Exam 1 Practice Questions

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A.) "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B.) "I need to take good care of my belly and ankle skin where it is swollen." C.) "A scrotal support may be more comfortable when I have scrotal edema." D.) "I can use pillows to support my head to help me breathe when I am in bed."

A.) "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Rationale: If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.) A client with nausea who needs a nasogastric tube inserted B.) A client in hypertensive crisis who needs titration of IV nitroglycerin C.) A newly admitted client who needs to have a plan of care established D.) A client who is ready for discharge who needs discharge teaching

A.) A client with nausea who needs a nasogastric tube inserted Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D).

The client presents with a cholesterol level of 325 mg/dL. In teaching the client about risk factors for coronary artery disease (CAD), how would the nurse best describe cholesterol? A.) A substance that sticks to the inside of blood vessels, decreasing blood flow B.) Something that deposits in the veins and prevents absorption of nutrients C.) The food that causes the blood vessels to get soft and pliable D.) The number one cause of heart failure

A.) A substance that sticks to the inside of blood vessels, decreasing blood flow Rationale: Cholesterol is the substance carried by lipids that deposits along the arterial walls causing stiffening and narrowing of the vessel. These atherosclerotic plaques lead to coronary artery disease.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? A.) Administer ordered morphine sulfate. B.) Position patient in a semi-Fowler's position. C.) Position patient on left side with head of bed flat. D.) Instruct patient on the use of relaxation techniques. E.) Use a calm, reassuring approach while talking to patient.

A.) Administer ordered morphine sulfate. B.) Position patient in a semi-Fowler's position. D.) Instruct patient on the use of relaxation techniques. E.) Use a calm, reassuring approach while talking to patient. Rationale: Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.) Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.) Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.) Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.) Notify the health care provider that the child's pulse rate is below normal for her age group.

A.) Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D).

The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A.) Blood pressure of 90/56 mm Hg B.) Apical pulse rate of 68 beats/min C.) Potassium level of 3.3 mEq/L D.) Urine output of 200 mL in 4 hours

A.) Blood pressure of 90/56 mm Hg Rationale: Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A.) Confusion B.) Peripheral edema C.) Crackles in the lungs D.) Dyspnea E.) Distended neck veins

A.) Confusion C.) Crackles in the lungs D.) Dyspnea Rationale: Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure.

Following the administration of sublingual nitroglycerin, which assessment finding indicates that the medication was effective? A.) Decrease in level of chest pain B.) Clear bilateral breath sounds C.) Increase in blood pressure D.) Increase in urinary output

A.) Decrease in level of chest pain Rationale: Nitroglycerin reduces myocardial oxygen consumption, which decreases ischemia and reduces chest pain (A). (B, C, and D) are not expected outcomes of sublingual nitroglycerin.

A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.) Determine if all employees have had the hepatitis B vaccine series. B.) Explain that this type of hepatitis can be transmitted when feeding the client. C.) Assure the employees that they cannot contract hepatitis B when providing direct care. D.) Tell the employees that wearing gloves and a gown are required when providing care.

A.) Determine if all employees have had the hepatitis B vaccine series. Rationale: Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).

A client who is hypertensive receives a prescription for hydrochlorothiazide. When teaching about the side effects of this drug, which symptoms are most important for the nurse to instruct the client to report? A.) Fatigue and muscle weakness B.) Anxiety and heart palpitations C.) Abdominal cramping and diarrhea D.) Confusion and personality changes

A.) Fatigue and muscle weakness Rationale: Thiazide diuretics, such as HCTZ, cause potassium wasting in the urine, so the client should be instructed to report fatigue and muscle weakness (A), which are characteristic of hypokalemia. Although (B, C, and D) should be reported, they are not indicative of hypokalemia, which is a side effect of HCTZ that can cause cardiac dysrhythmias.

In addition to nitrate therapy, a client is receiving nifedipine, 10 mg PO every 6 hours. The nurse should plan to observe for which common side effect of this treatment regimen? A.) Hypotension B.) Hyperkalemia C.) Hypokalemia D.) Seizures

A.) Hypotension Rationale: Nifedipine (Procardia) reduces peripheral vascular resistance and nitrates produce vasodilation, so concurrent use of nitrates with nifedipine can cause hypotension with the initial administration of these agents (A). (B, C, and D) are not side effects of this treatment regimen.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? A.) Left ventricular function is documented. B.) Controlling dysrhythmias will eliminate HF. C.) Prescription for digoxin (Lanoxin) at discharge D.) Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E.) Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

A.) Left ventricular function is documented. D.) Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E.) Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen Rationale: The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? A.) Oxygen, nitroglycerin, aspirin, and morphine B.) Oxygen, furosemide (Lasix), nitroglycerin, and meperidine C.) Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen D.) Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A.) Oxygen, nitroglycerin, aspirin, and morphine Rationale: The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

A patient with a recent diagnosis of heart failure has been prescribed furosemide in an effort to physiologically do what for the patient? A.) Reduce preload. B.) Decrease afterload. C.) Increase contractility. D.) Promote vasodilation.

A.) Reduce preload. Rationale: Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A.) Team 1: RN team leader, PN; team 2, PN team leader, UAP B.) Team 1, RN team leader, UAP; team 2, PN team leader, PN C.) Team 1, PN team leader, PN; team 2, RN team leader, UAP D.) Team 1, PN team leader, UAP; team 2, RN team leader, PN

A.) Team 1: RN team leader, PN; team 2, PN team leader, UAP Rationale: Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN (A). Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing staff for the high-risk clients.

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A.) There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B.) Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C.) Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D.) Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E.) Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

A.) There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B.) Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C.) Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Rationale: The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel? A.) This drug could cause heart attack or stroke when taken by patients with certain genetic conditions. B.) Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C.) This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D.) Clopidogrel can reduce the risk of a future heart attack when taken by patients with peripheral artery disease.

A.) This drug could cause heart attack or stroke when taken by patients with certain genetic conditions. Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects (A). (B, C, and D) are all desired effects of the drug.

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A.) Use smallest gauge needle possible when giving injections or drawing blood. B.) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C.) Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D.) Apply gentle pressure for the shortest possible time period after performing venipuncture. E.) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A.) Use smallest gauge needle possible when giving injections or drawing blood. B.) Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C.) Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. E.) Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Rationale: Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? A.) Unstable angina B.) Acute coronary syndrome (ACS) C.) ST-segment-elevation myocardial infarction (STEMI) D.) Non-ST-segment-elevation myocardial infarction (NSTEMI)

B.) Acute coronary syndrome (ACS) Rationale: The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A.) Flushing B.) Ashen skin C.) Diaphoresis D.) Nausea and vomiting E.) S₃ or S₄ heart sounds

B.) Ashen skin C.) Diaphoresis D.) Nausea and vomiting E.) S₃ or S₄ heart sounds Rationale: During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S₃ and S₄ heart sounds.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco₂, 30 mm Hg; HCO₃, 25 mEq/L; Pao₂, 96 mm Hg. Which intervention should the nurse implement based on these results? A.) Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B.) Assess the client for pain and administer pain medication as prescribed. C.) Encourage the client to take short shallow breaths for 5 minutes. D.) Prepare to administer sodium bicarbonate IV over 30 minutes.

B.) Assess the client for pain and administer pain medication as prescribed. Rationale: These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two LPNs, and two UAP. Which assignment is the most effective use of the available team members? A.) Assign the LPNs to perform am care and assist with feeding the clients. B.) Assign the UAPs to take vital signs and obtain daily weights. C.) Assign the RNs to answer the call lights and administer all medications. D.) Assign the LPNs to assist health care providers on rounds and perform glucometer checks.

B.) Assign the UAPs to take vital signs and obtain daily weights. Rationale: A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the LPN (A). All team members can answer call lights and LPNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the LPN these tasks is not an effective use of available personnel.

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A.) 3+ protein in the urine B.) Blood urea nitrogen >25 mg/dL C.) Blood pH >7.45 D.) Urine output, 2500 mL/day

B.) Blood urea nitrogen >25 mg/dL Rationale: Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.) Keep the medication in your pocket so that it can be accessed quickly. B.) Call 911 if chest pain is not relieved after one nitroglycerin. C.) Store the medication in its original container and protect it from light. D.) Activate the emergency medical system after three doses of medication. E.) Do not use within 1 hour of taking sildenafil citrate (Viagra).

B.) Call 911 if chest pain is not relieved after one nitroglycerin. C.) Store the medication in its original container and protect it from light. Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E).

The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.) Administer aspirin with tissue plasminogen activator (t-PA). B.) Complete the National Institute of Health Stroke Scale (NIHSS). C.) Assess the client for signs of bleeding during and after the infusion. D.) Start t-PA within 6 hours after the onset of stroke symptoms. E.) Initiate multidisciplinary consult for potential rehabilitation.

B.) Complete the National Institute of Health Stroke Scale (NIHSS). C.) Assess the client for signs of bleeding during and after the infusion. E.) Initiate multidisciplinary consult for potential rehabilitation. Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A.) Administer epinephrine. B.) Defibrillate immediately. C.) Bolus with isotonic fluid. D.) Notify the health care provider.

B.) Defibrillate immediately. Rationale: Defibrillation is the first and most effective emergency treatment for ventricular fibrillation (B). The others may follow the first action (A, C, and D).

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? A.) Delegated to the primary care provider B.) Discussed along with other physical activities C.) Avoided because it is embarrassing to the patient D.) Accomplished by providing the patient with written material

B.) Discussed along with other physical activities Rationale: Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? A.) High-potassium foods B.) Drugs to treat erectile dysfunction C.) Nonsteroidal antiinflammatory drugs D.) Over-the-counter H2-receptor blockers

B.) Drugs to treat erectile dysfunction Rationale: The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? A.) Niacin B.) Ezetimibe C.) Gemfibrozil D.) Atorvastatin E.) Cholestyramine

B.) Ezetimibe D.) Atorvastatin Rationale: Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure? A.) Acute anxiety B.) Hypotension and tachycardia C.) Peripheral edema and weight gain D.) Paroxysmal nocturnal dyspnea (PND)

B.) Hypotension and tachycardia Rationale: Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

Dopamine is administered to a client who is hypotensive. Which finding should the nurse identify as a therapeutic response? A.) Gain in weight B.) Increase in urine output C.) Improved gastric motility D.) Decrease in blood pressure

B.) Increase in urine output Rationale: Intropin activates dopamine receptors in the kidney and dilates blood vessels to improve renal perfusion, so an increase in urine output (B) indicates an increase in glomerular filtration caused by increased arterial blood pressure. (A) is related to fluid retention but is not an indicator of a therapeutic response to dopamine therapy. (C) is not related to the vasopressor effect of dopamine therapy. Dopamine increases cardiac output, which increases a client's blood pressure, not (D).

