 5 . Hyperpigmented patches

2. Increased wrinkles 5. Hyperpigmented patches

In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. The nurse identifies that the client understands the instructions when the client states, "I will: 1. Sit in a chair for several hours every day." 2. Inspect the incision for healing when I change the dressing." 3. Check to see whether the staples have dissolved within a few days." 4. Call the health care clinic if I see any clear drainage coming from the incision."

2. Inspect the incision for healing when I change the dressing."

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care? 1. Use calamine lotion for pruritus 2. Keep skin lubricated with lotion 3. Apply warm soaks to inflamed areas 4. Take frequent baths to remove scaly lesions

2. Keep skin lubricated with lotion

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. They are described best as: 1.Snorting sounds during the inspiratory phase 2. Moist rumbling sounds that clear after coughing 3. Musical sounds more pronounced during expiration 4. Crackling inspiratory sounds unchanged with coughing

2. Moist rumbling sounds that clear after coughing

A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? (Select all that apply.)

2. Obese trunk 4. Sleep Disturbance 5. Thin arms and legs

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication? 1. Percussing the neck and chest. 2. Palpating the neck or face. 3. Auscultating for abnormal breath sounds. 4. Observing for asymmetry of chest movement.

2. Palpating the neck or face. *Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue.

The nurse who is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB) is aware that this is beneficial for the client through which mechanism? 1. Increased respiratory rate to improve arterial oxygenation 2. Prolonged exhalation to decrease air trapping 3. Shortened inhalation to reduce bronchial swelling 4. Use of the diaphragm to increase the amount of inspired air

2. Prolonged exhalation to decrease air trapping

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube? 1. Lessens the client's chest discomfort 2. Restores negative pressure in the pleural space 3. Drains accumulated fluid from the pleural cavity 4. Prevents subcutaneous emphysema in the chest wall

2. Restores negative pressure in the pleural space

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1. Eggs." 2. Shellfish." 3. Fried poultry." 4. Cottage cheese."

2. Shellfish."

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1. Bananas 2. Strawberries 3. Green beans 4. Sweet potatoes

2. Strawberries **Strawberries contain 88 mg of vitamin C (ascorbic acid) per cup. One banana contains 12 mg of ascorbic acid. One cup of green beans contains 21 mg of ascorbic acid. One baked sweet potato contains 25 mg of ascorbic acid.

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? (Select all that apply.)

2. Tachycardia 5. Exopthalmos

When obtaining the history of a client recently diagnosed with type 1 diabetes, the nurse expects to identify the presence of:

22.5

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?

22.5%

A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record your answer using a whole number. __________ gtts/min

A client is admitted with a head injury. The nurse identifies that the client's urinary retention catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

A client is scheduled to have a thyroidectomy for cancer of the thyroid. Preoperative instructions for the postoperative period include teaching the client to:

A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. The nurse bases a response on the fact that:

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. The nurse concludes that regular insulin is needed because the:

A nurse is caring for a client after a thyroidectomy. Because of concerns about potential nerve injury associated with this type of surgery, the nurse should assess for which functional ability?

Blood studies are being performed on a client with the potential diagnosis of hyperparathyroidism. What serum blood level should the nurse expect to be decreased when reviewing this client's hematological studies?

For which client response should the nurse monitor when assessing for complications of hyperparathyroidism?

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 AM the next day. The nurse advises the client to: 1 "Have your dinner completed by 6 PM tonight and then no food or fluids after that." 2 "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." 3 "Consume a light evening meal tonight and then no food or fluids after midnight." 4 "Eat lunch today and then do not drink or eat anything until after your surgery."

3 "Consume a light evening meal tonight and then no food or fluids after midnight.

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? 1 "Adhere to the medical regimen." 2 "Remain normoglycemic for three weeks." 3 "Demonstrate correct use of the insulin pump." 4 "List three self-care activities that help control the diabetes."

3 "Demonstrate correct use of the insulin pump."

Which statement by an older adult most strongly supports the nurse's conclusion that the client is impacted with stool? 1 "I have a lot of gas pains." 2 "I don't have much of an appetite." 3 "I feel like I have to go and just can't." 4 "I haven't had a bowel movement for several days."

3 "I feel like I have to go and just can't."

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states what? 1 "I will wear socks." 2 "I will quit smoking." 3 "I will elevate my foot." 4 "I will increase fluid intake."

3 "I will elevate my foot."

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Pain is not a characteristic symptom of this disease process." 4 "Let's make a list of the things you need to ask your health care provider."

3 "Pain is not a characteristic symptom of this disease process." The response "Pain is not a characteristic symptom of this disease process" is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it is not a characteristic manifestation of multiple sclerosis . These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations).

A client exhibits blurred and double vision with muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? 1 "Don't worry; early treatment often alleviates symptoms of the disease." 2 "You should be glad that we caught it early so it can be cured." 3 "That must have really shocked you. Tell me what the health care provider told you about it." 4 "You should see a psychiatrist who will help you cope with this overwhelming news."

3 "That must have really shocked you. Tell me what the health care provider told you about it."

Which client should a nurse consider the greatest risk for developing hypernatremia? 1 52-year-old who is receiving 0.45% NaCl intravenously 2 76-year-old who developed syndrome of inappropriate antidiurectic hormone secretion (SIADH) as a result of head trauma 3 63-year-old who has had watery diarrhea since traveling abroad 4 48-year-old who is admitted with a diagnosis of Addison disease

3 63-year-old who has had watery diarrhea since traveling abroad Watery diarrhea involves loss of water in excess of sodium; this leads to an increased sodium concentration. Intravenous 0.45% NaCl is a hypotonic solution; concentration of sodium is less than body fluids. Increased secretion of antidiuretic hormone causes water retention, which decreases sodium concentration. Addison disease involves hyposecretion of adrenocortical hormones, which leads to hyponatremia.

While obtaining a health history, a nurse expects a client admitted to the hospital with chronic heart failure to report: 1 Tingling in the upper extremities 2 Feeling bloated after eating 3 A need to use three pillows at night to sleep 4 Swelling of the ankles that is more apparent in the morning

3 A need to use three pillows at night to sleep Heart failure causes a fluid volume excess that results in pulmonary edema and dyspnea in the supine position. Tingling in the upper extremities and feeling bloated after eating are unrelated to the cardiopulmonary system. Dependent edema usually occurs after standing or walking; swelling of the ankles is more evident in the evening.

A nurse is caring for a client who had a gastroscopy. What response indicates a major concern associated with this surgery? 1 Projectile vomiting 2 Increased gastrointestinal (GI) motility 3 Abdominal distention 4 Difficulty swallowing

3 Abdominal distention Abdominal distention, which may be associated with pain, may indicate perforation, a complication that can lead to peritonitis. Projectile vomiting usually does not occur. Increased GI motility, together with cramping, is considered an expected response. A local inflammatory response to insertion of the fiberoptic tube may result in a sore throat and dysphagia once the anesthetic wears off, but the client will be able to swallow.

An older adult client is demonstrating mild confusion after surgical repair of a hernia. What should the nurse do to provide for this client's safety? 1 Use a nightlight in the client's room. 2 Secure a prescription for a soft vest restraint. 3 Activate the position-sensitive bed alarm. 4 Raise the four side rails on the client's bed

3 Activate the position-sensitive bed alarm.

A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions? 1 Contact precautions 2 Droplet precautions 3 Airborne precautions 4 No additional precautions other than standard precautions

3 Airborne precautions Chickenpox is transmitted from person to person by directly touching the blisters, saliva, or mucus of an infected person. The virus can also be transmitted through the air. Chickenpox can be spread indirectly by touching contaminated items freshly soiled, such as clothing, from an infected person.

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is: 1 Sedatives 2 Hypnotics 3 Analgesics 4 Antibiotics

3 Analgesics Acetylsalicylic acid acts as an analgesic by protecting peripheral pain receptors from bradykinin, a component in the inflammatory process.

A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment? 1 Monitor for a pulse deficit. 2 Obtain hourly blood pressure readings. 3 Assess for capillary refill in the nail beds. 4 Place the shoulder through range of motion

3 Assess for capillary refill in the nail beds. Capillary refill and quality of the pulse in the affected arm reflect the status of circulation distal to the operative site.

Following surgery, a client asks the nurse if he or she can help measure intake and output. What is the best nursing response? 1 Determine the client's willingness to really help 2 Identify the client's reason for wanting to do this task 3 Assess the client's ability to measure the intake and output 4 Explain that measuring intake and output is the responsibility of the nurse

3 Assess the client's ability to measure the intake and output

A client with a recent colostomy expresses concern about the inability to control the passage of gas. The nurse should teach the client to: 1 Eliminate foods high in cellulose 2 Decrease fluid intake at mealtimes 3 Avoid foods that in the past caused flatus 4 Adhere to a bland diet before social events

3 Avoid foods that in the past caused flatus

A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1 Eat a low fat, low protein diet 2 Avoid foods high in carbohydrates 3 Avoid ingesting alcoholic beverages 4 Eat a bland diet of six small meals a day

3 Avoid ingesting alcoholic beverages

A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects that a diagnostic finding specific for multiple myeloma is: 1 Occult blood in the stool 2 Low serum calcium levels 3 Bence Jones protein in the urine 4 Positive bacterial culture of sputum

3 Bence Jones protein in the urine Bence Jones protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma. Occult blood in the stool is not specific for the diagnosis of multiple myeloma; it is a late complication of multiple myeloma related to coagulation defects. Hypercalcemia, not hypocalcemia, occurs with multiple myeloma because of bone erosion. Multiple myeloma is not caused by a bacterial infection.

A nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. What is the most common clinical manifestation that the nurse should include in the teaching program? 1 Rectal bleeding 2 Abdominal pain 3 Change in bowel habits 4 Alteration in caliber of stools

3 Change in bowel habits

During a home visit a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is unresponsive to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that intervention by an appropriate community resource is indicated. The nurse should make a referral to the: 1 Outpatient clinic 2 Hospital pediatric unit 3 Child Protective Services 4 Bureau of the handicapped

3 Child Protective Services

A client admitted to the hospital in the oliguric phase of acute renal failure estimates that the urine output for the last 12 hours was less than 240 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. The nurse concludes that this amount of fluid was prescribed to: 1 Equal the expected urinary output for the next 24 hours 2 Prevent the development of hypostatic pneumonia and fever 3 Compensate for both insensible and expected output over the next 24 hours 4 Prevent hyperkalemia, which can lead to life-threatening cardiac dysrhythmias

3 Compensate for both insensible and expected output over the next 24 hours Insensible losses are 400 to 500 mL in 24 hours; the measured output is about 400 mL in 24 hours based on the available history

Immediately after a liver biopsy, a client is placed onto the right side. The nurse explains that the rationale for this positioning is to: 1 Decrease pain to provide comfort 2 Support erythropoiesis to increase red blood cell production 3 Compress blood vessels to prevent bleeding 4 Expel fluid trapped in the biliary ducts to promote drainage

3 Compress blood vessels to prevent bleeding

A client is admitted to the hospital after sustaining a head injury. The nurse monitors for the most reliable sign of increased intracranial pressure, which is a slow: 1 Rise in respiratory rate 2 Narrowing of pulse pressure 3 Decrease in the level of consciousness 4 Increase in the diastolic blood pressure

3 Decrease in the level of consciousness

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. To decrease pain, the nurse should suggest: 1 For morning stiffness, take a tub bath rather than a hot shower 2 Apply an ice pack directly to the involved joint for no more than 20 minutes at a time 3 Decrease the number of repetitions of the exercises 4 Cease exercising for a day

3 Decrease the number of repetitions of the exercises

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client? 1 Increase left ventricular filling and improve cardiac output. 2 Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias. 3 Decrease the workload on the heart and promote maximum coronary artery filling. 4 Increase venous return to the right atrium and increase pulmonary arterial blood flow.

3 Decrease the workload on the heart and promote maximum coronary artery filling.

A nurse is caring for a client who is hospitalized because of injuries sustained in a major automobile collision. As the client is describing the accident to a friend, the client becomes very restless, and his pulse and respirations increase sharply. Which factor probably is related to the client's physical responses? 1 Client's method of seeking sympathy 2 Bleeding from an undiscovered injury 3 Delayed psychological response to trauma 4 Parasympathetic nervous system response to anxiety

3 Delayed psychological response to trauma

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first? 1 Notify the health care provider. 2 Clamp the nasogastric tube for one hour. 3 Determine that this is an expected finding. 4 Irrigate the nasogastric tube with iced saline.

3 Determine that this is an expected finding. Nasogastric drainage is expected to be bright red during the first 12 hours after surgery; bleeding lessens gradually during the 12 hours after surgery in response to hemostasis in the surgical area. Notifying the health care provider is unnecessary; bloody drainage is expected this soon after surgery. Nasogastric suction must be working, and the tube must remain patent to prevent stress on the suture line. The nasogastric tube is only irrigated if the health care provider prescribes it because of the danger of injury to the suture line; generally saline at room temperature is prescribed.

A client with hepatic cirrhosis develops hepatic encephalopathy. Neomycin sulfate (Mycifradin) is prescribed. The nurse concludes that the purpose of neomycin is to: 1 Decrease intestinal edema 2 Reduce abdominal distention 3 Diminish the blood ammonia level 4 Limit development of systemic infections

3 Diminish the blood ammonia level Neomycin sulfate reduces bacterial activity on blood and wastes in the gastrointestinal (GI) tract, thereby reducing the level of blood ammonia, a byproduct of protein metabolism; hepatic encephalopathy is a result of elevated ammonia levels in the blood. Neomycin sulfate interferes with bacterial protein synthesis but has little or no effect on intestinal edema. Neomycin sulfate reduces bacterial action in the GI tract but does not reduce abdominal distention. Neomycin sulfate does not limit the development of a systemic infection when it is ingested because it is not absorbed systemically.

A client returns to work as a carpenter after surgery for carpal tunnel syndrome of the right hand. What instructions should the nurse give to help prevent further problems with the hands when the client returns to work? 1 Avoid carrying tools with the arms 2 Learn to hammer with the left hand 3 Do stretching exercises during breaks 4 Avoid power tools such as cordless screwdrivers

3 Do stretching exercises during breaks

When assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies areas of white plaque on the client's tongue and palate. What is the nurse's initial response? 1 Scrape an area of one of the lesions and send the specimen for a biopsy. 2 Instruct the client to perform meticulous oral hygiene at least once daily. 3 Document the presence of the lesions, describing their size, location, and color. 4 Consider that these lesions are universally found in clients with AIDS and require no treatment.

