Exam 2 Review
The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)? □ 1. normal serum albumin □ 2. decreased ammonia □ 3. slightly decreased levels of calcium □ 4. elevated PT/INR
. The client with esophageal varices is at even higher risk for bleeding with elevated PT/INR. The nurse and HCP collaborate to prevent bleeding. The other laboratory findings are not as life threatening. A decreased serum albumin can cause fluid to move into the interstitial tissues. Increased ammonia levels are toxic to the brain. Calcium loss is more common to pancreatitis. CN: Physiological adaptation; CL: Synthesize
The nurse is developing a care plan with a client who has leukemia. What instructions should the nurse include in the plan? Select all that apply. □ 1. Monitor temperature and report elevation. □ 2. Recognize signs and symptoms of infection. □ 3. Avoid crowds. □ 4. Maintain integrity of skin and mucous membranes. □ 5. Take a baby aspirin each day.
1, 2, 3, 4. Nursing care of a client with leukemia includes managing and preventing infection, maintaining integrity of skin and mucous membranes, instituting measures to prevent bleeding, and monitoring for bleeding. Aspirin is an anticoagulant; bleeding tendencies, such as petechiae, ecchymosis, epistaxis, gingival bleeding, and retinal hemorrhages, are likely due to thrombocytopenia.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? 1. excessive alcohol use 2. gallstones 3. abdominal trauma 4. hypertension 5. hyperlipidemia with excessive triglycerides 6. hypothyroidism
1, 2, 3, 5 Pancreatitis is a potentially life threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis.
A client who had an exploratory laparotomy 3 days ago now has a white blood cell (WBC) count of 15,000 μL (15 × 109/L). For which clinical findings of this laboratory report should the nurse assess the client? Select all that apply. □ 1. swelling around the incision □ 2. redness around the incision □ 3. elevated temperature □ 4. nonproductive cough □ 5. weak pedal pulses
1, 2, 3. The client has an elevated white count. Normal white count is 4,300 to 10,800 μL (4.3 to 10.8 × 109/L). The client is at risk for infection, and the nurse should assess the client for inflammation around the incision site, redness at the incision site, and elevated temperature. The client should be encouraged to cough and deep breathe, and it is unlikely that a cough is related to an incisional infection. Weak pedal pulses are not indications of an infection, but the nurse should report this finding if it persists.
When the nurse is caring for a patient hospitalized with acute pancreatitis who has severe abdominal pain, which nursing interventions would be most appropriate for the client? 1. Place the client in a side lying position 2. Administer morphine sulfate for pain as needed 3. Maintain the client on a high-calorie, high-protein diet 4. Monitor the clients respiratory status 5. Obtain daily weights
1, 2, 4, 5 The client with acute pancreatitis usually experiences severe abdominal pain. The client will likely receive an opioid such as morphine to treat the pain. Placing the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. A semi-fowlers position is also appropriate. The nurse should also monitor the client's respiratory status because clients with pancreatitis are prone to develop respiratory complications. Daily weights are obtained to monitor the clients nutritional and fluid volume status. During the acute phase of the illness while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the diet is reintroduced, it is a high carb, low-fat, bland diet.
A client is being discharged home 3 days after transurethral resection of the prostate (TURP). What should the nurse instruct the client to do? SATA 1. Drink at least 3,000mL water per day 2. Increase calorie intake by eating six small meals a day 3. Report bright red bleeding to the healthcare provider 4. Take deep breaths and cough every 2 hours 5. Report a temperature over 99 degrees
1, 3, &5. The nurse should instruct the client to drink a large amount of fluids to keep the urine clear. The urine should be almost without color. About 2 weeks after TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the surgeon or go to the emergency department if at any time the urine turns bright red. The nurse should also instruct the client to report signs of infection such as a temperature over 99 degrees.
What is the priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. cholesterol level 2. pupil size and pupillary response 3. bowel sounds 4. echocardiogram
2. It is critical to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. An echocardiogram is not needed for a client with thrombotic stroke without heart problems.
When communicating with a client who has aphasia, which approaches are helpful? Select all that apply. □ 1. Present one thought at a time. □ 2. Avoid writing messages. □ 3. Speak with normal volume. □ 4. Make use of gestures. □ 5. Encourage pointing to the needed object.