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.) Assess the need to change a central line dressing. B.) Obtain a fingerstick blood glucose level. C.) Answer a family member's questions about the client's plan of care. D.) Teach the client side effects to report related to the current medication regimen.

B.) Obtain a fingerstick blood glucose level. Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.

The apical heart rate of an infant receiving digoxin for congestive heart failure is 80 beats/min. Which intervention should the nurse implement first? A.) Administer the next dose of digoxin as scheduled. B.) Obtain a serum digoxin level. C.) Administer a PRN dose of atropine sulfate. D.) Assess for S₃ and S₄ heart sounds.

B.) Obtain a serum digoxin level. Rationale: Sinus bradycardia (rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level is the highest priority (B). Further doses of digoxin should be withheld until the serum level is obtained (A). (C) is not indicated unless the client exhibits symptoms of diminished cardiac output. (D) provides information about cardiac function but is of less priority than (B).

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (LPN)? A.) Initiation of the blood product B.) Obtaining vital signs after infusion has begun C.) Assessment of client's condition prior to blood administration D.) Evaluation of client's response after receiving blood product

B.) Obtaining vital signs after infusion has begun Rationale: Blood and blood products must be initiated by the registered nurse (RN) (B); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. (A, C, and D) are all part of the nursing process and the scope of the RN.

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? A.) Sinus tachycardia B.) Pathologic Q wave C.) Fibrillatory P waves D.) Prolonged PR interval

B.) Pathologic Q wave Rationale: The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

A 67-year-old client is discharged from the hospital with a prescription for digoxin, 0.25 mg daily. Which instruction should the nurse include in this client's discharge teaching plan? A.) Take the medication in the morning before rising. B.) Take and record radial pulse rate daily. C.) Expect some vision changes caused by the medication. D.) Increase intake of foods rich in vitamin K.

B.) Take and record radial pulse rate daily. Rationale: Monitoring pulse rate is very important when taking digoxin (Lanoxin) (B). The client should be further instructed to report pulse rates below 60 or greater than 110 beats/min and to withhold the dosage until consulting with the health care provider in such a case. (A and D) are not necessary. (C) is an indication of drug toxicity, and the client should be instructed to report this immediately.

A client with angina pectoris is instructed to take sublingual nitroglycerin tablets PRN for chest pain. Which instruction should the nurse include in the client's teaching plan? A.) Take one tablet every 3 minutes, up to five tablets. B.) Take one tablet at the onset of angina and stop activity. C.) Replace nitroglycerin tablets yearly to maintain freshness. D.) Allow 30 minutes for a tablet to provide relief from angina.

B.) Take one tablet at the onset of angina and stop activity. Rationale: Nitroglycerin tablets should be taken at the onset of angina, and the client should stop activity and rest (B). One tablet can be taken every 5 minutes, up to three doses (A). Nitroglycerin should be replaced every 3 to 6 months, not every 12 months (C). Nitroglycerin should provide relief in 5 minutes, not 30 minutes (D).

A client being treated for an acute myocardial infarction is to receive the tissue plasminogen activator alteplase (Activase). The nurse would be correct in providing which explanation to the client regarding the purpose of this drug? A.) This drug is a nitrate that promotes vasodilation of the coronary arteries. B.) This drug is a clot buster that dissolves clots within a coronary artery. C.) This drug is a blood thinner that will help prevent the formation of a new clot. D.) This drug is a volume expander that improves myocardial perfusion by increasing output.

B.) This drug is a clot buster that dissolves clots within a coronary artery. Rationale: t-PA, or tissue plasminogen activator, is a coronary-specific fibrinolytic agent that dissolves clots within the coronary arteries (B). This drug is not a calcium channel blocker or nitrate, which would promote vasodilation of the coronary arteries (A). This medication is not an anticoagulant, such as warfarin or heparin, which would prevent new clot formation (C). Volume expansion is not provided by an infusion of TPA and would not necessarily improve myocardial perfusion caused by an increased cardiac output in a client with coronary artery disease (D).

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.) Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.) Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.) Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.) Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick.

B.) Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. STUDY MODE: Comprehensive Exam B Question 72 of 100 ID: 2_30 The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A.) Withhold the daily dose until the following day. B.) Withhold the dose and report the potassium level. C.) Give the digoxin with a salty snack, such as crackers. D.) Give the digoxin with extra fluids to dilute the sodium level.

B.) Withhold the dose and report the potassium level. Rationale: The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A.) "Monitoring Your Blood Pressure at Home" B.) "Smoking Cessation as a Lifelong Commitment" C.) "Decreasing Cholesterol Levels Through Diet" D.) "Stress Management for a Healthier You"

C.) "Decreasing Cholesterol Levels Through Diet" Rationale: A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol (C).

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a LPN? A.) A client with an admitting diagnosis of menorrhagia who is now 24 hours post-vaginal hysterectomy B.) A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C.) A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D.) A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

C.) A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) Rationale: (C) requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one on one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic and careful assessment is essential. (A, B, and D) could all be cared for by a PN under the supervision of the RN.

The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A.) Discontinue the digoxin. B.) Notify health care provider. C.) Administer the digoxin. D.) Reverify the digoxin level.

C.) Administer the digoxin. Rationale: A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should be continued to maintain a therapeutic range (C). The others actions are not indicated for a therapeutic range (A, B, and D).

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? A.) Dehydration B.) Paralytic ileus C.) Atrial dysrhythmias D.) Acute respiratory distress syndrome

C.) Atrial dysrhythmias Rationale: Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A.) Serum α-fetoprotein level B.) Ventilation/perfusion scan C.) Hepatic structure ultrasound D.) Abdominal girth measurement

C.) Hepatic structure ultrasound Rationale: Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

When caring for a client on digoxin therapy, the nurse knows to be alert for digoxin toxicity. Which finding would predispose this client to developing digoxin toxicity? A.) Low serum sodium level B.) High serum sodium level C.) Low serum potassium level D.) High serum potassium level

C.) Low serum potassium level Rationale: Hypokalemia (C) predisposes the client on digoxin to digoxin toxicity, which usually presents as abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and atrioventricular (AV) dissociation. Assessment of serum potassium levels with prompt correction of hypokalemia are important interventions for the client taking digoxin. (A, B, and D) are not relevant.

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.) Draw arterial blood gases. B.) Notify the primary health care provider. C.) Position in a high Fowler's position with the legs down. D.) Obtain a chest X-ray.

C.) Position in a high Fowler's position with the legs down. Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

A client who is HIV-positive is receiving combination therapy with the antiviral medication zidovudine (Retrovir). Which instruction should the nurse include in this client's teaching plan? A.) Take the drug as prescribed to cure HIV infections. B.) Use the drug to reduce the risk of transmitting HIV to sexual contacts. C.) Return to the clinic every 2 weeks for blood counts. D.) Report to the health care provider immediately if dizziness is experienced.

C.) Return to the clinic every 2 weeks for blood counts. Rationale: Bone marrow depression with granulocytopenia is a severe but common adverse effect of zidovudine (Retrovir). Careful monitoring of CBCs is indicated (C). (A and B) are not correct instructions related to use of this medication. (D) is an expected side effect. The client should be instructed to avoid driving until this reaction improves.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A.) Participating in telephone consultations with clients B.) Identifying oneself by name and title to clients in telehealth communications C.) Sending medical records to health care providers via the Internet D.) Answering a client-initiated health question via electronic mail

C.) Sending medical records to health care providers via the Internet Rationale: Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred (C). Client confidentiality is protected by federal wiretapping laws making telephone consultation (A) a private and protected form of communication. By stating one's name and credentials in telehealth communication (B), one is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk than sending records via the Internet.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A.) Serum digoxin level is 1.5 ng/mL B.) Blood pressure is 104/68 mm Hg C.) Serum potassium level is 2.5 mEq/L D.) Apical pulse is 68/min

C.) Serum potassium level is 2.5 mEq/L Rationale: Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A.) Potassium level, 3.9 mEq/dL B.) Creatinine level,1.1 mg/dL C.) Sodium level, 125 mEq/L D.) Calcium level, 9 mg/dL

C.) Sodium level, 125 mEq/L Rationale: The normal serum sodium level is 135 to 145 mEq/L (C). This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. (A, B, and D) are all within normal parameters.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A.) The apical heart rate is 64 beats/min. B.) The serum digoxin level is 1.5 ng/mL. C.) The client reports seeing yellow-green halos. D.) The potassium level is 4.0 mEq/L.

C.) The client reports seeing yellow-green halos. Rationale: Reports of yellow-green halos and blurred vision are a sign of digoxin toxicity (C). The others are normal findings (A, B, and C).

The health care provider prescribes cisplatin to be administered in 5% dextrose and 0.45% normal saline with mannitol added. Which assessment parameters would be most helpful to the nurse in evaluating the effectiveness of the mannitol therapy? A.) Oral temperature B.) Blood cultures C.) Urine output D.) Liver enzyme levels

C.) Urine output Rationale: The effectiveness of the diuresis is best measured by urine output (C). Mannitol, an osmotic diuretic, is given during cisplatin (Platinol) therapy to promote diuresis and reduce the risk of nephrotoxicity and ototoxicity associated with this chemotherapeutic agent. (A, B, and D) do not provide information about the risk for nephrotoxicity and ototoxicity related to Platinol administration.