3 Document the presence of the lesions, describing their size, location, and color.

A health care provider prescribes mannitol (Osmitrol) for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by: 1 Decreasing the production of cerebrospinal fluid 2 Limiting the metabolic requirements of the brain 3 Drawing fluid from brain cells into the bloodstream 4 Preventing uncontrolled electrical discharges in the brain

3 Drawing fluid from brain cells into the bloodstream Mannitol, an osmotic diuretic, pulls fluid from the white cells of the brain to relieve cerebral edema. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium (Dilantin), not mannitol.

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education? 1 Weight loss 2 Subnormal temperature 3 Elevated blood pressure 4 Increased urinary output

3 Elevated blood pressure Hypertension is caused by hypervolemia because of the failure of the new kidney. Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. The client will have an elevated temperature exceeding 100° F with kidney rejection. Urine output will be decreased or absent, depending on the degree of kidney rejection.

A nurse plans to teach the signs of rejection to a client who just had a transplanted kidney. What sign of rejection should the nurse include? 1 Weight loss 2 Subnormal temperature 3 Elevated blood pressure 4 Increased urinary output

3 Elevated blood pressure Hypertension results from hypervolemia because of failure of the new kidney. Weight gain will occur because of fluid retention with failure of a transplanted kidney. Body temperature will exceed 100° F if a kidney is rejected. Urine output will be decreased or absent, depending on the degree of failure.

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the priority nursing action is: 1 Irrigating the T-tube every hour 2 Changing the dressing every two hours 3 Encouraging coughing and deep breathing 4 Promoting an adequate fluid and food intake

3 Encouraging coughing and deep breathing

Before a client with syphilis can be treated, what should be determined? 1 Portal of entry 2 Size of chancre 3 Existence of allergies 4 Names of sexual contacts

3 Existence of allergies Although the treatment of choice is penicillin, clients who are allergic must be given other antimicrobial agents to avoid an anaphylactic reaction

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern? 1 Flexing 2 Localizing 3 Extending 4 Withdrawing

3 Extending

An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client? 1 Drink fruit juices if you start to feel dehydrated. 2 Thirst is a good guide to use to determine fluid intake. 3 Fluids should be increased if the urine is getting darker. 4 Water should be consumed when the skin becomes dry

3 Fluids should be increased if the urine is getting darker.

A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn's disease. Which expected outcome is most important for this client? 1 Does skin care 2 Takes oral fluids 3 Gains a half pound per week 4 Experiences less abdominal cramping

3 Gains a half pound per week Weight loss usually is severe with Crohn's disease ; therefore, weight gain is a priority; this goal is specific, realistic, measurable, and has a time frame. Although skin care, taking oral fluids, and experiencing less abdominal cramping are important, they are not as high a priority as weight gain.

A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated?

Hypotension

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug? 1 Administer the medication with meals or a snack. 2 Provide orange or other citrus fruit juice with the medication. 3 Give the medication an hour before milk products are ingested. 4 Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

3 Give the medication an hour before milk products are ingested. Any product containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose, because it decreases absorption by as much as 25% to 50%. Food interferes with absorption; it should be given one hour before or two hours after meals. Citrus juice has no influence on this drug. Antacids will interfere with absorption.

A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1 Ripe bananas." 2 Milk products." 3 Green vegetables." 4 Creamed potatoes."

3 Green vegetables."

The nurse is caring for a client with a diagnosis of acute kidney failure associated with drug toxicity. When the client complains of thirst, the nurse should offer: 1 Ice chips 2 Warm milk 3 Hard candy 4 Carbonated soda

3 Hard candy Sucking on candy will relieve thirst and provide calories without supplying extra fluid. Ice chips add to the restricted fluid intake. Milk contains both fluids and proteins, which should be restricted with acute kidney failure. Carbonated beverages may be high in sodium and provide additional fluid; both should be restricted.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1 Abdominal girth decrease 2 Mucous membranes becoming drier 3 Heart rate increases from 80 to 135 4 Blood pressure rises from 130/70 to 190/80

3 Heart rate increases from 80 to 135 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for what complication? 1 Peritonitis 2 Renal calculi 3 Hepatitis B 4 Bladder infection

3 Hepatitis B Hepatitis type B is transmitted by blood or blood products. The hemodialysis and routine transfusions needed for a client in end-stage renal failure constitute a high risk for exposure.

A client is to have gastric lavage following an overdose of acetaminophen (Tylenol). In which position should the nurse place the client when the nasogastric tube is being inserted? 1 Supine 2 Mid-Fowler 3 High-Fowler 4 Trendelenburg

3 High-Fowler -The high-Fowler position promotes optimal entry into the esophagus aided by gravity. Supine position does not take full advantage of the effect of gravity. Mid-Fowler and Trendelenburg positions will contribute to aspiration. The head of the bed should be raised, not lowered.

After cataract surgery the nurse teaches a client how to self-administer eye drops. The nurse reinforces the use of what technique? 1 Placing the drops on the cornea of the eye 2 Raising the upper eyelid with gentle traction 3 Holding the dropper tip above the conjunctival sac 4 Squeezing the eye shut after instilling the medication

3 Holding the dropper tip above the conjunctival sac

Which is the most serious complication for which the nurse must monitor a client with kidney failure? 1 Anemia 2 Weight loss 3 Hyperkalemia 4 Platelet dysfunction

3 Hyperkalemia

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints? 1 After assistive exercise 2 When the room is cool 3 In the morning on awakening 4 When the latex fixation test is positive

3 In the morning on awakening nactivity over an extended time increases stiffness and pain in joints. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The latex fixation test is positive when the rheumatoid factor is found in blood serum

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be: 1 Ambulated shortly after being transferred to the inpatient room after the procedure. 2 Given a general anesthesia and therefore will be asleep during the procedure. 3 In the supine position with the affected leg extended for several hours postprocedure. 4 Given only clear liquids for the remainder of the procedure day.

3 In the supine position with the affected leg extended for several hours postprocedure. Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. With the femoral approach, bed rest is maintained for several hours. Mild sedation is used for adult clients; the client is conscious. Post-procedural dietary restrictions are minimal, if any.

A client who is receiving radiation therapy for bone cancer lives alone and works full time. What should the nurse encourage this client to do? 1 Perform regularly scheduled aerobic activity daily. 2 Take a leave of absence from work when receiving therapy. 3 Include rest periods during the day while receiving radiation. 4 Continue the activities usually performed before becoming ill.

3 Include rest periods during the day while receiving radiation.

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? 1 Polyuria 2 Tachypnea 3 Increased restlessness 4 Intermittent tachycardia

3 Increased restlessness

A client has been diagnosed with cholelithiasis. Which fact about cholelithiasis should the nurse recall when assessing this client for risk factors? 1 Men are more likely to be affected than women. 2 Young people are affected more frequently than older people. 3 Individuals who are obese are more prone to this condition than those who are thin. 4 People who are physically active are more apt to develop this condition than those who are sedentary.

3 Individuals who are obese are more prone to this condition than those who are thin.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1 Narrowed airways 2 Impaired immunity 3 Ineffective coughing 4 Viscosity of secretions

3 Ineffective coughing Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

A female client is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection in the future?" The nurse evaluates that the teaching is understood when the client states, "My best protection is to: 1 Douche after every intercourse." 2 Avoid engaging in sexual behavior." 3 Insist that my partner use a condom." 4 Use a spermicidal cream with intercourse."

3 Insist that my partner use a condom."

Which insulin should the nurse prepare for the emergency treatment of ketoacidosis? 1 Glargine (Lantus) 2 NPH insulin (Novolin N) 3 Insulin aspart (NovoLog) 4 Insulin detemir (Levemir

3 Insulin aspart (NovoLog) Insulin aspart is a rapid-acting insulin (within 10 to 20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic acidosis the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of one to two hours; for diabetic acidosis the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic acidosis the individual needs rapid-acting insulin.

A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to: 1 Fluid imbalance 2 Sedentary lifestyle 3 Interruption in previous voiding habits 4 Nervous tension following the procedure

3 Interruption in previous voiding habits An indwelling catheter dilates the urinary sphincters, keeps the bladder empty, and short-circuits the reflex mechanism based on bladder distention. When the catheter is removed, the body must adapt to functioning once again.

The nurse is caring for a client with arthritis. The client asks, "Can I take Tylenol instead of aspirin? Aspirin irritates my stomach." The nurse explains that acetaminophen (Tylenol): 1 Lacks anticoagulant action 2 Has the same action as aspirin 3 Lacks an anti-inflammatory action 4 Has more severe side effects than aspirin Although acetaminophen (Tylenol) reduces pain,

3 Lacks an anti-inflammatory action

A client who had a laparoscopic cholecystectomy reports pain in the shoulder. In what position should the nurse place the client? 1 Prone 2 Supine 3 Left Sims 4 Right side-lying

3 Left Sims Retained carbon dioxide can irritate the phrenic nerve. Placing the client in the left Sims position helps to move the gas pocket away from the diaphragm. Deep breathing and ambulation should be encouraged. Prone position will not help to alleviate the problem. Supine position will not help to alleviate the problem. Right side-lying position will not help to alleviate the problem.

A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time? 1 Albuterol (Proventil) 2 Warfarin (Coumadin) 3 Metoprolol (Lopresor) 4 Acetaminophen (Tylenol)

3 Metoprolol (Lopresor)

A client who had a recent brain attack (CVA) has not had a bowel movement for five days. After addressing this problem, what does the nurse anticipate will be prescribed daily to prevent this from occurring in the future? 1 Fleet enema to stimulate peristalsis 2 Tap-water enema to evacuate the bowel 3 Mild stool softener to make stool easier to pass 4 Lubricant laxative to create more bulk in the intestines

3 Mild stool softener to make stool easier to pass

A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the client's condition after this therapy should the nurse consider when providing care? 1 Not radioactive and can be handled as any other individual 2 Highly radioactive and should be isolated as much as possible 3 Mildly radioactive but should be treated with routine safety precautions 4 Not radioactive but may still transmit some dangerous radiations and must be treated with precautions

3 Mildly radioactive but should be treated with routine safety precautions; An individual treated for a thyroid problem by intake of radioactive iodine (131I) becomes mildly radioactive, particularly in the region of the thyroid gland, which preferentially absorbs the iodine. Such clients should be treated with routine safety precautions for 48 hours (e.g., avoid prolonged contact or near-contact with others, flush toilet twice after using because radioactive iodine is excreted via the urine, and thoroughly wash hands after toileting). Because radioactive iodine is internalized, the client becomes the source of radioactivity. The amount of radioactive iodine used is not enough to cause high radioactivity.

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for: 1 Physical agitation 2 Reflex stimulation 3 Myocardial depression 4 Respiratory stimulation

3 Myocardial depression

A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery? 1 Chest 2 Intestinal 3 Nasogastric 4 Gastrostomy

3 Nasogastric Nasogastric surgery involves the stomach, duodenum, pancreas, and common bile duct; a nasogastric tube removes gastric secretions and prevents distention of the gastrointestinal tract. A chest tube is used to remove air or blood from the chest cavity; the chest is not entered in the Whipple procedure. Intestinal tubes are used for small bowel obstructions; except for the duodenum, the small bowel is not included in the Whipple procedure. A gastrostomy tube is used to deliver nutrients into the stomach of a client who cannot ingest food via the oral route.

A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed? 1 Bed rest must be maintained after the procedure. 2 The involved area will be shaved before the procedure. 3 Needles will be inserted into the affected muscles during the test. 4 Monitoring of the heart rate and rhythm will be done throughout the test.

3 Needles will be inserted into the affected muscles during the test. Needles will be inserted into the affected muscles during the test to assess electrical activity and to determine whether symptoms are primarily musculoskeletal or neurological

A client complains of pain four hours after a liver biopsy. The nurse identifies that there is a leakage of a large amount of bile on the dressing over the biopsy site. What should the nurse do first? 1 Tell the client to remain flat on the back. 2 Medicate the client for pain as prescribed. 3 Notify the client's health care provider immediately. 4 Monitor the client's vital signs every 10 minutes.

3 Notify the client's health care provider immediately.

The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. What breakfast items should the nurse encourage the client to select? 1 Cream of wheat, milk, and cranberry juice 2 Unstrained orange juice, pancakes, and bacon 3 Oatmeal, sliced bananas, whole-wheat toast, and milk 4 Poached eggs on whole-wheat toast, tomato juice, and tea

3 Oatmeal, sliced bananas, whole-wheat toast, and milk

A nurse is monitoring a client with renal failure for signs of fluid excess. Which finding does the nurse identify as inconsistent with fluid excess? 1 Increased weight 2 Distended neck veins 3 Orthostatic hypotension 4 Abnormal breath sounds

3 Orthostatic hypotension

A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes what physiological response? 1 Fever 2 Vomiting 3 Palpitations 4 Constipation

3 Palpitations Dumping syndrome is caused by a rapid emptying of gastric contents into the small intestine, resulting in a constellation of vasomotor responses, including tachycardia, vertigo, syncope, diaphoresis, and pallor. Fever is a sign of infection, not dumping syndrome. Vomiting is not a sign of dumping syndrome; excessive food intake may result in nausea and vomiting. Diarrhea and abdominal cramping occur, not constipation.

When caring for a client who is recovering from a gastrectomy, a nurse is concerned about the potential development of pernicious anemia. What should the nurse conclude may be the cause of this complication? 1 Vitamin B12 is just absorbed in the stomach. 2 Hemopoietic factor is secreted in the stomach. 3 Parietal cells of the stomach secrete the intrinsic factor. 4 Chief cells in the stomach promote the secretion of the extrinsic factor.

3 Parietal cells of the stomach secrete the intrinsic factor. Pernicious anemia is caused by a lack of vitamin B12 . Intrinsic factor, produced by the parietal cells of the gastric mucosa, is necessary for B12 absorption. B12 is absorbed in the ileum. The hemopoietic factor is the combination of B12 and intrinsic factor. The intrinsic factor is secreted by the stomach, and food is the source of vitamin B12 . Chief cells secrete the enzymes of the gastric juice.

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus? 1 Anxiety 2 Restlessness 3 Pinpoint red spots on the chest 4 Decreased arterial oxygen level

3 Pinpoint red spots on the chest Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae). Anxiety occurs in both fat embolism and thromboembolism. There often is a feeling of dread or impending doom. Restlessness and confusion due to cerebral hypoxia occur in both fat embolism and thromboembolism. The Po2 may be decreased in both fat embolism and thromboembolism.

A nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor? 1 Urea 2 Chloride 3 Potassium 4 Creatinine

3 Potassium

A client in a debilitated state is admitted for palliative treatment of cancer of the liver. Which objective information collected by the nurse is most helpful for future monitoring of the client's condition? 1 Diet history 2 Bowel sounds 3 Present weight 4 Pain description

3 Present weight

A nurse is caring for a client with a spinal cord injury. Which is the specific reason why fluid intake should be increased for this client? 1 Prevent dehydration 2 Maintain electrolyte balance 3 Prevent a urinary tract infection 4 Limit an increase in temperature

3 Prevent a urinary tract infection Lack of or reduced movement predisposes the client with paraplegia or quadriplegia to urinary stasis, which may result in a urinary tract infection and calculus formation

A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the physical exertion of crutch walking? 1 Pulse of 100 and deep respirations 2 Flushed skin and slowed respirations 3 Profuse diaphoresis and rapid respirations 4 Blood pressure of 150/88 mm Hg and shallow respirations

3 Profuse diaphoresis and rapid respirations Diaphoresis and tachypnea indicate that the client has exceeded tolerance for the activity.

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery? 1 Increasing activity tolerance 2 Preventing cardiac dysrhythmias 3 Promoting physical and emotional rest 4 Maintaining potassium and sodium intake

3 Promoting physical and emotional rest The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. There is no indication that the client has a history of dysrhythmias. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.

A nurse is caring for a client with an undescended testicle. The nurse teaches the client that the main reason why the testicles are suspended in the scrotum is to: 1 Protect the sperm from the acidity of urine. 2 Facilitate the passage of sperm through the urethra. 3 Protect the sperm from high abdominal temperatures. 4 Facilitate their maturation during embryonic development

3 Protect the sperm from high abdominal temperatures. Sperm cells are fragile and can be destroyed by heat, causing sterility.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client states, "TPN: 1 Provides short-term nutrition after surgery. 2 Assists in providing supplemental nutrition. 3 Provides total nutrition when gastrointestinal (GI) function is questionable. 4 Assists people who are unable to eat but have active GI function.

3 Provides total nutrition when gastrointestinal (GI) function is questionable.

An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the health care provider will most likely prescribe? 1 Increase intake of dietary roughage slowly. 2 Avoid oral feedings for a prolonged period. 3 Resume small, easily digested feedings gradually. 4 Limit intake to self-selection of personally preferred foods.

3 Resume small, easily digested feedings gradually.

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor? 1 Edema 2 Dysuria 3 Retention 4 Suppression

3 Retention

A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to: 1 Place the linen in an appropriate bag 2 Write an incident report about the situation 3 Review transmission-based precautions with the UAP 4 Place an anecdotal summary of the behavior in the UAP's personnel record

3 Review transmission-based precautions with the UAP

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? 1 Turkey salad, French fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake 3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

3 Salad, sliced chicken sandwich, gelatin dessert

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? 1 Pelvic warmth 2 Feeling flushed 3 Shortness of breath 4 Salty taste in the mouth

3 Shortness of breath

A nurse begins planning for the discharge of a client who had a brain attack (CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client? 1 Necessity for bed rest at home 2 Use of oxygen therapy at home 3 Significance of a safe environment 4 Need for decreased protein in the diet

3 Significance of a safe environment

When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid: 1 Climbing stairs 2 Stretching exercises 3 Sitting in a low chair 4 Lying prone for more than 15 minutes

3 Sitting in a low chair Excessive flexion of the hip can cause dislocation of the femoral head.

A client's serum albumin value is 2.8 g/dL. Which food selected by the client indicates that the nurse's dietary teaching is successful? 1 Beef broth 2 Fruit salad 3 Sliced turkey 4 Spinach salad

3 Sliced turkey This client's serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL. White meat turkey (two slices 4 × 2 × 1/4 inch) contains approximately 28 g of protein. A 4 oz serving of beef broth contains approximately 2.4 g of protein. A 6 oz serving of mixed fruit contains approximately 0.5 g of protein. A 3 oz serving of spinach salad contains approximately 9 g of protein

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? 1 Low-residue, bland diet 2 Fluid intake below 500 mL 3 Small, frequent feeding schedule 4 Low protein, high carbohydrate diet

3 Small, frequent feeding schedule

A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed? 1 Loop diuretic 2 Cardiac glycoside 3 Sympathomimetic 4 Alpha-adrenergic blocker

3 Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which will exacerbate hypovolemia associated with hypovolemic shock. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.

A client develops acute appendicitis. Prior to arrival to the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix? 1 Refusing food and liquids 2 Applying an ice pack to the abdomen 3 Taking a small volume enema 4 Taking acetaminophen (Tylenol) for pain

3 Taking a small volume enema Enemas can increase pressure in the intestines and cause rupture of an inflamed appendix. Fasting from food or applying an ice pack will not lead to rupture of the appendix. Taking acetaminophen will not increase the risk of rupture of the appendix.

A client who is to begin continuous ambulatory peritoneal dialysis (CAPD) asks the nurse what this treatment entails. What information should the nurse include in the explanation? 1 Peritoneal dialysis is done in an ambulatory care clinic. 2 Hemodialysis and peritoneal dialysis are provided continuously. 3 The peritoneal membrane allows passage of toxins into the dialysate. 4 A quarter of a liter of dialysate is maintained inter- and intraperitoneally.

3 The peritoneal membrane allows passage of toxins into the dialysate.

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is: 1 A computerized scan that outlines the bladder and surrounding tissue." 2 An x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." 3 The visualization of the inside of the bladder with an instrument connected to a source of light." 4 The visualization of the urinary tract through ureteral catheterization and the use of radiopaque material."

3 The visualization of the inside of the bladder with an instrument connected to a source of light."

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? 1 Skip the oral hypoglycemic pill, drink plenty of fluids, and rest. 2 Avoid food, drink clear liquids, take the daily medication, and stay in bed. 3 Take the oral medication, drink fluids, and monitor capillary glucose levels. 4 Delay taking the medication until tolerating food, and call the office the next day.

3 Take the oral medication, drink fluids, and monitor capillary glucose levels.

A client says, "I take baking soda in water when I get heartburn." The nurse suggests an antacid containing aluminum and magnesium hydroxide instead of baking soda. What is the advantage these antacids have over baking soda? 1 They contain little, if any, sodium. 2 Absorption by the stomach mucosa is markedly enhanced. 3 There is no direct effect on the systemic acid-base balance when taken as directed. 4 Fewer side effects, such as diarrhea or constipation, are experienced when they are used properly.

3 There is no direct effect on the systemic acid-base balance when taken as directed. Nonsystemic antacids are not readily absorbed, so they do not alter acid-base balance. Sodium bicarbonate is absorbed and can alter acid-base balance. These preparations do contain sodium. Nonsystemic antacids are insoluble and not readily absorbed. Diarrhea and constipation are side effects of nonsystemic antacids.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech

3 Thirst, cool skin, and orthostatic hypotension With hypovolemic shock extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics? 1 One dose of diphtheria toxoid, oral poliomyelitis, live measles, live rubella, and mumps vaccines. 2 Two doses of diphtheria toxoid, oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine. 3 Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine. 4 Three doses of diphtheria toxoid vaccine, two doses of oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.

3 Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole (Flagyl). The nurse explains, "Antibiotics are prescribed to: 1 Augment the immune response." 2 Potentiate the effect of antacids." 3 Treat Helicobacter pylori infection." 4 Reduce hydrochloric acid secretion."

3 Treat Helicobacter pylori infection."

A client taking levodopa (L-dopa) is taught about the signs of levodopa toxicity. The nurse instructs the client to contact the primary health care provider if the client develops: 1 Nausea 2 Dizziness 3 Twitching 4 Constipation

3 Twitching Abnormal involuntary movements (dyskinesias), such as muscle twitching, rapid eye blinking, facial grimacing, head bobbing, and an exaggerated protrusion of the tongue, are signs of toxicity; these probably result from the body's failure to readjust properly to the reduction of dopamine

A nurse is planning to administer a prescribed intravenous solution that contains potassium chloride. What assessment should be brought to the health care provider's attention before administration of the intravenous (IV) line? 1 Uncharacteristic irritability 2 Poor tissue turgor with tenting 3 Urinary output of 200 mL during the previous 8 hours 4 Oral fluid intake of 300 mL during the previous 12 hours

3 Urinary output of 200 mL during the previous 8 hours Decreased urinary output will result in the retention of potassium, causing hyperkalemia. Reporting uncharacteristic irritability is unnecessary; this is a sign of dehydration, which can be corrected with appropriate hydration.

To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to: 1 Increase the daily intake of citrus juice 2 Douche regularly with alkaline agents 3 Urinate as soon as possible after intercourse 4 Wipe carefully from back to front

3 Urinate as soon as possible after intercourse

To reduce a fracture of the hip, a client is placed in Buck's traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction? 1 Add more weight to the traction. 2 Elevate the head of the client's bed. 3 Use a slight Trendelenburg position. 4 Apply a chest restraint around the client

3 Use a slight Trendelenburg position.

A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take? 1 Wear a gown when entering the client's room. 2 Use caution when bringing in the client's food. 3 Use gloves when removing the client's bedpan. 4 Wear a protective mask when entering the client's room.

3 Use gloves when removing the client's bedpan.

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94. For what additional clinical manifestation associated with this data, should the nurse assess the client? 1 Thirst 2 Urinary retention 3 Weight gain 4 Urinary hesitancy

3 Weight gain Oliguria is the inability to produce more than 400 to 500 mL of urine daily. Expected daily urinary output is 1000 to 3000 mL daily, depending on the volume of fluid intake. If urine is not being produced in the presence of an average daily intake, fluid will be retained and reflected in weight gain. One liter of fluid weighs 2.2 pound

Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to:

3 Give supplemental doses of regular insulin

A health care provider writes prescriptions addressing the needs of a client with Addison disease. Which outcome does the nurse conclude is the main focus of treatment for this client? 1 Decrease in eosinophils 2 Increase in lymphoid tissue 3 Restoration of electrolyte balance 4 Improvement of carbohydrate metabolism

3 Restoration of electrolyte balance

In the preoperative period

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (Select all that apply.) 1 "I plan to start taking vitamin B6 (NesTrex) with breakfast." 2 "I'll still be taking this drug six months from now." 3 "I sometimes allow our children to sleep in our bed at night." 4 "I know I also have tuberculosis because the skin test was positive." 5 "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

3 "I sometimes allow our children to sleep in our bed at night." 4 "I know I also have tuberculosis because the skin test was positive." 5 "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

The nurse is caring for a client with a 25-year history of excessive alcohol use. The nurse expects that assessment findings will indicate: 1 Signs of liver infection 2 A low blood ammonia level 3 A small liver with a rough surface 4 An elevated temperature and a generalized rash

3 A small liver with a rough surface Scar tissue that forms as cirrhosis progresses causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points.

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis . Which clinical findings related to this event should the nurse document in the client's clinical record? (Select all that apply.)

3 Acetone breath 5 Decreased arterial carbon dioxide level

A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. What instructions should the nurse include in the client's discharge teaching? (Select all that apply.) 1 Add milk to coffee. 2 Elevate the foot of the bed. 3 Avoid caffeine-containing products. 4 Eat three evenly spaced meals daily. 5 Chew thoroughly while eating slowly.

3 Avoid caffeine-containing products. 5 Chew thoroughly while eating slowly.

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? (Select all that apply.) 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypertension 5 Polycythemia

3 Azotemia 4 Hypertension Azotemia is an increase in nitrogenous waste, particularly urea, in the blood; this is common in end-stage renal disease. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the rennin-angiotensin-aldosterone system. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not end-stage renal disease. Anemia, not polycythemia, occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.

A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram-sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? (Select all that apply.) 1 Lean steak 2 Celery sticks 3 Baked chicken 4 Tuna fish salad 5 Mashed potatoes

3 Baked chicken 5 Mashed potatoes

When a client develops steatorrhea, the nurse documents this stool as: 1 Dry and rock-hard 2 Clay colored and pasty 3 Bulky and foul smelling 4 Black and blood-streaked

3 Bulky and foul smelling Bulky and foul smelling characteristics describe steatorrhea, which results from impaired fat digestion

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: 1 A." 2 B." 3 C." 4 D."

3 C." 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. Recent studies document that the risk of contracting hepatitis C from a blood transfusion is 1 in 103,000 transfusions. The incubation period is 5 to 10 weeks. Hepatitis A, also known as infectious hepatitis, is caused by an RNA virus that is transmitted via the fecal-oral route. The incubation period is 2 to 6 weeks. Hepatitis B is transmitted parenterally, sexually, and by direct contact with infected body secretions. The incubation period is 1 to 6 months. It is not the major cause of posttransfusion hepatitis. Hepatitis D is a complication of hepatitis B.

When assessing a client with heart failure, the nurse asks when the client most notices an increase in symptoms. Which activity should the nurse expect will cause the client the greatest distress? 1 Getting up from bed in the morning 2 Walking to visit the next-door neighbor 3 Climbing a flight of stairs to the bedroom 4 Leaving the table immediately after a meal

3 Climbing a flight of stairs to the bedroom

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? (Select all that apply.) 1 Convulsions 2 Muscle spasms 3 Deep bone pain 4 Tingling of extremities 5 Depressed deep tendon reflexes

3 Deep bone pain 5 Depressed deep tendon reflexes Increased serum calcium comes from bone demineralization, which results in pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles).

A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome? 1 Increase activity after eating 2 Drink at least two to three glasses of fluid with each meal 3 Eat small meals with low carbohydrate and moderate fat content 4 Sit in a high-Fowler position for 30 minutes after eating

3 Eat small meals with low carbohydrate and moderate fat content Small meals with low carbohydrate, moderate fat, and high protein are recommended; these are digested more readily and prevent rapid stomach emptying. Rest, not activity, after meals assists in limiting dumping syndrome. Fluid intake with meals should be in moderation. Fluids with meals cause rapid emptying of the food from the stomach into the jejunum before it is adequately subjected to the digestive process; the hyperosmolar mixture causes a fluid shift to the jejunum. A high-Fowler position will not reduce the risk of dumping syndrome.

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, the nurse should advise the client to take the prescribed as needed oxycodone and acetaminophen (Percocet): 1 Just as a last resort 2 Before going to sleep 3 As the pain becomes intense 4 When the discomfort begins

4 When the discomfort begins

For which classic clinical finding should the nurse assess the stool of clients with malabsorption syndrome? 1 Melena 2 Frank blood 3 Fat globules 4 Currant jelly consistency

3 Fat globules Undigested fat in the feces (steatorrhea) is associated with diseases of the intestinal mucosa (e.g., celiac sprue) or pancreatic enzyme deficiency. Darkening of feces by blood pigments (melena) is related to upper gastrointestinal (GI) bleeding. Bright red blood in the stool is related to lower GI bleeding (e.g., hemorrhoids). Stools containing blood and mucus (currant jelly stools) are associated with intussusception.

A nurse reviews the plan of care for a client with less than adequate nutritional intake. The nurse should question which prescription? 1 Have client sit in a chair for meals 2 Provide six small feedings in 24 hours 3 Give one can of diet supplement at 8 am and 4 pm 4 Encourage the client's family members to bring food from home

3 Give one can of diet supplement at 8 am and 4 pm Supplements given before meals will make a client less hungry at mealtimes; supplements should be given after meals.

A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? (Select all that apply.) 1 Mask 2 Gown 3 Gloves 4 Face shield 5 Hand hygiene

3 Gloves 5 Hand hygiene

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? (Select all that apply.) 1 Ripe bananas 2 Milk products 3 Green vegetables 4 Creamed potatoes 5 Whole grain bread

3 Green vegetables 5 Whole grain bread

A client is admitted with a lesion in the descending colon. Which factor in the client's history is unrelated to a predisposition to cancer? 1 Colitis 2 Constipation 3 Hemorrhoids 4 Diverticulitis

3 Hemorrhoids

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone (Aldactone).What should the nurse monitor the client for? 1 Bruising 2 Tachycardia 3 Hyperkalemia 4 Hypoglycemia

3 Hyperkalemia Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? (Select all that apply.) 1 Constipation 2 Hypokalemia 3 Irregular pulse rate 4 Change in visual acuity 5 Orthostatic hypotension

3 Irregular pulse rate 5 Orthostatic hypotension Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan . It also may precipitate angina pectoris, myocardial infarction, and brain attack (CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.

A nurse provides dietary teaching for a client with an acute exacerbation of colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching was effective? (Select all that apply.) 1 Orange juice 2 Creamed soup 3 Jelly sandwich 4 Lean roast beef 5 Scrambled eggs

3 Jelly sandwich 4 Lean roast beef 5 Scrambled eggs A jelly sandwich is low in residue and therefore is less irritating to the colon than other foods. Lean roast beef is low in residue and therefore is less irritating to the colon than other foods. Eggs are low in residue and therefore are less irritating to the colon than other foods. Orange juice contains cellulose, which is not absorbed and irritates the colon. Milk in creamed soup contains lactose, which is irritating to the colon.

A client with chronic hepatic failure is to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider's prescription? 1 High fat 2 Low-calorie 3 Low protein 4 High sodium

3 Low protein With liver failure, the protein intake is limited to 20 g daily to decrease the possibility of hepatic encephalopathy. A high fat diet is avoided because of the related cardiovascular risks and the related demand for bile. Regeneration of tissue requires a high-calorie, high carbohydrate diet. Sodium usually is restricted to decrease the accumulation of fluid and help limit ascites and edema.

What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery? 1 Restrict family visits 2 Withhold analgesic medications 3 Plan for maximum periods of rest 4 Keep the room light on most of the time

3 Plan for maximum periods of rest

A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the: 1 Pulse rate, thereby strengthening cardiac contractility 2 Cardiac output, thereby reducing the cardiac workload 3 Preload of the heart, thereby reducing the cardiac workload 4 Coronary artery lumens, thereby reducing peripheral resistance

3 Preload of the heart, thereby reducing the cardiac workload Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect; it dilates coronary arteries, reduces myocardial ischemia, strengthens contractility, and increases efficiency of cardiac output. Decreasing the pulse rate does not strengthen cardiac contractility. Cardiac output is increased, not decreased. Peripheral resistance is affected not by dilating the coronary arteries but by dilating the peripheral arteries.

The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? (Select all that apply.) 1 Cheese omelet 2 Creamed spinach 3 Roast beef sandwich 4 Chicken noodle soup 5 Spaghetti and meatballs

3 Roast beef sandwich 4 Chicken noodle soup 5 Spaghetti and meatballs

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug? 1. Administer the medication with meals or a snack. 2. Provide orange or other citrus fruit juice with the medication. 3. Give the medication an hour before milk products are ingested. 4. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

3. Give the medication an hour before milk products are ingested.

A nurse is caring for a client with complications associated with peritoneal dialysis. For which signs and symptoms should the nurse monitor the client? (Select all that apply.) 1 Pruritus 2 Oliguria 3 Tachycardia 4 Cloudy outflow 5 Abdominal pain

3 Tachycardia 4 Cloudy outflow 5 Abdominal pain An increase in vital signs, including tachycardia, is associated with peritonitis, a complication of peritoneal dialysis . Cloudy outflow is associated with peritonitis; the presence of purulent material and red blood cells makes the outflow appear cloudy. Abdominal pain is a sign of peritonitis. Pruritus is a result of impaired renal function, not of peritoneal dialysis. Oliguria is a result of end-stage renal disease, not peritoneal dialysis.

When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in what position? 1 The left side-lying position with the head of the bed elevated 2 A high Fowler position with both arms supported on several pillows 3 The right side-lying position with pillows placed under the costal margin 4 Any comfortable recumbent position as long as the client remains immobile

3 The right side-lying position with pillows placed under the costal margin In the right side-lying position with pillows placed under the costal margin, the liver capsule at the entry site is compressed against the chest wall and escape of blood or bile is impeded. The left side-lying position with the head of the bed elevated, a high Fowler position with both arms supported on several pillows, and any comfortable recumbent position as long as the client remains immobile are unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.

A nurse observes the following dysrhythmia on a client's cardiac monitor. What rhythm does the nurse identify? 1 Atrial flutter 2 Atrial fibrillation 3 Ventricular fibrillation 4 Ventricular tachycardia

3 Ventricular fibrillation

The nurse is making rounds on a patient who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? (Select all that apply.) 1 Monitor for signs of alopecia. 2 Encourage an increase in fluids. 3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately. 6 Encourage the client to eat raw, fresh fruits and vegetables

3 Wash hands before entering the client's room. 4 Advise use of a soft toothbrush for oral hygiene. 5 Report an elevation in temperature immediately.

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3 ) and thyroxine (T4 )? (Select all that apply.)

3 Weight gain 4 Cold intolerance

A client with type 1 diabetes mellitus has a finger stick glucose level of 258 mg/dL at bedtime. A prescription for sliding scale regular insulin (Novolin R) exists. What should the nurse do? 1 Call the health care provider. 2 Encourage the intake of fluids. 3 Administer the insulin as prescribed. 4 Give the client a half cup of orange juice.

3 Administer the insulin as prescribed.

A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, mottled red, weeping, and edematous. These burns are classified as: 1. Eschar 2. Full-thickness burns 3. Deep partial-thickness burns 4. Superficial partial-thickness burns

3 Deep partial-thickness burns

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." The nurse suggests that a food that can be substituted for the broccoli is:

3 Green beans

A nurse is caring for a client with type 1 diabetes, and the health care provider prescribes one tube of glucose gel. What is the primary reason for the administration of glucose gel to this client?

3 Insulin-induced hypoglycemia

A client has a basal cell epithelioma that is scheduled to be removed. The client expresses concerns that the cancer has spread. What is the best response by the nurse? 1. "You are a low surgical risk." 2. "I can understand how you must feel." 3. "Basal cell tumors usually do not spread." 4. "The health care provider probably caught it just in time."

3. "Basal cell tumors usually do not spread."

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath? 1. 92° to 94° F 2. 95° to 97° F 3. 98° to 100° F 4. 101° to 103° F

3. 98° to 100° F

After a head injury a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider about the response to secretion of ADH before assessing this client? 1 Serum osmolarity increases 2 Urine concentration decreases 3 Glomerular filtration decreases 4 Tubular reabsorption of water increases

4 Tubular reabsorption of water increases

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? 1. Crackling 2. Wheezing 3. Decreased sounds 4. Adventitious sounds

3. Decreased sounds

A health care provider prescribes oxygen given in low concentration rather than in high concentration to a client with chronic obstructive pulmonary disease (COPD). What does this prevent? 1. Decrease in red cell formation 2. Rupture of emphysematous bullae 3. Depression of the respiratory center 4. Excessive drying of the respiratory mucosa

3. Depression of the respiratory center

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1. Cover the cast with plastic wrap until dry 2. Assist with weight bearing when the client ambulates 3. Elevate the affected leg above the level of the heart 4. Insert a finger inside the edges of the cast to check for skin abrasions

3. Elevate the affected leg above the level of the heart

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for: 1. Pallor and cyanosis 2. Dyspnea on exertion 3. Elevated hemoglobin 4. Decreased hematocrit

3. Elevated hemoglobin

A nurse is collecting information about a client who has type 1 diabetes and is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? (Select all that apply.)

3. Excessive emotional stress 4. Running a fever with the flu

What response provides evidence that a client with chronic obstructive pulmonary disease (COPD) understands the nurse's instructions about an appropriate breathing technique? 1. Inhales through the mouth. 2. Increases the respiratory rate. 3. Holds each breath for a second at the end of inspiration. 4. Progressively increases the length of the inspiratory phase.

3. Holds each breath for a second at the end of inspiration. *Holding each breath for a second at the end of inspiration allows added time for gaseous exchange at alveolar capillary beds.

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.)

3. It can improve A1c levels 5. Clients can exercise without eating more carbohydrates

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed-chest drainage system. What should the nurse do to determine if the chest tube is patent? 1. Milk the chest tube toward the drainage unit 2. Check the amount of bubbling in the suction control chamber 3. Observe for fluctuations of the fluid in the water-seal chamber 4. Assess for extent of chest expansion in relation to breath sounds

3. Observe for fluctuations of the fluid in the water-seal chamber *Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system.

A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the: 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

3. Plasma proteins moving out of the intravascular compartment

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? 1. Contains many small air bubbles. 2. Bubbles vigorously on inspiration. 3. Rises with inspiration and falls with expiration. 4. Remains at a consistent level during the respiratory cycle

3. Rises with inspiration and falls with expiration. *During inspiration, negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration, negative pressure in the pleural space decreases, causing fluid to drop in the chamber.

A client, complaining of fatigue, is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent fatigue, the nurse should: 1. Provide small, frequent meals 2. Encourage pursed-lip breathing 3. Schedule nursing activities to allow for rest 4. Encourage bed rest until energy level improves

3. Schedule nursing activities to allow for rest

A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to: 1. Hold the breath while spraying the medication into the mouth 2. Position the lips loosely around the mouthpiece and take rapid, shallow breaths 3. Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths 4. Inhale the medication from the nebulizer, remove the mouthpiece from the mouth, and then exhale

3. Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths *Sealing the lips around the mouthpiece ensures that medication is delivered on inspiration; slow, deep breaths promote better deposition and efficacy of medication deep into the lungs.

When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? 1. Substernal chest pain 2. Episodes of palpitation 3. Severe shortness of breath 4. Dizziness when standing up

3. Severe shortness of breath

The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis? 1. Anemia 2. Pneumonia 3. Tuberculosis 4. Leukocytosi

3. Tuberculosis *Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis

Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes?

A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of:

30 degrees

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. The nurse calculates that the hourly intravenous (IV) fluid should be: Record your answer using a whole number. __________ mL/hr

300 mL/hr is the correct rate that the IV should be set at based on the health care provider's prescription. 7200 mL ÷ 24 hours = 300 mL/hr. 175 mL/hr and 200 mL/hr are too slow and are incorrect calculations. 325 mL/hr is too fast and is an incorrect calculation.

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:

After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. __________ gtts/min

A client had a thyroidectomy. The nurse monitors for thyrotoxic crisis, which is evidenced by:

A client who was diagnosed recently with type 1 diabetes states, "I feel bad. I don't think I even want to go home. My spouse doesn't care about my diabetes." What is the most appropriate nursing response?

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. The nurse explains that:

A client with hyperthyroidism refuses radioactive iodine therapy and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription?

A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra pill should be taken before exercise. The best response by the nurse is:

A nurse is caring for a client who is scheduled for a bilateral adrenalectomy. Which medication should the nurse expect to be prescribed for this client on the day of surgery and in the immediate postoperative period?

A nurse is caring for an alert client who has diabetes and is receiving an 1800-calorie American Diabetic Association diet. The client's blood glucose level is 60 mg/dL. The health care provider's protocol calls for treatment of hypoglycemia with 15 g of a simple carbohydrate. The nurse should:

A nurse is providing postoperative care for a client who just had a thyroidectomy. For what response should the nurse assess the client when concerned about the potential risk of thyrotoxic crisis?

An obese client must self-administer insulin at home. The nurse should teach the client to use what technique?

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to:

Which statement made by a 28-year-old client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? 1 "I will need to have my eyes and vision examined once a year." 2 "I will need to check my blood sugar at home to evaluate my response to my treatment plan." 3 "I can improve metabolic and cardiac risk factors of this disease if I follow a low-calorie diet and lose weight." 4 "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."

4 "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication to control my blood sugar."

An 80-year-old client with dementia of the Alzheimer's type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? 1 "Most people at that age should be careful about weight gain." 2 "This is typical of older adults; they really don't eat well." 3 "It looks as though the frequent tanning has taken its toll." 4 "As we age, we lose the tissue that helps puff out the skin."

4 "As we age, we lose the tissue that helps puff out the skin."

A client with type 2 diabetes is taking one glyburide (Micronase) tablet daily. The client asks whether an extra pill should be taken before exercise. What is the nurse's best reply? 1 "You will need to decrease how much you are exercising." 2 "An extra pill will help your body use glucose when exercising." 3 "The amount of medication you need to take is not related to exercising." 4 "Do not take an extra pill because you may become hypoglycemic when exercising."

4 "Do not take an extra pill because you may become hypoglycemic when exercising."

A client was recently diagnosed with a cancerous lesion of the mouth. What should the nurse ask when analyzing the client's need for health education in relation to this health problem? 1 "Are you having difficulty sleeping?" 2 "Do feel like your gums are inflamed?" 3 "How frequently are you seeing the dentist?" 4 "Have you noticed any change in your appetite?"

4 "Have you noticed any change in your appetite?"

A nurse is teaching an older adult client about managing chronic pain with acetaminophen (Tylenol). Which client statement indicates that the teaching is effective? 1 "I need to limit my intake of acetaminophen to 650 mg a day." 2 "I can take oxycodone with the acetaminophen if it is ineffective." 3 "I should take an emetic if I accidentally overdose on the acetaminophen." 4 "I have to be careful about which over-the-counter cold preparations I take when I have a cold."