Which of the following cardiac rhythms is represented in the image? A.) Normal sinus rhythm B.) Sinus tachycardia C.) Ventricular fibrillation D.) Atrial fibrillation

C.) Ventricular fibrillation Rationale: Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. (A, B, and D) are not represented in the image.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A.) "The hepatitis vaccine will provide immunity from this exposure and future exposures." B.) "I am afraid there is nothing you can do since the patient was infectious before admission." C.) "You will need to be tested first to make sure you don't have the virus before we can treat you." D.) "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

D.) "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Rationale: Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A.) "I will not take my digoxin if my heart rate is higher than 100 beats/min." B.) "I should weigh myself once a week and report any increases." C.) "It is important to increase my fluid intake whenever possible." D.) "I should report an increase of swelling in my feet or ankles."

D.) "I should report an increase of swelling in my feet or ankles." Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C).

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A.) "I will use care when kissing my wife to prevent giving it to her." B.) "I will need to take adofevir (Hepsera) to prevent chronic HCV." C.) "Now that I have had HCV, I will have immunity and not get it again." D.) "I will need to be checked for chronic HCV and other liver problems."

D.) "I will need to be checked for chronic HCV and other liver problems." Rationale: The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

The nurse is preparing to administer a secondary infusion of a dobutamine solution to a client. The nurse notes that the solution is brown in color. Which action should the nurse implement? A.) Verify the prescribed dose with the health care provider. B.) Discard the solution and reorder from the pharmacy. C.) Dilute the solution with more normal saline until it becomes lighter in color. D.) Administer the drug if the solution's reconstitution time is less than 24 hours.

D.) Administer the drug if the solution's reconstitution time is less than 24 hours. Rationale: The color of the dobutamine solution is normal (D), and it should administered within 24 hours after reconstitution, so the time of reconstitution should be verified before administering the solution of medication. (A) is not indicated. (B) is not necessary. Additional dilution of a drug in solution is stated in the manufacturer's reconstitution instructions, but (C) is not needed.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A.) Muscle aches B.) Constipation C.) Pounding headache D.) Anorexia and nausea

D.) Anorexia and nausea Rationale: Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A.) Ask the UAP to check for the advanced directive while the nurse completes the assessment. B.) Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C.) Check the medical record for the advanced directive and then complete the client assessment. D.) Call for the charge nurse to check the advanced directive while continuing to assess the client.

D.) Call for the charge nurse to check the advanced directive while continuing to assess the client. Rationale: Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? A.) Baked flounder B.) Angel food cake C.) Baked potato with margarine D.) Canned chicken noodle soup

D.) Canned chicken noodle soup Rationale: Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? A.) Taper the patient off his current medications. B.) Continue education for the patient and his family. C.) Pursue experimental therapies or surgical options. D.) Choose interventions to promote comfort and prevent suffering.

D.) Choose interventions to promote comfort and prevent suffering. Rationale: The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

A client was prescribed lovastatin to treat hyperlipidemia, since diet therapy and weight reduction did not successfully lower cholesterol levels. The client does not understand why medication is necessary, because he has been careful with diet for three months. How would the nurse explain the relationship of drug therapy to dietary management? A.) Drug therapy should eliminate the need for watching the diet, and therefore the addition of the medication would be beneficial. B.) Drug therapy is only effective when there is documented weight loss. C.) Drug therapy will reduce both cholesterol and triglyceride levels, if taken properly. D.) Combination therapy (drugs and diet) often helps clients meet their treatment goals to reduce cholesterol levels.

D.) Combination therapy (drugs and diet) often helps clients meet their treatment goals to reduce cholesterol levels. Rationale: Often, clients who have multiple risk factors for developing hyperlipidemia must use a combination therapy of drugs and diet to achieve results. Diet management, weight control, and the use of drug therapy work together in supporting and maintaining lipid levels. There is also a genetic component to hyperlipidemia that needs to be addressed by the client. Clients who are compliant with diet therapy often have to use drug therapy because of this genetic predisposition to produce more cholesterol.

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A.) Relief of constipation B.) Relief of abdominal pain C.) Decreased liver enzymes D.) Decreased ammonia levels

D.) Decreased ammonia levels Rationale: Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A.) Warfarin B.) Ibuprofen C.) Nitroglycerin D.) Digoxin

D.) Digoxin Rationale: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. (A, B, and C) are unlikely to result in the symptoms described.

Which medication is useful in treating digoxin toxicity? A.) Atropine sulfate B.) Isoproterenol C.) Xylocaine D.) Digoxin immune Fab

D.) Digoxin immune Fab Rationale: Digibind (D) is useful in treating this type of drug toxicity because it is an antibody that binds antigenically to unbound serum digoxin (Lanoxin) or digitoxin (Digitalis), resulting in renal excretion of the bound complex. (A, B, and C) are not used to treat digitoxin (Lanoxin) toxicity.

Prior to administering a scheduled dose of digoxin, the nurse reviews the client's current serum digoxin level, which is 1.3 ng/dL. Which action should the nurse implement? A.) Administer Digibind to counteract the toxicity. B.) Withhold the drug and notify the health care provider immediately. C.) Withhold the dose and notify the health care provider during rounds that the dose was held. D.) Give the dose of digoxin if the client's heart rate is within a safe range.

D.) Give the dose of digoxin if the client's heart rate is within a safe range. Rationale: The client's digoxin level of 1.3 ng/dL is not above the upper range of its therapeutic index (toxic level is >2.0 ng/dL), so the dose should be administered after the client's heart rate is evaluated (D). Digibind is administered for toxic levels of digoxin, so (A) is not indicated. (B and C) are not necessary.

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? A.) Tramadol (Ultram) B.) Hydromorphone (Dilaudid) C.) Oxycodone with aspirin (Percodan) D.) Hydrocodone with acetaminophen (Vicodin)

D.) Hydrocodone with acetaminophen (Vicodin) Rationale: The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? A.) External pacemaker B.) An electrophysiologic study (EPS) C.) Medications to prevent dysrhythmias D.) Implantable cardioverter-defibrillator (ICD)

D.) Implantable cardioverter-defibrillator (ICD) Rationale: An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A.) Impaired skin integrity related to edema, ascites, and pruritus B.) Imbalanced nutrition: less than body requirements related to anorexia C.) Excess fluid volume related to portal hypertension and hyperaldosteronism D.) Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D.) Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Rationale: Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

Alteration of which laboratory finding represents the achievement of a therapeutic goal for heparin administration? A.) Prothrombin time (PT) B.) Fibrin split products C.) Platelet count D.) Partial thromboplastin time (PTT)

D.) Partial thromboplastin time (PTT) Rationale: Heparin therapy is guided by changes in the partial thromboplastin time (PTT) (D). (A, B, and C) are not used to track the therapeutic effect of heparin administration.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.) Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.) High-calorie, low-sodium diet C.) Fluid restriction to 1500 mL/day D.) Pentobarbital (Nembutal sodium) at bedtime for rest

D.) Pentobarbital (Nembutal sodium) at bedtime for rest Rationale: Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed because the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

The nurse assesses a client who has been prescribed furosemide for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A.) Tall, spiked T waves B.) A prolonged QT interval C.) A widening QRS complex D.) Presence of a U wave

D.) Presence of a U wave Rationale: A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; Pco₂,50 mm Hg; Po₂, 70 mm Hg; HCO₃, 26 mEq/L. How should the nurse interpret these results? A.) Metabolic acidosis B.) Respiratory alkalosis C.) Metabolic alkalosis D.) Respiratory acidosis

D.) Respiratory acidosis Rationale: A pH <7.25 and Pco₂ >45 mm Hg with a normal HCO₃ indicates respiratory acidosis (D). The others are incorrect analyses of the ABGs (A, B, and C).

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.) Avoid high-carbohydrate foods. B.) Decrease intake of fat-soluble vitamins. C.) Decrease caloric intake. D.) Restrict salt and fluid intake.

D.) Restrict salt and fluid intake. Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention.

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? A.) ADHF B.) Chronic HF C.) Left-sided HF D.) Right-sided HF

D.) Right-sided HF Rationale: An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A.) Increase the rate of the heparin infusion using a nomogram. B.) Decrease the heparin infusion rate and give vitamin K IM. C.) Continue the heparin infusion at the current prescribed rate. D.) Stop the heparin drip and prepare to administer protamine sulfate.

D.) Stop the heparin drip and prepare to administer protamine sulfate. Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C).

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A.) Has completed a college education B.) Has been able to stop smoking cigarettes C.) Has well-controlled type 1 diabetes mellitus D.) The chest x-ray showed another lung cancer lesion.

D.) The chest x-ray showed another lung cancer lesion. Rationale: Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.

A client with hepatic failure tells the nurse about recent use of acetaminophen. How should the nurse respond to this client's statement? A.) Bleeding precautions should be implemented. B.) Tylenol is indicated for minor aches and pains. C.) Acetaminophen reduces inflammation. D.) The drug is hepatotoxic and contraindicated.

D.) The drug is hepatotoxic and contraindicated. Rationale: Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated (D). Although bleeding (A) is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although (B) is an indicated use for this drug, it remains contraindicated in patients with hepatic failure. (C) is inaccurate.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? A.) Consume a diet low in fats. B.) Reduce total caloric intake. C.) Increase intake of olive oil. D.) The lipid levels are normal.

D.) The lipid levels are normal. Rationale: For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

Identify the quality that a good follower would least likely display. a. Criticizes the leader b. Think outside the box c. Is always compliant and obedient d. Questions the leader

c. Is always compliant and obedient

A High Task - Low Relationship style of leadership is similar to what other style of leadership? a. Laissez-Faire b. Democratic c. Low Task - High Relationship d. Authoritarian

d. Authoritarian

A client is to begin weight-based intravenous heparin therapy for treatment of a deep vein thrombosis. The client's weight is 220 pounds. The client is to receive an infusion of 6 units per kilogram per hour. The intravenous heparin on hand contains 100 units per milliliter. The client will receive _________ mL of heparin per hour. Record your answer as a whole number.

6 mL of heparin per hour Rationale: The key to answering the question on weight-based heparin is to identify the infusion rate, which is 6 units per kilogram per hour. Thus, to accurately obtain the information, the weight must be converted from pounds to kilograms. There are 2.2 pounds per kilogram. To convert this amount into milliliters, it is necessary to identify how many units are in each milliliter of available solution.