4 "I have to be careful about which over-the-counter cold preparations I take when I have a cold."

A client is suspected of having late-stage (tertiary) syphilis. When obtaining a health history, the nurse determines that the client statement that most supports this diagnosis is: 1 "I noticed a wart on my penis." 2 "I have sores all over my mouth." 3 "I've been losing a lot of hair lately." 4 "I'm having trouble keeping my balance."

4 "I'm having trouble keeping my balance." Neurotoxicity, as manifested by ataxia, is evidence of tertiary syphilis, which may involve the central nervous system (CNS); other CNS signs include confusion, paralysis, delusions, impaired judgment, and slurred speech. A sore on the penis occurs in the secondary stage. Sores in the mouth occur in the secondary stage. Alopecia is not a sign of late-stage syphilis.

A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? 1 "My fluid intake should be restricted." 2 "I should limit the number of daily food servings." 3 "Salt should not be used during cooking but can be used at the table." 4 "Labels on prepackaged food products should be evaluated before purchase."

4 "Labels on prepackaged food products should be evaluated before purchase."

A client signs a legal consent for hip replacement surgery. Shortly before surgery, the client states, "I decided not to go through with the surgery." What is the best initial response by the nurse? 1 "Then you shouldn't have signed the consent." 2 "I can understand why you changed your mind." 3 "Tell me why you decided to refuse the operation." 4 "Let's talk about your concerns regarding the procedure.

4 "Let's talk about your concerns regarding the procedure.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? 1 "There are no dietary restrictions because the tumor has been removed." 2 "Your diet should be low in calories to prevent taxing your diseased pancreas." 3 "Meals should be restricted in protein because of your compromised liver function." 4 "Low fat meals should be eaten to prevent interference with your fat digestion mechanism."

4 "Low fat meals should be eaten to prevent interference with your fat digestion mechanism." Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine; interference with fat digestion occurs, causing dyspepsia. Clients require small, frequent meals and should eat a high-calorie, high protein, low fat diet. The response "There are no dietary restrictions because the tumor has been removed" is false assurance. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.

An x-ray film indicates that an older client has a fractured femur. The client asks the nurse, "Will I be able to walk again?" What is the best response by the nurse? 1 "I have no idea because only time will tell." 2 "You only broke a bone. It could have been worse." 3 "You'll walk again. This is a common issue in older people." 4 "Tell me more about your concerns about being able to walk."

4 "Tell me more about your concerns about being able to walk."

Prednisone (Meticorten) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that: 1 Symptoms associated with the colitis will decrease slowly over time 2 The client will be protected from getting an infection 3 Although the medication causes anorexia, weight loss may not occur 4 Although the medication decreases intestinal inflammation, it will not cure the colitis

4 Although the medication decreases intestinal inflammation, it will not cure the colitis

A health care provider prescribes a dose of medication that is much higher than is recommended for the clinical situation, and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate? 1 "The dose is too high. I do not feel comfortable administering this dose." 2 "Please tell me how you arrived at this dose. I think your calculations are incorrect." 3 "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug." 4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself."

4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself." The response "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself" informs the health care provider of the nurse's dilemma and legal position without creating an adversarial professional position. A confrontational response may make the health care provider look and feel incompetent and jeopardize the collegial relationship. "The dose is too high. I do not feel comfortable administering this dose," "Please tell me how you arrived at this dose. I think your calculations are incorrect," and "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug" are confrontational responses that may make the health care provider look and feel incompetent and jeopardize the collegial relationship.

A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. What is an appropriate nursing response? 1 "The staff will provide total care because the infection causes severe fatigue." 2 "Mood elevators will be prescribed to improve depression and irritability." 3 "Iron will be prescribed for the anemia and the stools will be dark." 4 "The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."

4 "The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."

Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin? 1 "I should drink a glass of milk with each pill." 2 "I should drink at least six glasses of water every day." 3 "The medicine should be taken with meals and at bedtime." 4 "The medicine should be taken one hour before or two hours after meals."

4 "The medicine should be taken one hour before or two hours after meals."

A client with hepatitis B asks the nurse, "Are there any medications to help me get rid of this problem?" Which is the best response by the nurse? 1 "Sedatives can be given to help you relax." 2 "We can give you immune serum globulin." 3 "Vitamin supplements are frequently helpful and hasten recovery." 4 "There are medications to help reduce viral load and liver inflammation."

4 "There are medications to help reduce viral load and liver inflammation."

After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is: 1 "Repeated phlebotomies may be able to rid you of the virus." 2 "You may be cured of AIDS after prolonged pharmacological therapy." 3 "Perhaps you should have worn condoms to prevent contracting the virus." 4 "There is no cure for AIDS but there are drugs that can slow down the virus."

4 "There is no cure for AIDS but there are drugs that can slow down the virus."

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The most appropriate response by the nurse is: 1 "You will have an abdominal incision and a dressing." 2 "Your urine will be pink and free of clots." 3 "There will be an incision between your scrotum and rectum." 4 "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."

4 "There will be an indwelling urinary catheter and a continuous bladder irrigation in place." The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for hemostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure? 1 110 to 119 mm Hg 2 120 to 129 mm Hg 3 130 to 139 mm Hg 4 140 to 159 mm Hg

4 140 to 159 mm Hg

What does the nurse determine is the most likely cause of renal calculi in clients with paraplegia? 1 High fluid intake 2 Increased intake of calcium 3 Inadequate kidney function 4 Accelerated bone demineralization

4 Accelerated bone demineralization Calcium that has left the bones as a response to prolonged inactivity enters the blood and may precipitate in the kidneys, forming calculi.

A 50-year-old male client has difficulty communicating because of expressive aphasia after a brain attack (CVA). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1 Ask the wife how she knows how the client feels. 2 Instruct the wife to let the client answer for himself. 3 When the wife leaves return to speak with the client. 4 Acknowledge the wife but look at the client for a response.

4 Acknowledge the wife but look at the client for a response.

Building confidence in one's worth is important for a client who is scheduled for a below-the-knee amputation (BKA) because an amputation: 1 Alters a person's sexuality 2 Implies a lack of wholeness 3 Increases dependency needs 4 Affects an idealized self-image

4 Affects an idealized self-image

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, the nurse should: 1 Limit the client's contact with others to minimize communication attempts 2 Anticipate needs so the client does not need to ask for help 3 Face the client while speaking loudly 4 Allow the client adequate time to speak

4 Allow the client adequate time to speak

A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to: 1 Maintain the client's nothing by moth status for the first 24 hours 2 Monitor the client's abdominal incision for bleeding 3 Offer clear carbonated beverages to the client 4 Ambulate the client when the client is alert and oriented

4 Ambulate the client when the client is alert and oriented

What should the nurse do when caring for a client with an ileostomy? 1 Teach the client to eat foods high in residue. 2 Explain that drainage can be controlled with daily irrigations. 3 Expect the stoma to start draining on the third postoperative day. 4 Anticipate that any emotional stress can increase intestinal peristalsis.

4 Anticipate that any emotional stress can increase intestinal peristalsis. -Emotional stress of any kind can stimulate peristalsis and thereby increase the volume of drainage. The client should be encouraged to eat a regular diet if possible. Ileostomy drainage is liquefied and continuous, so irrigations are not indicated. The stoma will start to drain within the first 24 hours after surgery.

A client has a colostomy after surgery for cancer of the colon. What postoperative nursing intervention maximizes skin integrity? 1 Empty the colostomy bag when it is three fourths full 2 Allow one half inch between the stoma and the appliance 3 Help the client to remove the appliance on the first postoperative day 4 Apply stoma adhesive around the stoma and then attach the appliance

4 Apply stoma adhesive around the stoma and then attach the appliance

The major nursing concern when caring for a client with the diagnosis of hyperthyroidism is: 1 Monitoring for hypoglycemia 2 Protecting visitors and staff from radiation exposure 3 Providing foods to increase appetite 4 Arranging for sufficient rest periods

4 Arranging for sufficient rest periods Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism . With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL. What should the nurse do first in response to this laboratory result? 1 Notify the health care provider. 2 Check the intravenous (IV) infusion. 3 Obtain current blood test results. 4 Assess for decreased urine output.

4 Assess for decreased urine output. The expected serum creatinine range is 0.5 to 1.2 mg/dL. The nurse should obtain additional information that may indicate acute rejection; therefore, the nurse must first assess for decreased urine output and changes in vital signs. Once additional data are collected (e.g., urine output, current blood work reports) and the IV infusions are checked, the nurse should contact the health care provider, explain the situation, and implement further prescriptions. Eventually the nurse should ensure that proper infusion rates, along with IV medications, are being maintained after the client is first assessed for decreased urine output and for changes in vital signs. Current blood work reports should be obtained after the client is assessed for decreased urine output and changes in vital signs.

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1 Remove the weights from the traction every two hours to promote comfort. 2 Turn the client from side to side every two hours to prevent pressure on the coccyx. 3 Raise the knee gatch on the bed every two hours to limit the shearing force of traction. 4 Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.

4 Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.

A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? 1 Check the client's temperature 2 Take the client's blood pressure 3 Obtain the client's pulse oximetry 4 Assess the client's respiratory status

4 Assess the client's respiratory status

To facilitate micturition in a male client, the nurse should instruct him to: 1 Use a urinal for voiding 2 Drink cranberry juice daily 3 Wash the hands after voiding 4 Assume the standing position for voiding

4 Assume the standing position for voiding Assuming the standing position for voiding uses gravity to allow urine to exert pressure on the area of the trigone, initiating relaxation of the urinary sphincter and facilitating micturition.

A nurse is caring for a client who sustained a transection of the spinal cord. The nurse continually monitors this client for what medical emergency? 1 Pressure ulcer 2 Gastrointestinal atony 3 Urinary tract infection 4 Autonomic hyperreflexia

4 Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic and 100 mm Hg diastolic; it is a medical emergency. Although a pressure ulcer can result from prolonged immobility, it is not an emergency.

A client with chronic gastritis is being treated with medication and diet. What should the nurse teach the client when discussing the therapeutic regimen? 1 Lie down after eating when possible 2 Take an antacid preparation with meals 3 Limit high carbohydrate foods in the diet 4 Avoid using analgesics that contain aspirin

4 Avoid using analgesics that contain aspirin Aspirin interferes with the gastric mucosa's natural protection from pepsin and hydrochloric acid, worsening the gastritis. The client should avoid lying down after eating; sitting up for one hour after meals uses gravity to minimize esophageal reflux. Antacids usually are prescribed after meals. Small, frequent, bland feedings are preferred; carbohydrate intake may be increased to provide calories needed during tissue repair.

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? 1 Absent reflexes 2 Flaccid muscles 3 Trousseau sign 4 Babinski response

4 Babinski response A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. Hyperreflexia is associated with upper motor neuron damage. Increased muscle tone (spasticity) is associated with upper motor neuron damage. The Trousseau sign is indicative of hypocalcemia.

What client response indicates to the nurse that a vasodilator medication is effective? 1 Pulse rate decreases from 110 to 75 2 Absence of adventitious breath sounds 3 Increase in the daily amount of urine produced 4 Blood pressure changes from 154/90 to 126/72

4 Blood pressure changes from 154/90 to 126/72

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will: 1 Cut my toenails before bathing." 2 Soak my feet daily for one hour." 3 Examine my feet using a mirror at least once a week." 4 Break in my new shoes over the course of several weeks."

4 Break in my new shoes over the course of several weeks." A slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown. The toenails should be cut by a podiatrist; they usually are cut after a foot bath when the nails are softer. Soaking the feet daily for one hour will cause maceration of the skin and should be avoided. Examining the feet using a mirror at least once a week is too long a period of time; the client should examine the feet daily for signs of trauma.

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? 1 Blood clotting 2 Bone formation 3 Muscle contraction 4 Cellular membranes

4 Cellular membranes Cholesterol is an essential structural and functional component of most cellular membranes. That it is associated with atherosclerotic plaques does not detract from its essential functions. Cholesterol is not necessary for blood clotting; calcium and vitamin K are necessary. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are necessary. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are necessary.

A nurse is caring for a client who just returned from the postanesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm? 1 Performing range-of-motion exercises 2 Humidifying the room air continuously 3 Assessing for hoarseness every two hours 4 Checking vital signs every two hours after they stabilize

4 Checking vital signs every two hours after they stabilize Checking vital signs helps detect complications such as thyrotoxic crisis, hemorrhage, and respiratory obstruction that may occur early in the postoperative period.

A client was diagnosed with cancer of the head of the pancreas two months ago. The client is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the client's assessment, the nurse expects the client's stool to be what color? 1 Green 2 Brown 3 Red-tinged 4 Clay-colored

4 Clay-colored -Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum. Green stools may occur with prolonged diarrhea associated with gastrointestinal inflammation. The feces are brown when there is unobstructed bile flow into the duodenum. Inflammation or ulceration of the lower intestinal mucosa results in blood-tinged stools.

A nurse is administering an enema to a client who is scheduled for gastrointestinal surgery. What should the nurse do when the client complains of abdominal cramps during the enema? 1 Reduce the rate of flow of the infusion. 2 Discontinue the enema and try again later. 3 Lower the container below the level of the rectum. 4 Close the lumen of the tubing and wait until the discomfort subsides

4 Close the lumen of the tubing and wait until the discomfort subsides Stopping the flow reduces cramping caused by distention of the intestinal lumen. Distention results from the volume of fluid instilled. Reducing the rate of flow of the enema fluid still infuses fluid into the intestine, which will increase the discomfort. There is no need to discontinue the enema. An effective enema must be administered before gastrointestinal surgery. Lowering the container several inches below the anus will result in the fluid flowing back out through the rectal tube into the container; this is the principle used when administering a return-flow enema (also known as Harris flush). The purpose of the preoperative enema is to evacuate the bowel of feces, not just flatus.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. The nurse recalls that the diagnostic test conducted to confirm this diagnosis is: 1 Myelography 2 Lumbar puncture 3 Electromyography 4 Computed tomography

4 Computed tomography

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1 Dilating the pupil 2 Resting the eye muscles 3 Preventing secondary infection 4 Controlling intraocular pressure

4 Controlling intraocular pressure

A client asks the nurse to review a list of the foods the client has been choosing to combat constipation. Upon review, the nurse identifies that the food item that has the least amount of fiber content is: 1 Stewed prunes 2 Whole-bran cereal 3 Grapefruit sections 4 Cream of wheat cereal

4 Cream of wheat cereal Cream of wheat cereal is highly refined, with reduced fiber content. Prunes are high in bulk and promote intestinal motility. The fiber residue of whole-bran cereal promotes intestinal motility. The fiber residue of grapefruit sections promotes intestinal motility.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. What would be appropriate to include in the dietary plan? 1 Soft-textured foods to reduce the digestive burden 2 Low-cholesterol foods to avoid further formation of gallstones 3 Increased protein intake to promote tissue healing and improve energy reserves 4 Decreased fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

4 Decreased fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

Which clinical manifestation should a nurse expect a client with diabetes insipidus to exhibit? 1 Increased blood glucose 2 Decreased serum sodium 3 Increased specific gravity 4 Decreased urine osmolarity

4 Decreased urine osmolarity Insufficient antidiuretic hormone (ADH) decreases water uptake by the kidney tubules, resulting in very dilute urine with low osmolarity. Diabetes insipidus does not affect glucose levels. Serum sodium levels increase because of hemoconcentration. Specific gravity decreases with dilute urine.

A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure? 1 Hypervigalence 2 Constricted pupils 3 Increased heart rate 4 Widening pulse pressure

4 Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. What information about the purpose of a vagotomy should the nurse include when reviewing the health care provider's discussion with the client? 1 Increases the heart rate 2 Hastens gastric emptying 3 Eliminates pain sensations 4 Decreases acid in the stomach

4 Decreases acid in the stomach The vagus nerve stimulates the stomach to secrete hydrochloric acid. When it is severed, this neural pathway is interrupted and stomach acid is decreased. The portion of the vagus nerve that is severed innervates the stomach, not the heart; therefore, the heart rate is not affected. The vagus nerve controls hydrochloric acid secretion, not gastric emptying; emptying is determined by the nature of foods being digested. The vagus nerve is not a sensory nerve.

After a successful kidney transplant for a client with end-stage kidney disease, the nurse anticipates that laboratory studies will demonstrate: 1 Increased specific gravity 2 Correction of hypotension 3 Elevated serum potassium 4 Decreasing serum creatinine

4 Decreasing serum creatinine As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease.

A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive? 1 Tachycardia 2 Extended Korotkoff sound 3 Sustained systolic pressure ranging from 110 to 120 mm Hg 4 Diastolic blood pressure that remains higher than 90 mm Hg

4 Diastolic blood pressure that remains higher than 90 mm Hg A sustained diastolic pressure that exceeds 90 mm Hg reflects pathology and indicates hypertension. Tachycardia reflects the heart rate, not the pressures within the arteries. Extended Korotkoff sound is heard when measuring blood pressure by auscultation; it is unrelated to hypertension. Sustained systolic pressure ranging from 110 to 120 mm Hg is an expected systolic blood pressure.

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider? 1 Blurred vision 2 Dizziness on rising 3 Excessive urination 4 Difficulty breathing

4 Difficulty breathing

When admitting a client with benign prostatic hyperplasia, the most relevant assessment made by the nurse is: 1 Perineal edema 2 Urethral discharge 3 Flank pain radiating to the groin 4 Distention of the suprapubic area

4 Distention of the suprapubic area

A client whose total cholesterol level is found to be 210 mg/dL at a screening session at a health fair asks the nurse what to do in light of this result. The nurse responds, "Your level is: 1 High and you may need medication." 2 Within the acceptable range and no action is required." 3 Low and you should eat more foods that contain cholesterol." 4 Elevated slightly and a diet low in saturated fats should be followed."

4 Elevated slightly and a diet low in saturated fats should be followed." A level more than 200 mg/dL is considered elevated, and foods high in cholesterol and saturated fats should be limited in the diet. A level of 240 mg/dL or more is considered high. Levels more than 140 and less than 200 mg/dL are considered desirable. A low level is less than 140 mg/dL. Medical attention should be sought because low cholesterol levels are associated with hyperthyroidism, malabsorption syndrome, malnutrition, and myeloproliferative disease.

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. The nurse instructs them to: 1 Speak louder than usual during visits while looking directly at the client 2 Tell the client to use the correct words when speaking 3 Give positive reinforcement for correct communication 4 Encourage the client to speak while being patient with each attempt

4 Encourage the client to speak while being patient with each attempt

After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will: 1 Have dilute urine." 2 Be unable to urinate." 3 Produce dark red urine." 4 Experience some burning on urination."

4 Experience some burning on urination." Because of the trauma to the mucous membranes of the urinary tract, burning on urination is an expected response that should subside gradually. The urine should no longer be dilute after the continuous bladder irrigation is discontinued and removed. However, the urine may have a slight pink tinge because of the trauma from the surgery and the presence of the catheter. An inability to urinate should not occur unless the indwelling catheter is removed too soon and there is still edema of the urethra. Production of dark red urine is a sign of hemorrhage, which should not occur.

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client: 1 Contracts HIV-specific antibodies. 2 Develops an acute retroviral syndrome. 3 Is capable of transmitting the virus to others. 4 Has a CD4+ T lymphocyte level of less than 200 cells/µL

4 Has a CD4+ T lymphocyte level of less than 200 cells/µL AIDS is diagnosed when an individual with HIV develops one of the following: a CD4+ T lymphocyte level of less than 200 cells/µL, wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flu-like syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain), one to three weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? 1 Empty feeding bag stays attached to the tubing. 2 Tube is flushed with air after medication is given. 3 Replacement of the tube is done on a weekly basis. 4 Head of the bed remains elevated after the feeding.

4 Head of the bed remains elevated after the feeding.

The health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. The nurse explains that this drug:

Interferes with the synthesis of thyroid hormone

A hospice client who has severe pain asks for another dose of oxycodone (OxyContin). The nurse's primary consideration when responding to the client's request is to: 1 Prevent addiction 2 Determine why the drug is needed 3 Provide alternate comfort measures 4 Help reduce the client's pain immediately

4 Help reduce the client's pain immediately Hospice clients with severe pain need increasing levels of analgesics and should be maintained at a pain-free level, even if addiction occurs. Pain management, not the prevention of addiction, is the priority. The client has severe pain and the priority is to relieve the pain.

A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the health care provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? 1 Ascites 2 Acidosis 3 Hypertension 4 Hyperkalemia

4 Hyperkalemia Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis. Ascites occurs in liver disease and is not an indication for dialysis. Dialysis is not the usual treatment for acidosis; usually this responds to administration of alkaline drugs. Dialysis is not a treatment for hypertension; this is usually controlled by antihypertensive medication and diet.

A nurse is developing a discharge plan for a client who was hospitalized with severe cirrhosis of the liver. The plan should include the: 1 Need for a high protein diet 2 Use of a sedative for relaxation 3 Need to increase fluids 4 Importance of reporting personality changes to the health care provider

4 Importance of reporting personality changes to the health care provider The damaged liver may cause increased ammonia levels, resulting in central nervous system (CNS) irritation, which produces behavioral changes. A damaged liver does not metabolize protein adequately; a low protein diet is indicated.

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals is to: 1 Limit the appetite 2 Promote absorption 3 Prevent gastric irritation 4 Increase chewing strength

4 Increase chewing strength Peak action of the medication will occur during meals to promote chewing and swallowing and prevent aspiration. It should be given with a small amount of food to prevent gastric irritation. Pyridostigmine improves muscle strength; it does not affect appetite.

A client with Parkinson disease complains about a problem with elimination. The nurse should encourage the client to: 1 Eat a banana daily 2 Decrease fluid intake 3 Take cathartics regularly 4 Increase residue in the diet

4 Increase residue in the diet Increasing residue in the diet produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson disease. Bananas are binding and will intensify the problem of constipation. Decreasing fluid intake will intensify the problem; fluids need to be increased. Cathartics are irritating to the intestinal mucosa, and their regular administration promotes dependence.

A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? 1 Promotes the formation of calculi in the cystic duct 2 Stimulates the pancreas to secrete more insulin than it can immediately produce 3 Alters the composition of enzymes so they are capable of damaging the pancreas 4 Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

4 Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. Although blockage of the bile duct with calculi may precipitate pancreatitis, this is not associated with alcohol. Alcohol does not deplete insulin stores; the demand for insulin is unrelated to pancreatitis. Although the volume of secretions increases, the composition remains unchanged.

Initially after a brain attack (cerebrovascular accident), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? 1 Spinal shock 2 Hypovolemic shock 3 Transtentorial herniation 4 Increasing intracranial pressure

4 Increasing intracranial pressure

Ranitidine (Zantac) has been prescribed to help treat a client's gastric ulcer. The nurse expects this drug to act specifically by: 1 Lowering the gastric pH 2 Promoting the release of gastrin 3 Regenerating the gastric mucosa 4 Inhibiting the histamine H2 receptors

4 Inhibiting the histamine H2 receptors Ranitidine inhibits histamine at H2 receptor sites in parietal cells, which limits gastric secretion. Lowering the gastric pH is not the direct action of this drug; it eventually will raise the pH. Promoting the release of gastrin is undesirable; gastric hormones increase gastric acid secretion. Ranitidine does not regenerate the gastric mucosa; the drug prevents its erosion by gastric secretions.

A client is admitted with a diagnosis of cancer of the colon. What information about malignant tumors of the colon should the nurse consider when caring for this client? 1 They are detected easily. 2 They usually are localized. 3 Women are more at risk than men. 4 Intestinal obstructions usually are malignant

4 Intestinal obstructions usually are malignant Mechanical obstruction most often is caused by obliteration of the lumen of the intestine by malignant cells. In the early stages, symptoms of cancer of the colon are vague or absent. Localized tumors usually are benign. Cancer of the lower bowel is more common in men than in women; however, the incidence is increasing in women.

A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. What type of stool should the nurse expect? 1 Pencil-shaped 2 Mucus-coated 3 Loose and liquid 4 Moist and formed

4 Moist and formed A colostomy on the left side involves the descending colon, leaving most of the colon intact to absorb fluid. Pencil-shaped stool is associated with conditions that narrow the intestinal lumen; this usually is not associated with a colostomy. Stools usually are not covered with mucus; they may be moist but not mucoid. Loose and liquid stools are associated with a colostomy that involves the ascending colon.

A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis than the client with Crohn's disease? 1 Inclusion of transmural involvement of the small bowel wall 2 Correlation with increased malignancy because of malabsorption syndrome 3 Pathology beginning proximally with intermittent plaques found along the colon 4 Involvement starting distally with rectal bleeding that spreads continuously up the colon

4 Involvement starting distally with rectal bleeding that spreads continuously up the colon In ulcerative colitis, pathology usually is in the descending colon; in Crohn's disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. There is no direct correlation of colitis with malignancy of the bowel, although psychological, environmental, genetic, and nutritional factors, as well as preexisting disease, appear to be influential in malignancy. Involvement is in the distal portion of the colon, not the proximal portion.

A client who recently immigrated to the United States has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1 Vitamin A is an integral part of the retina's pigment called melanin. 2 It is a component of the rods and cones, which control color visualization. 3 Vitamin A is the material in the cornea that prevents the formation of cataracts. 4 It is a necessary element of rhodopsin, which controls responses to light and dark environments.

4 It is a necessary element of rhodopsin, which controls responses to light and dark environments. Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.

The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" The nurse explains that the primary purpose of early ambulation is to: 1 Promote healing of the incision 2 Lower the incidence of urinary tract infections 3 Use energy to help the client sleep better at night 4 Keep blood from pooling in the legs to prevent clots

4 Keep blood from pooling in the legs to prevent clots

A nurse is assisting a health care provider to perform a sigmoidoscopy. In which position should the nurse place the client for this procedure? 1 Sims 2 Prone 3 Lithotomy 4 Knee-chest

4 Knee-chest Knee-chest position maximally exposes the rectal area and facilitates entry of the sigmoidoscope . The Sims position does not expose the rectal area to the same extent as does the knee-chest position; it can be used for a sigmoidoscopy if a client is unable to maintain the knee-chest position. Although prone refers to a facedown position, the rectal area is not exposed. The lithotomy position is appropriate for gynecological examinations.

A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1 Inadequate arterial blood supply." 2 Delayed healing of tissues after an injury." 3 Increased production of melanin in the area." 4 Leakage of red blood cells through the vascular wall."

4 Leakage of red blood cells through the vascular wall."

A client with a history of ulcerative colitis has a large portion of the large intestine removed and the creation of an ileostomy. For which potential life-threatening complication should the nurse assess the client after this surgery? 1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy 4 Limited water reabsorption caused by removal of intestine

4 Limited water reabsorption caused by removal of intestine The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury, this is not a life-threatening complication. Although altered bowel elimination is a concern, it is not a life-threatening complication.

A health care provider prescribes furosemide (Lasix) for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in what part of the renal system? 1 Distal tubule 2 Collecting duct 3 Glomerulus of the nephron 4 Loop of Henle

4 Loop of Henle

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report: 1 Flashes of light 2 Sensitivity to light 3 Seeing floating specks 4 Loss of peripheral vision

4 Loss of peripheral vision

A client is diagnosed with type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. For what side effect should the nurse teach this client to monitor? 1 Ketonuria 2 Weight loss 3 Ketoacidosis 4 Low blood sugar

4 Low blood sugar Oral hypoglycemic agents decrease serum glucose levels that may precipitate hypoglycemia. Ketonuria occurs with insulin-dependent diabetes. Weight gain usually is noted in adult-onset diabetes. Ketoacidosis occurs with insulin-dependent diabetes.

A client with Parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary health care provider only if other neurological deficits are present 2 Ask the primary health care provider to increase the client's dosage of the anticholinergic medication 3 Stress the importance of having the client call the primary health care provider as soon as possible 4 Make arrangements immediately for further medical evaluation by the client's primary health care provider

4 Make arrangements immediately for further medical evaluation by the client's primary health care provider

A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client? 1 Changing position every two hours 2 Keeping a serial record of the pulse 3 Performing range-of-motion exercises 4 Monitoring for increased intracranial pressure

4 Monitoring for increased intracranial pressure

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? 1 Apply a warm soak. 2 Document the symptom. 3 Elevate the leg above the heart. 4 Notify the health care provider

4 Notify the health care provider Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the health care provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: 1 Urge incontinence 2 Stress incontinence 3 Reflex incontinence 4 Overflow incontinence

4 Overflow incontinence

A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. The nurse should: 1 Limit oral fluids until the client voids 2 Assure the client that this is expected 3 Insert a urinary retention catheter 4 Palpate above the pubic symphysis

4 Palpate above the pubic symphysis A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema.

A client who is employed as a carpenter has trouble holding tools because of carpal tunnel syndrome but continues to work to meet family financial obligations. Which is the priority concern when health care instructions are discussed with the client? 1 Anxiety 2 Chronic pain 3 Low self-esteem 4 Potential for injury

4 Potential for injury

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Recognizing that adherence to a medical regimen improves with understanding, the nurse explains that the salt must be limited to: 1 Prevent an increase in blood pressure from tissue edema. 2 Reduce the circulating blood volume via a diuretic effect. 3 Reduce the amount of edema present, which interferes with heart action. 4 Prevent further accumulation of fluid, which increases the workload of the heart.