The client with cirrhosis of the liver asks the nurse why he has edema. The nurse would use which statement to explain how edema results from pathophysiologic changes in cirrhosis? A.) "The edema occurs because your liver produces fewer proteins that help draw fluid into the blood stream." B.) "The high osmotic pressure of proteins in your blood pushes fluid into body tissues." C.) "Because of the liver disease, the kidneys are able to filter less fluid, so the body cannot excrete it as urine very easily." D.) "Your body is metabolizing sex hormones more quickly, leading to fluid retention."

A.) "The edema occurs because your liver produces fewer proteins that help draw fluid into the blood stream."

A charge nurse is supervising the work of a new registered nurse (RN). The new nurse is asking for help with delegating tasks to licensed practical/vocational nurses (LPN/LVNs). How should the charge nurse respond? A.) "Delegate based on the task and the skill of the LPN/LVN." B.) "When delegating, provide constant feedback." C.) "Only delegate tasks that you are not able to complete yourself." D.) "Give the LPN/LVN full responsibility to complete the task."

A.) "Delegate based on the task and the skill of the LPN/LVN." Rationale: The charge nurse should tell the nurse to delegate tasks based on the task and the LPN/LVN's skill.

A staff nurse is orienting a new nurse to the unit. The orientee is overwhelmed by the many tasks required. How should the staff nurse respond? A.) "Make a to-do list, and prioritize to keep yourself on track." B.) "Start with the tasks that require less time and skill." C.) "Try to get most of the work done yourself." D.) "Start medication administration, then go from there."

A.) "Make a to-do list, and prioritize to keep yourself on track." Rationale: The staff nurse should respond by instructing the orientee to make a to-do list and prioritize to stay on track. Many sources recommend to-do lists to help organize tasks, and prioritizing the list allows the nurse to focus on tasks that require immediate attention first.

A charge nurse is delegating assignments on the medical-surgical unit. Which aspect of delegation would be appropriately done by the RN? A.) Include all personnel in the delegation process. B.) Reprimand for even the most minor of violations. C.) Limit the number of "check-ins" with staff. D.) Take the duties away once they have been assigned.

A.) Include all personnel in the delegation process. Rationale: When people are a part of the delegation process, they tend to take more pride in doing a good job. In addition, the health care team might find something that is not clear to the nurse who is delegating.

When providing discharge teaching to a client with chronic cirrhosis, the client's partner asks why there is so much emphasis on bleeding precautions. What is the most appropriate response? A.) "The liver affected by cirrhosis is unable to produce sufficient clotting factors." B.) "The low protein diet will result in reduced clotting factors." C.) "The increased production of bile decreases clotting factors." D.) "The required medications reduce clotting factors."

A.) "The liver affected by cirrhosis is unable to produce sufficient clotting factors." Rationale: When bile production is reduced, the body has reduced ability to absorb fat-soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts.

The client who has liver disease asks the nurse why he bruises so easily. Which information should the nurse include in the response? A.) "Your liver is unable to make the proteins that are needed to make clotting factors." B.) "Your liver can no longer metabolize drugs and render them inactive." C.) "Your liver is breaking down blood cells too rapidly." D.) "Your liver can't store Vitamin C any longer."

A.) "Your liver is unable to make the proteins that are needed to make clotting factors." Rationale: The liver synthesizes clotting factors I, II, VII, IX, and X as well as prothrombin and fibrinogen. These substances are needed for adequate clotting, so their reduction leads to increased risk of bleeding.

When staffing the surgical nursing unit, which of the following clients could the nurse delegate to an unlicensed assistive person (UAP)? A.) A third-day-postoperative client who needs to be walked and have a blood glucose check at bedtime B.) A new surgical client who has just complained of oozing from the mastectomy site C.) A new amputee who is stable, but needs dressings reinforced D.) A fourth-day coronary artery bypass client who still has stable angina after surgery

A.) A third-day-postoperative client who needs to be walked and have a blood glucose check at bedtime Rationale: Delegation to UAPs can include any activity that is within their role. Ambulating the client and blood glucose monitoring are within this role.

Which of the following medications are hepatotoxic? Select all that apply. A.) Amiodarone B.) Isoniazid C.) Calcium Channel Blockers D.) Acetaminophen E.) Allopurinol F.) Sulfonylureas G.) Fluconaole H.) Proton Pump Inhibitors I.) Selective Serotonin Reuptake Inhibitors

A.) Amiodarone B.) Isoniazid D.) Acetaminophen E.) Allopurinol F.) Sulfonylureas G.) Fluconaole

A nurse is delegating care of clients to the certified nursing assistant (CNA) and licensed practical/vocational nurse (LPN/LVN). Which tasks should the nurse give the CNA and LPN/LVN? A.) CNA: Measure vital signs; LPN/LVN: Give oral medications on assigned clients B.) CNA: Change a non-infected dressing; LPN/LVN: Administer IV piggyback medications C.) CNA: Ambulate a client who had a CVA; LPN/LVN: Assess two clients D.) CNA: Measure vital signs; LPN/LVN: Complete a head-to-toe assessment on a newly admitted client

A.) CNA: Measure vital signs; LPN/LVN: Give oral medications on assigned clients Rationale: The scope of practice and most job descriptions for CNAs include vital signs. It is within the scope of practice for the LPN/LVN to administer oral medications.

The nurse caring for a client with hemolytic jaundice anticipates which findings on laboratory test results? A.) Elevated serum indirect bilirubin B.) Decreases serum protein C.) Elevated urine bilirubin D.) Decreased urine pH

A.) Elevated serum indirect bilirubin Rationale: Hemolytic jaundice is caused by excessive breakdown of red blood cells and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Serum protein is not measured to detect hemolytic jaundice. Unconjugated bilirubin is insoluble in water and is not found in the urine. Urine pH is not deceased by hemolytic jaundice.

Which assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis? Select all that apply. A.) Hemorrhoids B.) Bleeding gums C.) Muscle wasting D.) Splenomegaly E.) Ascites

A.) Hemorrhoids D.) Splenomegaly E.) Ascites Rationale: Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels predominantly in the paraumbilical and hemorhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis.

The nurse would assess a client receiving a nonselective beta blocker for development of which of the following complications related to drug therapy? A.) Hyperlipidemia B.) Decreased liver enzymes C.) Hypoglycemia D.) Increased BUN

A.) Hyperlipidemia

A client taking digoxin along with amphotericin B (Fungizone) could experience digitalis toxicity due to which of the following? A.) Hypokalemia B.) Antifungal attaching to receptors before digoxin C.) Increased plasma concentration of amphotericin B D.) Increased gastrointestinal absorption of digoxin and amphotericin B

A.) Hypokalemia

The nurse is reviewing the medication administration record for a client newly admitted for congestive heart failure. The client is receiving hydrochlorothiazide (HydroDiuril). Which conditions should concern the nurse in relation to administration of this medication? Select all that apply. A.) Hypokalemia, hyperglycemia, and sulfa allergy B.) Hyperkalemia, hypoglycemia, and penicillin allergy C.) Hypouricemia and hyperglycemia D.) Hyponatremia and hypocalcemia E.) Hypercalcemia, hyperuricemia, and hyperglycemia

A.) Hypokalemia, hyperglycemia, and sulfa allergy E.) Hypercalcemia, hyperuricemia, and hyperglycemia Rationale: ~ Thiazide diuretics are sulfa-based medications; therefore, a client with a sulfa allergy is at risk for an allergic reaction. The side effects of hydrochlorothiazide are hypokalemia and hyperglycemia. ~ Hyperkalemia, hypoglycemia, and penicillin allergy are not conditions of concern when administering hydrochlorothiazide. ~ Hyperglycemia is a concern when administering hydrochlorothiazide; hypouricemia is not a concern. ~ Hyponatremia is not a concern when administering hydrochlorothiazide. ~ Hypercalcemia, hyperuricemia, and hyperglycemia are all conditions of concern when administering hydrochlorothiazide.

What is an appropriate task for the registered nurse (RN) to delegate to the unlicensed assistant (UA)? A.) Intake and output B.) Irrigating a nasogastric (NG) tube C.) Changing a burn dressing D.) Monitoring pain status

A.) Intake and output Rationale: Intake and output are tasks that fall within the scope of practice for the UA.

The nurse instructs a client receiving hydrochlorothiazide (HCTZ) to report which of the following symptoms to the health care provider?2 A.) Leg cramps and muscle weakness B.) Muscle weakness and diarrhea C.) Fatigue and irritability D.) Nausea and irritability

A.) Leg cramps and muscle weakness Rationale: HCTZ is a potassium-wasting diuretic, and its use can lead to hypokalemia. Leg cramps and muscle weakness are two of the symptoms seen in a client with hypokalemia.

The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which nursing care activity can the nurse delegate to the unlicensed assistive person (UAP) working with this client? Select all that apply. A.) Measure oxygen saturation level every hour. B.) Listen to breath sounds. C.) Provide mouth care. D.) Teach use of incentive spirometer. E.) Assess for Homan's sign while bathing client.

A.) Measure oxygen saturation level every hour. C.) Provide mouth care. Rationale: ~ The UAP can perform tasks or nursing care activities, such as measuring oxygen saturation level, under supervision of the nurse. ~ The RN retains responsibility for assessment of breath sounds. ~ The UAP can perform tasks or nursing care activities, such as mouth care, under the supervision of the RN. ~ The RN retains responsibility for teaching. ~ The RN retains responsibility for assessment of Homan's sign.

The client has just had a liver biopsy. Which nursing action would be the priority after the biopsy? A.) Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours. B.) Ambulate every 4 hours for the first day as long as client can tolerate this. C.) Measure urine specific gravity every 8 hours for the next 48 hours. D.) Maintain NPO status for 24 hours post-biopsy.

A.) Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours. Rationale: Complications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should assess for signs of hemorrhage (increased pulse, decreased blood pressure) every 30 minutes for the first few hours and then hourly for 24 hours.

In caring for a client recovering from hepatitis A, who is no longer infectious and has no hepatic encephalopathy, which meal would the nurse consider to be most appropriate? A.) Pancakes, poached eggs, orange juice, coffee (breakfast) B.) Fried chicken, potatoes and gravy, green beans (noon) C.) Enchiladas, tortillas, chips, salsa (evening) D.) Salami sandwich, French fries, ketchup, coca cola (evening)

A.) Pancakes, poached eggs, orange juice, coffee (breakfast) Rationale: If there are no complications, it is better to give high-calorie and high-protein food items early in the morning before developing nausea.

The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply. A.) Prothrombin time B.) Urinalysis C.) Serum lipase D.) Serum troponin E.) Serum albumin

A.) Prothrombin time E.) Serum albumin Rationale: Many clotting factors are producedin hte liver, including fibrinogen (factorI), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client's ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability. Urinalysis is a general screening measure or can be used to diagnose problems with the urinary tract. Serum lipase is a useful indicator of disorders of the pancreas. Serum torponin is a common laboratory test used to diagnose myocardial infarction. One function of the liver is to synthesize protein, which may be impaired with cirrhosis.

A female staff nurse on the unit asks the charge nurse to complete the wound care and dressing change on an assigned client because she finds wound care distasteful. The nurse manager would counsel the nurse about which subject? A.) Reverse delegation B.) Overdelegation C.) Underdelegation D.) Incomplete delegation

A.) Reverse delegation Rationale: Reverse delegation occurs when a person with a lower rank delegates to someone with authority. In this instance, the nurse with a limited client assignment is delegating upward to a nurse who has responsibility for the entire nursing unit for that shift.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A.) Support the client to a sitting position. B.) Ask the client to walk slowly back to the room. C.) Administer a sublingual nitroglycerin tablet. D.) Provide oxygen via nasal cannula.

A.) Support the client to a sitting position. Rationale: The nurse should safely assist the client to a resting position (A) and then perform (C and D). The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B).

A nurse delegates to an unlicensed assistant (UA) the task of blood glucose (BG) monitoring, which must be done every two hours. What critical component of delegation by the nurse is necessary to ensure the measurements are completed every two hours? A.) The nurse must provide feedback and evaluate performance. B.) The nurse must limit the nursing assistant's authority. C.) The nurse must watch the assistant to make sure the BG monitoring is done. D.) The nurse and the nursing assistant should rotate the BG monitoring.

A.) The nurse must provide feedback and evaluate performance. Rationale: The nurse must provide feedback and evaluate performance to ensure the BG checks are completed every two hours.

The nurse has given medication instructions to the client receiving nicardipine (Cardene) for angina. What statement by the client would indicate to the nurse that the teaching needs to be reinforced? A.) "I will keep track of angina episodes, and report them if they increase." B.) "Edema or weight gain are expected side effects of the medication." C.) "I will report a pulse rate of fewer than 50 beats per minute." D.) "I will take any missed dose as soon as remembered, unless it is almost time for the next dose."

B.) "Edema or weight gain are expected side effects of the medication."

The client is exposed to hepatitis A. When teaching this client about infection control, the nurse explains that the client is most infectious to others at which of these times? A.) 7 days after exposure B.) 10 days before the onset of symptoms C.) 2 months after exposure D.) 14 days after symptoms begin

B.) 10 days before the onset of symptoms

A nurse is preparing for a busy morning. The first assigned client has hemodialysis in two hours. The second client has discharge orders. The third client has congestive heart failure (CHF), and needs furosemide (Lasix) IV push. The fourth client is a 36-year-old with type 2 diabetes mellitus and a blood glucose of 156 mg/dL. What should the nurse do first? A.) Assess the client who is going to dialysis in two hours. B.) Administer furosemide (Lasix) IVP to the client with CHF. C.) Provide discharge teaching to the client who is ready to go home. D.) Administer ordered regular insulin 2 units subcutaneously to the client with diabetes.

B.) Administer furosemide (Lasix) IVP to the client with CHF. Rationale: The nurse should use the ABCs of care to help guide this decision. The client who needs furosemide (Lasix) to treat CHF, has a cardiac illness that can also affect respiratory status. The other clients can wait until this client is medicated.

The nurse notes that the international normalized ratio (INR) of a client with aortic valve replacement taking sodium warfarin is 2.6. What action should the nurse take at this time? A.) Encourage the client to eat foods high in vitamin K. B.) Administer the daily dose of Coumadin as ordered. C.) Monitor the client closely for signs of a deep vein thrombosis. D.) Withhold the next scheduled dose of Coumadin, and notify the prescriber.

B.) Administer the daily dose of Coumadin as ordered. Rationale: The usual therapeutic INR level during medication therapy with sodium warfarin (Coumadin) is 2-3. The next dose should be given as scheduled.

The nurse would anticipate that a client with cirrhosis of the liver would have increased levels of which laboratory values? Select all that apply. A.) Albumin B.) Bilirubin C.) Ammonia D.) Prothrombin time E.) Calcium

B.) Bilirubin C.) Ammonia D.) Prothrombin time Rationale: ~ In cirrhosis, the damaged liver is unable to properly metabolize amino acids and synthesize albumin, resulting in decreased serum concentrations. ~ The cirrhotic liver is unable to completely break down bilirubin, and serum levels are elevated. ~ Ammonia is normally converted to urea in the liver; serum levels are increased with liver damage. ~ Prothrombin times are increased when the liver is unable to synthesize clotting factors. ~ Calcium levels should be unaffected by cirrhosis.

Diffuse fibrosis and conversion of normal liver tissue into abnormal nodules with fibrous bands describes the progression of which hepatic disorders? A.) Liver failure B.) Cirrhosis C.) Hepatitis A D.) Liver cancer

B.) Cirrhosis Rationale: The process of cirrhosis involves fibrotic changes in the liver in which fibrous bands form nodules, which gives the liver a cobblestone appearance. Liver failure is a secondary condition. The process in hepatitis is more necrosis, hyperplasia, and inflammation. Liver cancer is the development of tumor cells.

The registered nurse (RN) is working with an unlicensed assistant (UA) for the shift. Which activity is best retained by the RN rather than delegated to the UA? A.) Weighing a client B.) Discharging a client C.) Emptying the urinary catheter D.) Bathing a client

B.) Discharging a client Rationale: Discharging a client (and the associated teaching that is involved) is within the scope of the RN only.

A client who has elevated cholesterol levels has been prescribed nicotinic acid (Niacin). What information would the nurse provide to this client? A.) Niacin treatment is highly individualized, and there might be dose adjustments based on lab values. B.) Expect facial flushing, as this is a common expected effect of this medication. C.) Dietary sources of niacin are necessary to ensure that the medication works effectively. D.) Niacin can be taken concurrently with lovastatin (Mevacor) in order to maximize the therapeutic effect.

B.) Expect facial flushing, as this is a common expected effect of this medication. Rationale: Facial flushing is an expected side effect of niacin, caused by its vasodilator properties.

A client on the unit with hepatitis B suddenly develops anorexia, vomiting, abdominal pain, progressive jaundice, lethargy, and disorientation. The nurse interprets that these indicate which of the following? A.) Laënnec's cirrhosis B.) Fulminant hepatitis C.) Portal hypertension D.) Cancer of the liver

B.) Fulminant hepatitis Rationale: A condition developing 6 to 8 weeks after initial symptoms in a client with hepatitis is fulminant hepatitis where there is necrosis and shrinking of the liver with possible liver damage. The symptoms are classic and the condition often leads to coma, possibly death.

A staff nurse on the clinical excellence committee must prepare an in-service on delegation for nursing staff. In preparing the presentation, the nurse includes which explanation of how delegation impacts the safety and quality of client care? A.) Prevents nursing staff from becoming nonproductive and ineffective B.) Gets assigned nursing tasks done in most efficient way, utilizing appropriate resources C.) Gives nursing tasks to staff who can best understand the goal to be met D.) A way to make nursing staff feel as though they are part of the team

B.) Gets assigned nursing tasks done in most efficient way, utilizing appropriate resources Rationale: The main purpose of delegation is to get the job done in the most efficient way using appropriate resources.

Which of the following findings would strongly indicate the possibility of cirrhosis? A.) Dry skin B.) Hepatomegaly C.) Peripheral edema D.) Pruritus

B.) Hepatomegaly

The physician has prescribed propranolol for a client with frequent premature ventricular contractions (PVCs). The nurse collects material to conduct an education session with the client. Which of the following should the nurse plan to include in the teaching session? A.) A description of other effective medications B.) Information about side effects and adverse reactions C.) Material about the cellular effect of the medication D.) Data regarding various dysrhythmias

B.) Information about side effects and adverse reactions Rationale: The medication has side effects that could be disturbing to the client. These include hypotension, insomnia, lethargy, bronchospasm, mood changes, and decreased libido. The client should be alert to these so that he can notify the health care provider.

A client presents to the emergency department with a stab wound to the right upper abdominal quadrant. The client's vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ? A.) Stomach B.) Liver C.) Large intestine D.) Kidney

B.) Liver Rationale: The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding.

A client has an order to begin an IV nitroglycerin (Nitrostat) drip. What consideration should the nurse make in preparing to administer this medication? A.) Cover the solution with a plastic bag. B.) Maintain the solution in a glass bottle. C.) Replace the solution every 2 hours due to instability. D.) Prepare the solution under a laminar flow hood.

B.) Maintain the solution in a glass bottle.

The nurse on a cardiac medical unit has an unlicensed assistive person (UAP) assigned to the nursing team. The nurse would delegate which client care activities to the UAP? A.) Assist the client to choose low-fat and low-sodium food selections from the dietary menu. B.) Measure client's pulse, blood pressure, and oxygen saturation after ambulation. C.) Explain the need to alternate activity periods with rest. D.) Help the client use nitroglycerin left at the bedside if chest pain occurs.

B.) Measure client's pulse, blood pressure, and oxygen saturation after ambulation. Rationale: The nurse should delegate the activity that is procedural in nature, which is within the scope of training of the UAP.

A nurse is prepared to administer 0900 medications. Which medication should the nurse administer first? A.) Montelukast (Singulair) 10 mg orally for a client with asthma. B.) Potassium 40 mEq orally for a client with a potassium level of 2.8 mEq/L. C.) Two liters of oxygen for a client with an oxygen saturation of 94%. D.) Metoprolol (Toprol) 50 mg for a client with a BP of 108/66.