4 Prevent further accumulation of fluid, which increases the workload of the heart.

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia? 1 Increased blood pressure 2 Prolonged edema in the thigh 3 Increased skin temperature of the foot 4 Prolonged reperfusion of the toes after blanching

4 Prolonged reperfusion of the toes after blanching

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass

4 Pulsating abdominal mass As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Signs of shock are not definitive for an abdominal aortic aneurysm unless the aneurysm ruptures. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not definitive for an abdominal aortic aneurysm.

Digoxin (Lanoxin) and furosemide (Lasix) are prescribed for a client with the diagnosis of pulmonary edema. What client response to digoxin is unrelated to toxicity? 1 Nausea 2 Yellow vision 3 Irregular pulse 4 Pulse of 64

4 Pulse of 64

4 Pulse of 64 A pulse of 64 is acceptable when the client is receiving digoxin; digoxin lengthens the atrioventricular conduction time, which slows the heart rate; toxicity may be present if the heart rate drops to less than 60. Nausea is a symptom of toxicity; nausea and vomiting can occur because of gastric irritation and its action at central nervous system sites. Yellow vision is a symptom of toxicity; xanthopsia (yellow vision) is caused by digoxin's effect on visual cones. An irregular pulse is a sign of toxicity; premature nodal or ventricular impulses and varying degrees of heart block can occur because of slowed transmission of impulses through the atrioventricular node.

A client falls at home and is brought to the emergency department by family members. The client reports intercostal pain and is confused and disoriented. What is the best way for the nurse to determine whether this behavior is new for the client? 1 Ask the primary health care provider when the confusion was noted first 2 Interview the client to identify when the confusion started 3 Observe the client for a few hours before determining the onset of confusion 4 Question the family members about the client's usual behavior

4 Question the family members about the client's usual behavior

A client with a diagnosis of gastric cancer has a gastric resection with a vagotomy. Which clinical response should alert the nurse that the client is experiencing dumping syndrome? 1 Constipation 2 Clay-colored stools 3 Sensations of hunger 4 Reactive hypoglycemia

4 Reactive hypoglycemia

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first? 1 Remove all jewelry 2 Wash the chest area 3 Use a grounded electric source 4 Remove any medication patches

4 Remove any medication patches Medication patches must be removed before application of electrodes because of possible electrical conduction in the area of the patch causing a burn. Jewelry usually is not a problem with the function of an automated external defibrillator. Skin preparation is unnecessary. The AED is battery operated and does not need a grounded electric source.

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? 1 Avoid foods high in vitamin K. 2 Check the pulse several times a day. 3 Drink a glass of milk when taking aspirin. 4 Report signs of bleeding no matter how slight.

4 Report signs of bleeding no matter how slight.

A nurse is caring for a client who is cachectic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client? 1 Releases glucose for energy 2 Regulates cholesterol production 3 Uses lipoproteins for fat transport 4 Stores triglycerides for energy reserves

4 Stores triglycerides for energy reserves A triglyceride is composed of three fatty acids and a glycerol molecule. When energy is required, the fatty acids are mobilized from adipose tissue for fuel. The nurse needs to consider that a client who is cachectic will have limited reserves to meet energy needs. Releasing glucose for energy is not the function of adipose tissue; its main function is storage. Regulating cholesterol production is not a function of adipose tissue; cholesterol is produced in the liver. Using lipoproteins for fat transport is not the function of adipose tissue in fat metabolism.

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart? 1 Heart rate 2 Refractory period 3 Pulmonary pressure 4 Strength of contractions

4 Strength of contractions A direct relationship exists between the strength of cardiac contractions and electrical conductions through the myocardium. The heart rate is related to such factors as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. Refractory period is the period when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes increased in the presence of left ventricular failure.

What should a nurse do when caring for a client with continuous bladder irrigation? 1 Measure the output hourly. 2 Monitor the specific gravity of the urine. 3 Irrigate the catheter with saline three times daily. 4 Subtract the amount of irrigant instilled from the output.

4 Subtract the amount of irrigant instilled from the output. The amount of irrigant instilled must be deducted from the total output to determine the amount of urine voided.

A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should: 1 Instruct the client to provide a semen specimen 2 Swab the discharge when it appears on the prepuce 3 Teach the client how to obtain a clean catch specimen of urine 4 Swab the drainage directly from the urethra to obtain a specimen

4 Swab the drainage directly from the urethra to obtain a specimen Swabbing the drainage directly from the urethra obtains a specimen uncontaminated by environmental organisms.

A nurse in the post-anesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider? 1 Client pushes the airway out. 2 Client has snoring respirations. 3 Respirations of 16 breaths/min are shallow. 4 Systolic blood pressure drops from 130 to 90 mm Hg

4 Systolic blood pressure drops from 130 to 90 mm Hg

A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must: 1 Avoid fats and proteins 2 Drink a large amount of fluids 3 Omit dinner and limit beverages 4 Take a laxative before going to bed

4 Take a laxative before going to bed Laxatives remove feces and flatus, providing better visualization.

The nurse has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 and 164/98. What is the appropriate nursing action in response to these readings? 1 Refer the client to a nutritionist after providing health teaching about a low-sodium diet. 2 Place the client in a recumbent position and call the paramedics for transport to the hospital. 3 Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. 4 Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

4 Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment? 1 Turn the client to the side-lying position 2 Ask the client to cough and deep breathe 3 Instruct the client to wiggle the toes of the right foot 4 Take the client's pedal pulse in the affected extremity

4 Take the client's pedal pulse in the affected extremity

A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question? 1 The arterial blood supply is inadequate. 2 There is delayed healing in the area after an injury. 3 The production of melanin in the area has increased. 4 There is leakage of red blood cells (RBCs) through the vascular wall.

4 There is leakage of red blood cells (RBCs) through the vascular wall. Increased venous pressure alters the permeability of the veins, allowing extravasation of RBCs; lysis of RBCs causes brownish discoloration of the skin. Varicose veins do not affect the arterial circulation. Although healing may be delayed, the brownish discoloration does not result from trauma. There is no increase in melanocyte activity in individuals with varicose veins.

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a brain attack? 1 Glaucoma 2 Hypothyroidism 3 Continuous nervousness 4 Transient ischemic attacks (TIAs)

4 Transient ischemic attacks (TIAs)

A client with osteoarthritis who had a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position? 1 Maintain the left leg in an adduction position. 2 Place the client in a right-lying position. 3 Place the left leg in an internal rotation. 4 Use pillows to keep the client's legs abducted.

4 Use pillows to keep the client's legs abducted.

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care? 1 Nutrition supplements 2 Cardiac monitoring 3 Oxygen therapy 4 Venous thromboembolism prevention (VTE)

4 Venous thromboembolism prevention (VTE) VTE causes most fatalities in elderly clients with hip fractures.

The nurse teaches a group of clients that nutritional support of natural defense mechanisms indicates the need for a diet high in: 1 Essential fatty acids 2 Dietary cellulose and fiber 3 Tryptophan, an amino acid 4 Vitamins A, C, E, and selenium

4 Vitamins A, C, E, and selenium

The nurse provides education to a client about the side effects of furosemide (Lasix). Which client statements indicate that the teaching is understood? (Select all that apply.) 1 "I must not eat citrus fruits." 2 "I should wear dark glasses." 3 "I should avoid lying flat in bed." 4 "I should change my position slowly." 5 "I must eat a food that contains potassium every day."

4 "I should change my position slowly." 5 "I must eat a food that contains potassium every day."

The nurse is reviewing the plan of care for a client that is scheduled for a barium swallow. The plan will include: 1 Giving clear fluids on the day of the test 2 Asking the client about allergies to iodine 3 Administering cleansing enemas before the test 4 Administering a laxative after the procedure

4 Administering a laxative after the procedure Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium. The client must be kept nothing by mouth. Iodine is not used with barium. Administering cleansing enemas before the test is not part of the preparation; feces in the lower gastrointestinal (GI) tract will not interfere with visualization of the upper GI tract.

After taking spironolactone (Aldactone), a potassium-sparing diuretic, the client inquires about foods and fluids that are low in potassium. Which juice should the nurse teach the client contains the least amount of potassium? 1 Apple juice 2 Orange juice 3 Tomato juice 4 Cranberry juice

4 Cranberry juice Cranberry juice contains approximately 46 mg of potassium per 8 ounces. Apple juice contains approximately 295 mg of potassium per 8 ounces. Orange juice contains approximately 496 mg of potassium per 8 ounces. Tomato juice contains approximately 535 mg of potassium per 8 ounces.

4 Difficulty breathing Dyspnea may indicate development of pulmonary edema, which is a life-threatening condition. Blurred vision may occur in some people, but it is not life-threatening. Dizziness on rising and excessive urination are common side effects of this medication, which are not life-threatening.

A client is scheduled for a barium swallow. How should the nurse prepare the client for this test? (Select all that apply.) 1 Ask about allergies to iodine before the test. 2 Administer cleansing enemas before the test. 3 Suggest a light breakfast on the day of the test. 4 Ensure that a laxative is prescribed after the test. 5 Instruct to withhold prescribed opioids for one day before the test.

4 Ensure that a laxative is prescribed after the test. 5 Instruct to withhold prescribed opioids for one day before the test. Barium will harden and may lead to constipation and a possible impaction; a laxative and increased fluids promote elimination of barium. Opioids are withheld for 24 hours before the test to prevent intestinal immobility.

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life threatening response of thrombocytopenia? (Select all that apply.) 1 Fever 2 Diarrhea 3 Headache 4 Hematuria 5 Ecchymosis

4 Hematuria 5 Ecchymosis Hematuria is blood in the urine. Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood. Ecchymosis is a superficial bruise caused by bleeding under the skin or mucous membrane. With thrombocytopenia, bleeding occurs because there are insufficient platelets. Fever is unrelated to thrombocytopenia. Fever is a sign of infection; infection results when the white blood cells are reduced (leukopenia). Diarrhea is unrelated to thrombocytopenia; diarrhea may result from the effects of chemotherapy on the rapidly dividing cells of the gastrointestinal system. Headache is unrelated to thrombocytopenia; headache may be caused by the effects of chemotherapy on central nervous system cells or indicate that the leukemia has invaded the central nervous system.

A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe: 1 Nausea 2 Tachypnea 3 Constipation 4 Hypotension

4 Hypotension Concurrent use of sildenafil and a nitrate, which causes vasodilation, may result in severe, potentially fatal hypotension. Nausea is not a side effect associated with concurrent use of sildenafil and a nitrate. Tachypnea is not a side effect associated with concurrent use of sildenafil and a nitrate. Sildenafil may cause diarrhea, not constipation.

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? (Select all that apply.) 1 Acidosis 2 Lethargy 3 Bone pain 4 Chvostek sign 5 Muscle cramps

4 Muscle twitching 5 Respiratory acidosis Chvostek sign is elicited by tapping the face in front of the ear over the facial nerve; a positive sign is evidence of tetany and is caused by decreased serum calcium. Muscle cramps result from decreased serum calcium; functions of calcium include muscle contraction and transmission of nerve impulses.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1 Elevate the foot of the bed 2 Perform urinary catheter care every 12 hours 3 Place in the high-Fowler position 4 Perform a neurovascular assessment every two hours

4 Perform a neurovascular assessment every two hours Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of or lower than the heart. A general anesthetic is not used; therefore, voiding is not a concern. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

4. 36 **Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% for both arms) and 18% for the chest; thus the total body surface area burned is 36%. Twenty percent, 25%, and 30% are too low.

A client appears depressed since the surgical creation of a colostomy five days ago. The nurse determines that there is some movement toward adaptation to the change in body image when the client: 1 Discusses the necessity of the colostomy 2 Requests the nurse to change the dressing 3 Looks at the face of the nurse during care 4 Stares at the stoma during dressing changes

4 Stares at the stoma during dressing changes\ A willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image. Discussing the necessity of the colostomy is evidence of intellectualization rather than acceptance of the change in body image. Requesting the nurse to change the dressing indicates lack of readiness to participate in the care of the stoma. Watching the face of the nurse during the care indicates that the client is observing the staff's response to and acceptance of the stoma and, by extension, the client as an individual.

A health care provider prescribes bisacodyl (Dulcolax) for a client with cardiac disease. The nurse explains to the client that this drug acts by: 1 Producing bulk 2 Softening feces 3 Lubricating feces 4 Stimulating peristalsis

4 Stimulating peristalsis Bisacodyl stimulates nerve endings in the intestinal mucosa, precipitating a bowel movement. Bisacodyl is not a bulk cathartic. Bulk-forming laxatives, such as *psyllium hydrophilic mucilloid (Metamucil)*, form soft, pliant bulk that promotes physiological peristalsis. Bisacodyl is not a stool softener. Stool softeners, such as *docusate sodium*, permit fat and water to penetrate feces, which softens and delays the drying of the feces. Bisacodyl is not an emollient. Emollient laxatives, such as *mineral oil (Kondremul)*, lubricate the feces and decrease absorption of water from the intestinal tract.

A client is experiencing chronic constipation and the nurse discusses how to include more bulk in the diet. The nurse concludes that learning has occurred when the client states, "Bulk in the diet promotes defecation by: 1 Irritating the bowel wall." 2 Stimulating the intestinal mucosa chemically." 3 Acting on the microorganisms in the large intestine." 4 Stretching intestinal smooth muscle, which causes it to contract."

4 Stretching intestinal smooth muscle, which causes it to contract."

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? (Select all that apply.) 1 Pitting edema of the ankle 2 Reddened area at the ankle 3 Pruritus on the side of the calf 4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel

4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel Thrombophlebitis, not uncommon after abdominal surgery, is inflammation of a vein; it is associated with the formation of a clot (thrombus) in a vein in the leg. Findings associated with thrombophlebitis include pain, redness, swelling, and heat. Warmth along the course of the involved vessel is related to the inflammatory process accompanying the thrombus. Although swelling accompanies thrombophlebitis, it is not a pitting edema. Thrombophlebitis usually is located in the area of the calf, not over a bony prominence. Itching is not a symptom of phlebitis.

The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by: 1. Massaging the bony prominences 2. Maintaining a sheepskin pad under the client 3. Promoting range-of-motion activities 4. Encouraging the client to move around as much as possible

4 Encouraging the client to move around as much as possible

An older client is brought to the hospital by a family member because of deep partial-thickness burns on thearms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse? 1. "You sound upset, but your health care provider knows best. You should do what is prescribed." 2. "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." 3. "Your burns are more serious than you think, and we have specially trained people here just to take care of you." 4. "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

4. "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

A client complains of left-sided chest pain after the client finished playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify: 1. Dull sound on percussion 2. Vocal fremitus on palpation 3. Rales with rhonchi on auscultation 4. Absence of breath sounds on auscultation

4. Absence of breath sounds on auscultation

A client with burns is to receive the exposure method of treatment with application of mafenide (Sulfamylon) twice a day. With this type of treatment the nurse plans to: 1. Use medical asepsis 2. Apply a dry sterile dressing 3. Monitor liver function studies 4. Administer prescribed pain medication

4. Administer prescribed pain medication

4. Bed rest 2. Oxygen via nasal cannula 1. Specimens for C&S 3. Administration of an antibiotic

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? 1. Readiness to discuss the client's deformities 2. Indication of a change in family relations 3. Need for more time to think about the future 4. Beginning realization of implications for the future

4. Beginning realization of implications for the future

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person that suffers extensive burns. An appropriate response by the nurse is to call 911 and: 1. Apply ice to burned areas; the intervention will decrease pain 2. Use first aid cream to burned areas 3. Do nothing; attempting to treat the burned areas may cause further damage 4. Cover the burned areas with a bed sheet

4. Cover the burned areas with a bed sheet

A client is admitted to the hospital for medical treatment of bronchopneumonia. What test result should the nurse examine to help determine the effectiveness of the client's therapy? 1. Bronchoscopy 2. Pulse oximetry 3. Pulmonary function studies 4. Culture and sensitivity tests of sputum

4. Culture and sensitivity tests of sputum *The aim of therapy is to eliminate the causative agent, which is determined from culture and sensitivity tests of sputum.

What breathing exercises should the nurse teach a client with the diagnosis of emphysema? 1. An inhalation that is prolonged to promote gas exchange. 2. Abdominal exercises to limit the use of accessory muscles. 3. Sit-ups to help strengthen the accessory muscles of respiration. 4. Diaphragmatic exercises to improve contraction of the diaphragm

4. Diaphragmatic exercises to improve contraction of the diaphragm

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department? 1. Ataxia 2. Hypoxia 3. Arthralgia 4. Dysphagia

4. Dysphagia

A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" The nurse explains that full-thickness burns: 1. Extend into the subcutaneous tissue; deep partial-thickness burns affect only the epidermis 2. Involve superficial layers of the epidermis; deep partial-thickness burns extend through the epidermis 3. Extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue 4. Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

4. Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained thick secretions. To decrease the amount of secretions retained, the nurse plans to: 1. Administer continuous oxygen 2. Instruct the client to gargle deep in the throat using warmed normal saline 3. Place the client in a high Fowler position 4. Increase fluid intake to at least 2 L a day

4. Increase fluid intake to at least 2 L a day *Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration.

The nurse provides instructions to a client who will be using an incentive spirometer postoperatively. During the client's return demonstration, the nurse concludes that the teaching has been effective when the client: 1. Coughs twice before inhaling deeply through the mouthpiece 2. Uses the incentive spirometer for 10 consecutive breaths an hour 3. Inhales deeply, seals the lips around the mouthpiece, and then exhales 4. Inhales deeply through the mouthpiece, holds the breath for two seconds, and then exhales

4. Inhales deeply through the mouthpiece, holds the breath for two seconds, and then exhales

The nurse reinforces instructions about how to use a nebulizer to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that additional teaching is needed when the client: 1. Places the tip of the mouthpiece an inch beyond the lips 2. Holds the inspired breath for at least three seconds 3. Exhales slowly through the mouth with lips pursed slightly 4. Inhales with the lips tightly sealed around the mouthpiece of the nebulizer

4. Inhales with the lips tightly sealed around the mouthpiece of the nebulizer

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? (Select all that apply.)

4. Nervousness 5. Increased appetite

A nurse is teaching a preoperative client about postoperative breathing exercises. What information should the nurse include? (Select all that apply.) 1. Take short, frequent breaths 2 Exhale with the mouth open wide 3. Perform the exercises twice a day 4. Place a hand on the abdomen while feeling it rise 5. Hold the breath for several seconds at the height of inspiration

4. Place a hand on the abdomen while feeling it rise 5. Hold the breath for several seconds at the height of inspiration

A nurse is caring for clients with various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider? 1. Are self-limiting infections caused by spirilla 2. Can be controlled through childhood vaccination 3. Are caused by parasitic bacteria that normally live outside the body 4. Result from streptococcal infections that enter via the upper respiratory tract

4. Result from streptococcal infections that enter via the upper respiratory tract

A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? 1. Supine 2. Left Sims 3. Immobilized 4. Right side-lying

4. Right side-lying

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). The plan should include the importance of: 1. Trimming toenails so that they are short and rounded 2. Checking bathwater temperature by putting the toes in first 3. Using alcohol to rub hands, feet, legs, and arms at least two times a day 4. Securing professional treatment for any minor injuries to the extremities

4. Securing professional treatment for any minor injuries to the extremities

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking? 1. Teach pursed-lip breathing 2. Encourage the client to reduce emotional stress 3. Obtain a referral to a smoking cessation program in the community 4. Suggest that the client limit smoking to one pack of cigarettes a day

4. Suggest that the client limit smoking to one pack of cigarettes a day

A client is experiencing severe respiratory distress. What response should the nurse expect the client to exhibit? 1. Tremors 2. Anasarca 3. Bradypnea 4. Tachycardia

4. Tachycardia *The heart rate increases in an attempt to compensate for the lack of oxygen to body cells.

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will: 1. Leave the skin markings intact 2. Protect the skin from sources of heat 3. Wear soft clothing over the upper body 4. Use an oatmeal-based lotion after each treatment

4. Use an oatmeal-based lotion after each treatment

4. Yellow

A client who is dehydrated is to receive an intravenous (IV) solution of normal saline to be infused at 175 mL/hr. The drop factor of the IV set is 15 gtts/mL. At what drop rate should the nurse adjust the flow to provide the prescribed solution? Record your answer using a whole number. __________ gtts/min

44 gtts/min is a correct calculation. Multiply the amount of fluid to be infused (175 mL) by the drop factor (15) and divide this result by the amount of time in minutes (1 hr x 60 min).

A client is discharged the same day after ambulatory surgery for a laparoscopic cholecystectomy. The nurse is providing discharge teaching about how many days the client should wait to engage in certain activities. Place in order the activities from the first to the last in which the client may engage. 1. Showering 2. Driving a car 3. Performing light exercise 4. Lifting objects of more than 10 lbs 5. Getting out of bed in a chair

5. Getting out of bed in a chair 3. Performing light exercise 1. Showering 2. Driving a car 4. Lifting objects of more than 10 lbs

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath?

98° to 100° F

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person?

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever" The nurse's best initial response is:

A client had surgery on the shoulder and the nurse is to obtain a brachial pulse. Use the illustration to indicate where the nurse should palpate to best obtain the brachial pulse rate.

When advising a college student about dietary choices, the nurse should consider the caloric value of the most commonly ordered fast foods eaten by active young adults. List the following foods in order from the one with the least number of calories to the one with the most number of calories. 1. French fries 2. Garden salad 3. Hamburger with cheese 4. One slice of French toast 5. Six pieces of chicken tenders

A garden salad has 95 calories. One slice of French toast has 126 calories. Six chicken tenders have 236 calories. An order of French fries has 372 calories. A hamburger with cheese has 720 calories.

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent?

An inaccurate interpretation Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub?

Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration

A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?

Apply moisturizing lotion several times a day

Ask the client to ingest one tube of glucose gel

A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has: 1 Contracted clinical tuberculosis 2 Passive immunity to tuberculosis 3 Been exposed to the tubercle bacillus 4 Developed a resistance to the tubercle bacillus

Correct3 Been exposed to the tubercle bacillus

A client had an abdominal cholecystectomy. Postoperatively, the client refuses to deep breathe and cough, saying, "It's too painful." The nurse should: 1 Give pain medication regularly as soon as possible 2 Obtain a prescription to increase the client's pain medication 3 Medicate the client for pain before coughing and deep breathing 4 Substitute incentive spirometry for coughing and deep breathing

Correct3 Medicate the client for pain before coughing and deep breathing

A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?

Deep breathing exercises

A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, mottled red, weeping, and edematous. These burns are classified as:

Deep partial-thickness burns

When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. The nurse evaluates that the client understands the teaching when the client says, "I should call my health care provider if I develop:

Dry hair and an intolerance to cold."

The nurse is providing postoperative care eight hours after a client had a total cystectomy and the formation of an ileal conduit. What assessment finding should be reported immediately? 1 Edematous stoma 2 Dusky-colored stoma 3 Absence of bowel sounds 4 Pink-tinged urinary drainage

Dusky-colored stoma may denote a compromised blood supply to the stoma and impending necrosis. Edematous stoma and absence of bowel sounds are expected in the early postoperative period after this surgery. Pink-tinged urine may be present in the immediate postoperative period.

Dysphagia

The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by:

Encouraging the client to move around as much as possible

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications?

Examining the feet daily, Wearing well-fitting shoes, Performing regular exercise

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is:

Exposure to radiation

Fatigue

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome?

Glucose level

A client with scleroderma complains of numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud's phenomenon, a condition commonly associated with scleroderma. The nurse plans to advise the client to:

Keep the hands warm by wearing gloves

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?

Kussmaul respirations Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones.

The nurse is caring for a client diagnosed with Cushing syndrome. The nurse expects that the client will exhibit:

Lability of mood

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response?

Less thyroid tissue is available to supply thyroid hormone after surgery.

Which health problem should the nurse consider 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 and to form glucose from glycogen. Cushing's syndrome causes hyperglycemia.

The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches that the most effective method for putting out the flames is to:

Log-roll the victim in the grass

A nurse is assessing a client who has possible appendicitis. The nurse assesses the client for rebound tenderness. Mark where the client is expected to report pain.

McBurney's point is located in the right lower quadrant of the abdomen over the appendix. This point is one third of the distance from the anterior iliac spine to the umbilicus; rebound tenderness in this area may indicate appendicitis.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. They are described best as:

Moist rumbling sounds that clear after coughing

Multiply the amount to be infused (2000 mL) by the drop factor (10), and divide the result by the amount of time in minutes (12 hours × 60 min).

Propylthiouracil (PTU) is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get the atomic cocktail?" The nurse explains that the medication is being prescribed because it decreases the:

Production of thyroid hormones. Propylthiouracil is a thyroid hormone antagonist that inhibits thyroid hormone synthesis by decreasing the use of iodine in the manufacture of these hormones

A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for:

Prolonged wound healing

A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe?

Regular insulin (Novolin R) Regular insulin is rapid-acting and should be used for diabetic coma

A skier skied off the marked trail into the woods and collided with a tree. After several hours, the skier was found by the ski patrol and brought to the emergency department of the hospital. Moderate hypothermia (temperature range 87° to 90° F) is diagnosed. What clinical findings specific to moderate hypothermia should the nurse expect the client to exhibit?

Rigidity and slowed respiratory rate

A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client?

Skin integrity

A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care?

Skin lesions

A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is:

Small, frequent, high-calorie meals

An older client who is living in a nursing home is admitted to the hospital to be treated with intravenous antibiotics for sepsis resulting from a urinary tract infection. The client becomes agitated and attempts to pull out the IV. The health care provider prescribes a stat dose of haloperidol (Haldol) 0.5 mg IM. The haloperidol is available in a vial that states there are 2 mg/mL. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places. __________ mL

Solve the problem by using ratio and proportion. Desire 0.5 mg x mL ------------- = ---- Have 2 mg 1 mL 2x = 0.5 x = 0.5 ÷ 2 x = 0.25 mL

A client is scheduled to have a thyroidectomy for cancer of the thyroid. Preoperative instructions for the postoperative period include teaching the client to:

Support the head with the hands when changing position

Supports a better response to stress Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrates, fats, and proteins, causing elevation of the blood glucose level. Thus, it enables the body to adapt to stress.

When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle?

Surgical asepsis

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to:

Test for Chvostek's and Trousseau's signs and notify the health care provider of the complaints. These symptoms may indicate impending hypocalcemic tetany, a complication after removal of parathyroid tissue during a thyroidectomy. Physical assessment and notification of the health care provider are the priorities.

A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery?

Tetany; Parathyroid removal eliminates the body's source of parathyroid hormone (parathormone), which increases the blood calcium level. The resulting low body fluid calcium affects muscles, including the diaphragm, resulting in dyspnea, asphyxia, and death.

The tumor must be removed to prevent heart and kidney damage. Renal and cardiac complications will occur if hypertension caused by the tumor is not arrested. Aldosteronomas are benign tumors; metastasis is not possible.

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the:

Urinary output every hour

A nurse is preparing to administer insulin to a client with diabetes. In which order should the nurse perform the actions associated with insulin administration? 1. Wipe the top of the insulin vial with an alcohol swab 2. Wash hands with soap and water 3. Rotate the vial of insulin between the palms of the hands 4. Withdraw the correct amount of insulin from the inverted vial 5. Instill air into the vial of insulin equal to the desired dose

Washing the hands prevents cross contamination. Rotating the insulin vial distributes the drug evenly throughout the vial. Wiping the seal on the insulin vial prevents contamination of the needle and the fluid. Instilling air into the vial increases the pressure in the closed space so that the correct amount of fluid finally can be withdrawn.

When assessing a client with Graves disease, the nurse expects to identify:

Weight loss, exophthalmos, and restlessness

The primary health care provider has prescribed for a client's apical pulse to be taken. Place the steps in the order that the nurse should follow to identify the client's point of maximal impulse when taking the client's apical pulse. 1. Move the finger laterally along the fifth intercostal space to the midclavicular line 2. Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet) 3. Slide the finger to the edge of the left sternal border to the second intercostal space 4. Place the index finger in the second intercostal space and continue palpating downward to the fifth intercostal space

a) Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet) b) Slide the finger to the edge of the left sternal border to the second intercostal space c) Place the index finger in the second intercostal space and continue palpating downward to the fifth intercostal space d) Move the finger laterally along the fifth intercostal space to the midclavicular line

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