B.) Potassium 40 mEq orally for a client with a potassium level of 2.8 mEq/L. Rationale: The client with a potassium level of 2.8 mEq/L has a critically low level and could develop a cardiac dysrhythmia. This client should receive potassium immediately.

The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? A.) Recommend mental health counseling. B.) Review the medication actions and interactions. C.) Assess for the client's daily activity level. D.) Provide information regarding a support group.

B.) Review the medication actions and interactions. Rationale: Interferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed.

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first? A.) Administer an antidysrhythmic medication. B.) Start cardiopulmonary resuscitation. C.) Defibrillate the client at 200 J. D.) Assess the client's pulse oximetry.

B.) Start cardiopulmonary resuscitation. Rationale: Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately (B). (A and C) are appropriate, but CPR is the priority action. The client is dying, and (D) does not address the seriousness of this situation.

The nurse just finished receiving the morning change-of-shift report. Which client should the nurse assess first? A.) The client diagnosed with pneumonia who continues to have bilateral crackles. B.) The client on strict bed rest who is now complaining of calf pain. C.) The client who complains of back pain after being in the chair for several hours. D.) The client who is very angry because he needs to have more blood drawn due to a lab error.

B.) The client on strict bed rest who is now complaining of calf pain.

A nurse in an outpatient clinic is returning phone calls that have been made to the clinic. Which client call should have the highest priority? A.) The client with diabetes who states "I am starting to have breakdown on one of my heels." B.) The client who received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today." C.) A client reports, "I fell and hurt my ankle yesterday and today it is very swollen." D.) A client reports, "My knee is still hurting from the total knee repair I had two weeks ago."

B.) The client who received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."

The client with a diagnosis of anterior myocardial infarction (MI) begins to show dysrhythmias on the monitor. Which of the following most likely predisposes to dysrhythmia development with a myocardial infarction? A.) Respiratory alkalosis B.) Tissue ischemia C.) Hypokalemia D.) Digitalis toxicity

B.) Tissue ischemia Rationale: The ischemia that causes the MI can also cause the heart muscle to become irritable and irritated cells fire early, causing dysrhythmias. Although hypokalemia and digoxin toxicity are true, nothing in the stem indicates that these are specific to this client. Acidosis is usually the shift with MI, if one occurs.

The nurse is caring for a client who is being discharged after valve replacement surgery. The client has a new St. Jude Medical valve, and the nurse is reviewing the instructions for the client's follow-up care. The nurse determines that the client understands an important aspect of responsibility in the care of this valve when the client makes which of the following statements? A.) "I will take Coumadin for two months, and get my blood drawn every week until I stop taking it." B.) "I will remind the doctor to give me a prescription for anticoagulant medication every time I go to the dentist." C.) "I will need to take anticoagulant medication for the rest of my life." D.) "I won't take any anticoagulant medication or blood thinners because they could cause a problem with my new valve."

C.) "I will need to take anticoagulant medication for the rest of my life." Rationale: St. Jude Medical is a mechanical valve. Lifelong anticoagulation therapy is required with this mechanical valve because there is a risk of thrombus formation. If a valve is replaced with a tissue valve, anticoagulation might be required during the immediate postoperative period, but not necessarily lifelong anticoagulation. It is recommended to take antibiotics prior to dental care.

The nurse is caring for a client who has ascites, and the health care provider prescribes spironolactone. The client asks why this drug is being used. What is the best response by the nurse? A.) "This drug will help increase the level of protein in your blood." B.) "The drug will cause an increase in the amount of the hormone aldosterone your body produces." C.) "This medication is a diuretic but does not make the kidneys excrete potassium." D.) "This will help you excrete larger amounts of ammonia."

C.) "This medication is a diuretic but does not make the kidneys excrete potassium." Rationale: Spironolactone is used in clients with ascites who show no improvement with bedrest and fluid restriction. It inhibits sodium reabosprtion in the distal tubule and promotes potassium retention by inhibiting aldosterone. Spironolactone does not increase protein levels in the blood. Spironolactone does not aid in excreting ammonia, although lactulose (Cephulac) will do this.

The nurse is caring for a client with atrial fibrillation. The nurse is administering digoxin, and is assessing the apical pulse. The nurse expects to hear which of the following types of rhythms? A.) A very rapid, regular rhythm B.) A regular rhythm with intermittent irregular beats C.) A rhythm that is irregularly irregular D.) A regular rhythm with intermittent pauses

C.) A rhythm that is irregularly irregular Rationale: Atrial fibrillation is characterized by irregularly irregular QRS complexes and rhythm. There is no underlying regular rhythm with atrial fibrillation.

Decreased excretion of bilirubin would probably be attributed to which of the following? A.) A blood transfusion reaction B.)Hemolytic anemia C.) An obstructed common bile duct D.) An obstructed pancreatic duct

C.) An obstructed common bile duct Rationale: Obstruction of the common bile duct interferes with movement of the bile so that it cannot be excreted.

Which task would not be appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN) or unlicensed assistive personnel (UAP)? A.) Instructing the LPN/LVN to reinforce teaching of the RN's assigned clients prior to discharge B.) Assigning UAPs to complete vital signs and document and report changes to the RN C.) Asking the UAP to assess and evaluate the client response to IV pain medication D.) Instructing the LPN/LVN to remove a dressing from a postoperative client's abdominal wound

C.) Asking the UAP to assess and evaluate the client response to IV pain medication Rationale: The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse.

A nurse is assessing a surgical client. An unlicensed assistant (UA) enters the room and informs the nurse that a client in the next room is cold, clammy, and diaphoretic. What should the nurse do first? A.) Call the charge nurse for help. B.) Continue to assess the surgical client. C.) Assess the client who is clammy and diaphoretic. D.) Call the client's health care provider for new orders.

C.) Assess the client who is clammy and diaphoretic. Rationale: There is an urgent situation in the next room, and the nurse should assess that client to determine the extent of the client's change in status.

Which task is best delegated by the registered nurse (RN) to the unlicensed assistant (UA)? A.) Recording weights of a client with burn injury B.) Draining the irrigation bags for a colostomy C.) Assisting a client to eat and bathe D.) Monitoring the cardiac status of a client post-myocardial infarction

C.) Assisting a client to eat and bathe Rationale: The nursing assistant can complete and be assigned tasks that do not require teaching or assessment. In this case, the tasks that can best be assigned are feeding and bathing.

A client is admitted with dehydration secondary to prolonged nausea and vomiting. Which serum laboratory test results would the nurse expect to note as a result of the dehydration? Select all that apply. A.) Sodium 138 mEq/dL B.) Potassium 4.2 mEq/dL C.) Blood urea nitrogen (BUN) 30mg/dL D.) Hematocrit 49% E.) Total protein 6.8 mg/dL

C.) Blood urea nitrogen (BUN) 30mg/dL D.) Hematocrit 49% Rationale: ~ The sodium is normal and would be more likely to be elevated from hemoconcentration with dehydration. ~ The potassium level is normal, and would most likely be lower because of losses from the vomiting. ~ Dehydration results in loss of fluids, causing a hemoconcentration of BUN, which is elevated. ~ The hematocrit would be elevated secondary to hemoconcentration from dehydration. ~ The total protein level is normal, and would not likely be influenced by dehydration.

The nurse has received preoperative medications from the pharmacy for an adult male is scheduled for a coronary artery bypass graft. Which nursing action is a priority in administering these drugs? A.) Checking the gag reflex B.) Obtaining consent from the client C.) Checking the allergy history D.) Asking the family to leave the room

C.) Checking the allergy history Rationale: Checking the allergy history is important so that potentially fatal reactions do not occur.

The nurse notes that the physical assessment findings of spider angiomas, palmar erythema, peripheral edema, ascites, and change in mental status are consistent with which client disorder? A.) Cholelithiasis B.) Cholecystitis C.) Cirrhosis D.) Pancreatitis

C.) Cirrhosis Rationale: Portal hypertension and liver cell failure contribute to the late manifestations of cirrhosis. Cholelithiasis and cholecystitis will be accompanied by pain, food intolerances and/or vomiting. Pancreatitis presents with pain radiating to the back, mild cardiovascular changes, and hypocalcemia.

The registered nurse (RN) is assigning staff to a group of clients. What is an appropriate assignment for the unlicensed assistant (UA)? A.) Client requiring measurement of arterial blood gases every four hours B.) Client requiring frequent blood glucose measurements C.) Client requiring assistance to the bathroom for diarrhea D.) Client requiring complete blood counts for increasing anemia

C.) Client requiring assistance to the bathroom for diarrhea Rationale: A client requiring assistance to the bathroom is within the scope of the UA and this client is stable at present.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.) Increased serum albumin level B.) Decreased serum creatinine C.) Decreased serum ammonia level D.) Increased liver function test results

C.) Decreased serum ammonia level Rationale: The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia (C). (A, B, and D) will not be significantly affected by the removal of blood.

A nurse plans to delegate some responsibilities of client care to a licensed practical/vocational nurse (LPN/LVN). Which task should the nurse delegate to the LPN/LVN? A.) Assessment of a newly admitted client B.) Admission of a postoperative client C.) Dressing changes for a client with wounds D.) Assist a client with ambulation and AM care

C.) Dressing changes for a client with wounds Rationale: The best choice is to assign the LPN to change the client's dressing.

The staffing on the unit consists of one registered nurse (RN), two licensed practical nurses (LPNs), and an unlicensed assistant (UA). Which task is the most appropriate to be completed by the LPN? A.) Assessing a client following chest tube removal B.) Dressing changes on a client who sustained a major burn C.) Dressing changes on a client who underwent an appendectomy D.) Emptying the urinary catheters on the unit

C.) Dressing changes on a client who underwent an appendectomy Rationale: This is a stable client, and dressing changes on a stable client are within the scope of practice of the LPN.

In reviewing the possible causes of hepatitis A in a 22-year-old male, which of the following would be the most likely factor? A.) Contact with blood in his profession as a policeman B.) Receiving a blood transfusion during surgery C.) Eating shrimp at the local pub D.) Admitting to being sexually active

C.) Eating shrimp at the local pub Rationale: Hepatitis A is transmitted by fecal-oral route. The virus is excreted in oropharyngeal secretions (nose and throat) and transmitted by direct contact of person-to-person, or by fecal contamination of food or water. A worker at the pub could have hepatitis A and transfer it to the food that is being prepared.

A client with a diagnosis of cirrhosis of the liver and a history of alcohol abuse is admitted to the unit. The nurse knows that portal hypertension is a possible complication of this condition for which reason? A.) Hyponatremia and hypoproteinemia B.) Ecchymosis, edema, and jaundice C.) Fibrotic tissue from cell destruction D.) Development of esophageal varices

C.) Fibrotic tissue from cell destruction Rationale: Portal hypertension develops as a result of development of fibrous bands, which develop following necrosis and regeneration of lung tissue. The other conditions are due to other changes in the liver as well as bleeding. Esophageal bleeding occurs as a result of portal hypertension, not just the opposite.

A client has been admitted to the hospital with chest pain. The pain has not been relieved after one dose of nitroglycerine (NTG) sublingually. Upon monitoring the vital signs (VS), the nurse notices that the blood pressure has dropped to 126/84 from 130/90. Which action should the nurse take next? A.) Notify the physician. B.) Obtain an electroencephalogram (EEG). C.) Give another dose of nitroglycerine. D.) Add a dose of nitroglycerine paste.

C.) Give another dose of nitroglycerine.

A newly admitted client with cirrhosis of the liver has a distended abdomen and the umbilicus is protruding. The nurse interprets that what is the pathological basis for this sign? A.) Increased fluid intake resulting from excessive use of alcohol causing overhydration. B.) Increased size of the liver results in abdominal distension. C.) Hypoalbuminemia causes fluid to leave the vascular system and enter the peritoneal cavity. D.) Shunting of the blood to the collateral circulation in the esophagus results in decreased blood volume and accumulation of fluid.

C.) Hypoalbuminemia causes fluid to leave the vascular system and enter the peritoneal cavity. Rationale: Low albumin in the blood causes a decrease in plasma colloidal osmotic pressure, causing fluid to escape into the extravascular compartment.

While working on a nursing unit that has been short-staffed for three months, a nurse has fallen behind schedule in performing care to some assigned clients. The charge nurse recommends delegating some tasks to another nurse or CNA. The nurse responds, "I'll catch up; I can handle it." The charge nurse then counsels the nurse about which delegation barrier? A.) Inexperience B.) Disorganization C.) Inadequate support D.) Self-absorbing attitude

C.) Inadequate support Rationale: Nurses are often hesitant to ask for help because they may be expected to meet the needs of all clients at all times. In this case, however, the chronic short-staffing on the unit is a barrier because fewer staff mean less support from others in the work of the unit.

When completing discharge teaching for a client who has cirrhosis and ascites, the nurse should instruct the client to avoid which food used by the client as a snack? A.) Whole wheat bread B.) Cookies C.) Potato chips D.) Hard candy

C.) Potato chips Rationale: A low-sodium diet is recommended for clients who have cirrhosis and ascites. Potato chips are high in sodium.

A client with advanced liver disease is being treated with antibiotics for a respiratory infection. The nurse should assess the client for which of the following? A.) High risk for allergy to drugs B.) Teratogenic effects of antibiotics C.) Symptoms of drug toxicity D.) Drug dependence

C.) Symptoms of drug toxicity

The nurse is caring for a client with new-onset atrial fibrillation. The nurse anticipates that which of the following is a possible treatment for this dysrhythmia when it first develops? A.) External pacemaker application B.) Insertion of automatic internal cardiac defibrillator (AICD) C.) Synchronized cardioversion D.) Defibrillation

C.) Synchronized cardioversion Rationale: Synchronized cardioversion is most effective with new-onset atrial fibrillation. Pacemakers are indicated for heart block, AICDs are used for ventricular dysrhythmias, and defibrillation is indicated for ventricular fibrillation and pulseless ventricular tachycardia.

A client has been exposed to hepatitis A. Which client factor would be an indication to the nurse for withholding administration of immune serum globulin to the client? A.) The client has received a hepatitis B vaccine. B.) The client has recently fallen and suffered a hip fracture. C.) The client has a history of a coagulation disorder. D.) The client is scheduled for foreign travel.

C.) The client has a history of a coagulation disorder. Rationale: Immune serum globulin should not be administered to clients with a history of coagulation disorders.

You are a charge nurse on the medical-surgical unit. You are expecting 4 admissions. Which patient will you assign to the room directly across from the nurses' station? A.) The patient admitted with diverticulitis. B.) The patient admitted with unrelenting migraine headaches. C.) The patient admitted after a fall who has a history of dementia and wandering. D.) The patient who had a right total knee replacement done this morning.

C.) The patient admitted after a fall who has a history of dementia and wandering.

Which statement is true regarding viral hepatitis infection? A.) Hepatitis B is transmitted by the fecal-oral route. B.) Hepatitis A is a sexually transmitted disease. C.) The posticteric phase follows jaundice and lasts several weeks. D.) Hepatitis D has a slow onset.

C.) The posticteric phase follows jaundice and lasts several weeks.

The nurse assesses a client taking cholestyramine (Questran) for signs of possible deficiency of which vitamins? A.) Niacin and thiamine B.) Folic acid and vitamin C C.) Vitamins A and D D.) Thiamine and cyanocobalamin

C.) Vitamins A and D

When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding? A.) "Trousseau's sign noted." B.) "Caput medusa noted." C.) "Fetor hepaticus noted." D.) "Asterixis noted."

D.) "Asterixis noted." Rationale: Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. Trousseau's sign reflects hypocalcemia. Caput medusa refers to spider-like abdominal veins that are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Fector hepaticus is a specific odor noted in liver failure.

A client is getting ready to go home after a myocardial infarction (MI). The client is asking questions about his medications, and wants to know why metoprolol was prescribed. The nurse's best response would be which of the following? A.) "Your heart was beating too slowly, and metoprolol increases your heart rate." B.) "Metoprolol helps to increase the blood supply to the heart by dilating your coronary arteries." C.) "Metoprolol helps make your heart beat stronger to supply more blood to your body." D.) "Metoprolol slows your heart rate and decreases the amount of work it has to do so it can heal."

D.) "Metoprolol slows your heart rate and decreases the amount of work it has to do so it can heal." Rationale: Metoprolol (Lopressor) is a beta adrenergic blocker that slows the heart rate and decreases myocardial contractility.

A 65-year-old female with a history of hepatic encephalopathy is hospitalized for pneumonia and dehydration. When she complains about the small portions of meat ordered by the dietitian, what is the the best response by the nurse? A.) "Ask your doctor about it in the morning." B.) "I will call and order larger portions for you." C.) "The amount of meat on your tray is dictated by certain blood test results." D.) "Your protein is being limited, but you can have more food from another group."

D.) "Your protein is being limited, but you can have more food from another group." Rationale: The client is at increased risk for a return of encephalopathy because of the diagnosis of pneumonia and dehydration. She has volume depletion and the potential for electrolyte imbalance, both of which can contribute to the development of encephalopathy. Protein needs to be controlled to prevent this.

A charge nurse is making assignments for the unit. Which assignment is best for the licensed practical nurse (LPN)? A.) Client post-myocardial infarction who is also three days postoperative and receiving IV fluids B.) Client post-chest tube removal who is on oxygen at three liters/minute by nasal cannula C.) A client who is post-tonsillectomy who is complaining of a feeling of wetness in the throat D.) A client who is post-craniotomy who is going home in the morning

D.) A client who is post-craniotomy who is going home in the morning Rationale: The post-craniotomy client who is approaching discharge is the most stable of clients. LPNs should take clients who are more likely to achieve expected outcomes without complications.

The registered nurse (RN) must delegate care of an assigned client to an unlicensed assistive person (UAP) for the shift. Which client would be best to delegate to the UAP? A.) A client who would benefit from talking about the recent death of her husband B.) A client with a urinary drainage catheter and nasogastric feedings who is on bedrest C.) A client with an ostomy who has persistent problems with leakage D.) A client who was transferred from the critical care unit 4 days ago and is ambulatory

D.) A client who was transferred from the critical care unit 4 days ago and is ambulatory Rationale: Factors to consider when delegating care include complexity of task, problem-solving innovation required, unpredictability, and level of client interaction. The ambulatory client is best to delegate because this client is likely to be stable with a low level of unpredictability. The client who recently lost her husband would benefit from professional communication with the RN and requires a high level of client interaction. The client receiving enteral feedings and is immobilized represents a more complex client, who is better assigned to a licensed nurse. The client with a leaking ostomy would benefit from problem-solving innovation and is best cared for by the RN.

After receiving intershift report, the registered nurse (RN) is aware that it will be a busy shift. Which task is a priority nursing action? A.) Administer potassium to a client with a potassium level of 3.7 mEq/L. B.) Check oxygen saturation on a client whose arterial blood gases (ABGs) are pH 7.38, PCO2 38 mmHg, and HCO3- 22 mEq/L. C.) Assess a wound on a client with a diabetic foot ulcer and a blood glucose level of 168 mg/dL. D.) Administer ordered magnesium sulfate to a client with a magnesium level of 0.8 mEq/L.

D.) Administer ordered magnesium sulfate to a client with a magnesium level of 0.8 mEq/L. Rationale: The client with a magnesium level of 0.8 mEq/L is at risk for seizures and tetany if it falls further, so administering magnesium is a priority to keep this client safe and prevent seizure activity.

The nurse interprets that which of the following clients is most likely to acquire hepatitis? A.) A child with a bacterial infection B.) A client with dysfunction of the biliary system C.) A client with metastasis of liver cancer D.) An adult with varicella zoster

D.) An adult with varicella zoster Rationale: Although hepatitis is associated with cholestasis, the most likely candidate would be someone with a viral infection. Other causes include alcohol, toxins, and severe hepatocellular damage.

The nurse has begun a continuous infusion of nitroglycerin intravenously. Which of the following indicates to the nurse that the client is experiencing an adverse reaction? A.) Pulmonary capillary wedge pressure (PCWP) falling from 13 to 11 mm Hg B.) Central venous pressure (CVP) falling from 10 to 7 mm Hg C.) Heart rate (HR) falling from 96 to 78 D.) Blood pressure (BP) falling from 130/80 to 90/64

D.) Blood pressure (BP) falling from 130/80 to 90/64 Rationale: Nitroglycerin is an antianginal of the nitrate type that causes vasodilation of coronary and other arteries. It would be expected to cause a decrease in PCWP and CVP. The heart rate could also decrease with overall improvement in cardiac output. A decrease in BP from 130/80 to 90/64 is excessive, and warrants further assessment by the nurse to determine whether perfusion to major organs is adequate.

A client on a telemetry monitor has a heart rate of 54 bpm. The nurse knows that this rate would probably not increase oxygen demand for the myocardium, but the rate is indicative of which of the following? A.) Tachycardia B.) Ventricular hypertrophy C.) Hypertension D.) Bradycardia

D.) Bradycardia Rationale: Bradycardia decreases the myocardium's demand for oxygen by decreasing the workload of the heart. Heart rates less than 60 bpm are considered bradycardia. However, if the heart rate is too low, blood supply is decreased and oxygen supply may be hindered.

A client scheduled for discharge after coronary artery bypass grafting (CABG) reports a new onset of anorexia and nausea. The client's new medications include digoxin, metoprolol, and furosemide. The nurse plans to report this finding to the health care provider after checking the result of which laboratory test drawn earlier in the morning? A.) Potassium level B.) Sodium level C.) Creatinine kinsease level D.) Digoxin level

D.) Digoxin level Rationale: Nausea and anorexia are signs of digitalis toxicity, making the digoxin level high priority for assessment. The potassium, sodium, and creatinine kinase levels would not explain the client's symptoms and therefore are not priorities to assess before telephoning the health care provider.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement? A.) Advise the client to come to the clinic immediately for further assessment. B.) Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C.) Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D.) Encourage the client to keep taking the drug until seen by the health care provider.

D.) Encourage the client to keep taking the drug until seen by the health care provider. Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication (D). Immediate evaluation is not needed (A). Antihypertensive medications should not be stopped abruptly (B) because rebound hypertension may occur. (C) is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

A client who has multiple sclerosis and receives cyclophosphamide (Cytoxan) and digoxin (Lanoxin) reports nausea. The nurse would place highest priority on which of the following actions? A.) Evaluate the cyclophosphamide level. B.) Administer an oral anti-emetic daily. C.) Provide six small, frequent meals. D.) Evaluate the digoxin level.

D.) Evaluate the digoxin level. Rationale: Cyclophosphamide (Cytoxan) combined with digoxin (Lanoxin) can result in digoxin toxicity, so the health care team must continually assess for signs and symptoms of toxicity. Nausea is an early sign of digoxin toxicity.

In caring for a client with liver failure, the nurse explains that the pathophysiology of the disease causes which of the following? A.) Decreased serum creatinine B.) Increased red blood cells (RBCs) C.) Increased calcium D.) Increased ammonia

D.) Increased ammonia Rationale: Increased ammonia occurs because the liver is unable to convert ammonia to urea. Calcium is probably decreased because of bedrest. Serum creatinine is probably increased because of impaired renal function; RBCs are probably decreased because of decreased production in the bone marrow.

Hepatic fat accumulation in a 55-year-old man is usually a result of which type of cirrhosis? A.) Biliary B.) Metabolic C.) Postnecrotic D.) Laënnec's

D.) Laënnec's

Which consideration by the nurse is of the highest priority when preparing to administer a medication to a client with cirrhosis? A.) Frequency of the medication B.) Purpose of the medication C.) Necessity of the medication D.) Metabolism of the medication

D.) Metabolism of the medication Rationale: In cirrhosis, the liver cannot metabolize or biotransform medications as well because of scarring of liver tissue. Certain medications are metabolized primarily by the liver, while other medications are metabolized by other organs. Consideration should be made for each medicine ordered to avoid overburdening the liver.

After receiving digoxin 0.125 po daily for 5 days, the client exhibits visual disturbances and cardiac dysrhythmias. After administering digoxin immune fab (Digibind), the nurse should take which action? A.) Monitor serum digoxin at least 12 hrs later. B.) Monitor for hyperkalemia C.) Explain that the current symptoms will not be of further concern. D.) Monitor for allergic reaction

D.) Monitor for allergic reaction

A nurse is caring for a group of clients. One client is scheduled for the operating room (OR) in one hour. The second client needs information on nursing homes, and the third client needs to provide a urine specimen. The nurse has not documented on any clients. What task would the nurse delegate to an licensed practical nurse (LPN/LVN)? A.) Preparing the client for the OR B.) Documenting client care C.) Providing nursing home information D.) Retrieving the urine specimen

D.) Retrieving the urine specimen Rationale: The nurse should delegate the retrieval of the urine specimen to the LPN. This task is in the LPN's scope of practice, and constitutes appropriate use of staff.

True or False Management and leadership are the same thing.

False

How can leaders better understand their effectiveness by using information from their followers? a. How do the followers view themselves in the organizational structure? b. Followers believe they have little power over decisions that are made? c. How do the followers view the mistakes the leader makes? d. How submissive are the followers to the leader?

a. How do the followers view themselves in the organizational structure?

In which setting would the Laissez-Faire style of leadership work best? a. A busy intensive care unit b. A organization involved in long term nursing research c. A nursing home staffed mostly by ancillary health care workers d. An ambulance service staffed by paramedics

b. A organization involved in long term nursing research

Select all that apply. Select the key behaviors of successful leaders and managers. a. Chooses one person in the work group to rely on b. Acknowledges good work and success c. Provides individuals with more difficult challenges d. Resolves conflicts before they get out of control e. Keeps good records of all the mistakes individuals in the group make f. Maintains a highly competitive environment

b. Acknowledges good work and success c. Provides individuals with more difficult challenges d. Resolves conflicts before they get out of control

Which of the following is an example of collective power? a. Informing legislators about issues that affect health and nursing. b. Organizing a large group of individuals who have similar beliefs and concerns. c. Working through professional organizations to increase individual accountability. d. Demonstrating that they are professionals dedicated to a career.

b. Organizing a large group of individuals who have similar beliefs and concerns.

Which skill would a good leader least likely have? a. Good listener b. Problem solver c. Quick decision maker d. Maintain convictions in the face of adversity

c. Quick decision maker

Care Delivery Models Describe: ~ Functional Nursing ~ Team Nursing ~ Primary Care Nursing ~ Modular Nursing

• Functional o Nurses are Called ~ Charge Nurse ~ Medical Nurse ~ Treatment Nurse o Description ~ Nurses are assigned to specific tasks rather than specific clients o Where Model is Used ~ Hospitals ~ Nursing Homes ~ Nurse Consultants ~ Operating Rooms • Team o Nurses are Called ~ Team Leader ~ Team Member o Description ~ Nursing staff members are divided into small groups responsible for the total care of a given number of clients. o Where Model is Used ~ Hospitals ~ Nursing Homes ~ Home Care ~ Hospice • Primary Care o Nurses are Called ~ Primary Nurse ~ Associate Nurse o Description ~ Nurses are designated either as the primary nurse responsible for clients' care or as the associate nurse who assists in carrying out the care o Where Model is Used ~ Hospitals ~ Specialty Units ~ Dialysis ~ Home Care • Modular o Nurses are Called ~ Care Pair o Description ~ Nurses are paired with less-trained caregivers. Generally involves cross-training of personnel. o Where Model is Used ~ Hospitals ~ Home Health Care ~ Transport Teams

Leadership-Style Theory

• Leadership-Style Theory o A continuum of leadership style that ranges from a mostly passive approach to a highly controlling one. ~ Laissez-faire ~ Democratic - The democratic leadership style is based on four beliefs: 1. Every member of the group needs to participate in all decision-making. 2. Within the limits established by the group, freedom of expression is allowed to maximize creativity. 3. Individuals in the group accept responsibility for themselves and for the welfare of the whole group. 4. Each member must respect all the other members of the group as unique and valuable contributors. ~ Authoritarian

Sources of Power Define: ~ Referent Power ~ Expert Power ~ Reward Power ~ Coercive Power ~ Legitimate Power ~ Collective Power

• The following list includes some of the more accessible and acceptable sources of power that nurses should consider using in their practice: o Referent (Close Personal Relationships) ~ The referent source of power depends on establishing and maintaining a close personal relationship with someone. In any close personal relationship, one individual often will do something he or she would really rather not do because of the relationship. This ability to change the actions of another is an exercise of power. o Expert (Knowledge) ~ The expert source of power derives from the amount of knowledge, skill, or expertise that an individual or group has. This power source is exercised by the individual or group when knowledge, skills, or expertise is either used or withheld in order to influence the behavior of others. o Reward ~ The reward source of power depends on the ability of one person to grant another some type of reward for specific behaviors or changes in behavior. o Coercive ~ The coercive source of power is the flip side of the reward source. The ability to reprimand, withhold rewards, and threaten punishment is the key element underlying the coercive source of power. o Legitimate (Legal Act) ~ The legitimate source of power depends on a legislative or legal act that gives the individual or organization a right to make decisions that they might not otherwise have the authority to make. o Collective (Use of Media) ~ The collective source of power is often used in a broader context than individual client care and is the underlying source for many other sources of power. When a large group of individuals who have similar beliefs, desires, or needs become organized, a collective source of power exists.

Trait Theory

• Trait Theory o The trait theory identifies qualities that are common to effective leaders. o Trait theory by itself is limited because it focuses only on the traits of the individual and does not take into account how the person acts in specific situations. o Leadership Traits ~ High level of intelligence and skill ~ Self-motivation and initiative ~ Ability to communicate well ~ Self-confidence and assertiveness ~ Creativity ~ Persistence ~ Stress tolerance ~ Willingness to take risks ~Ability to accept criticism