1, 3, 4, 5. The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.
13. A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which additional signs and symptoms? Select all that apply. □ 1. respiratory distress □ 2. bleeding □ 3. fluid and electrolyte imbalance □ 4. weight gain □ 5. infection
1, 3. Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure, precipitating movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation. CN: Physiological adaptation; CL: Analyze
Which outcomes indicate effective management of a conscious client who is being treated with TPA during an initial CVA? SATA 1. headache reduced 2. dysphagia improved 3. visual disturbances improved 4. responds to comfort measures 5. no signs or symptoms of bleeding
1, 4, 5 A headache which is treated with analgesics, is commonly associated with an ischemic CVA. A conscious client responds to comfort measures. Bleeding is a side effect of recombinant tissue plasminogen (T-PA) therapy to dissolve the clots; absence of bleeding is a desired outcome. Reduction of dysphagia and visual disturbances is unpredictable and less likely to occur during this phase.
The nurse is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It is so horrible, and I brought it on myself. I should have quit smoking years ago. What would be the nurses best response to the client? 1. It's ok to be scared. What is it about cancer that you are afraid of? 2. Its normal to be scared. I would be too. We will help you through it. 3. Don't be so hard on yourself. You don't know if your smoking caused the cancer. 4. Do you feel guilty because you smoked?
1. Acknowledging the basic feeling that the client expresses- fear- and asking open-ended questions allow the client to explain any fears. The other options dismiss the clients feelings and may give false reassurance or label the clients feelings. The client should be encouraged to explore feelings about a cancer diagnosis.
The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions? □ 1. "There is a strong link between alcohol use and acute pancreatitis." □ 2. "Alcohol intake can interfere with the tests used to diagnose pancreatitis." □ 3. "Alcoholism is a major health problem, and all clients are questioned about alcohol intake." □ 4. "The health care provider must obtain the pertinent facts, regardless of religious beliefs."
1. Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care. CN: Health promotion and maintenance; CL: Apply
52. What diet should be implemented for a client who is in the early stages of cirrhosis? □ 1. high-calorie, high-carbohydrate □ 2. high-protein, low-fat □ 3. low-fat, low-protein □ 4. high-carbohydrate, low-sodium
1. For clients who have cirrhosis without complications, a high-calorie, high-carbohydrate diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict fat, protein, or sodium.
A client with jaundice has poor appetite, nausea, and two episodes of emesis in the past 2 hours. The client reports having spasms in the stomach area. The client does not have pruritis. The nurse should develop a care plan for which symptom first? 1. nausea 2. poor appetite 3. jaundice 4. abdominal spasms
1. The nurse should first plan to relieve the nausea and vomiting. If these continue, the client is at risk for dehydration and electrolyte imbalance. The clients poor appetite is likely related to the underlying health problem and is not the priority. The nausea may adversely affect the appetite, and relieving the nausea may allow the client an opportunity to eat and drink. The client has jaundice but dose not have uncomfortable symptoms such as pruitis. The abdominal spasms may be related to nausea and vomiting and can be assessed again when the nausea and vomiting have stopped.
The nurse is developing an educational program about prostate cancer. The nurse should provide information about which topic? □ 1. The prostate-specific antigen (PSA) test is reliable for detecting the presence of prostate cancer. □ 2. For all men, age 50 and older, the American and Canadian Cancer Societies recommend an annual rectal examination. □ 3. Men over 50 should have a colonoscopy. □ 4. Regular sexual activity promotes health of the prostate gland to prevent cancer.
100. 2. Most cases of prostate cancer are adenocarcinomas. An adenocarcinoma is palpable on rectal examination because it arises from the posterior portion of the gland. Although the PSA is not a perfect screening test, the American Cancer Society and the Canadian Cancer Society recommend an annual rectal examination and blood PSA level for all men age 50 years and older, or starting at age 40 years if the client is of African descent, or if there is family history of prostate cancer. A colonoscopy is performed to diagnose colon cancer, not prostate cancer. Regular sexual activity does not prevent cancer of the prostate. CN: Health
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? □ 1. Have the UAP keep a steady pull on the client to promote forward ambulation. □ 2. Explain how to overcome a freezing gait by telling the client to march in place. □ 3. Assist the UAP with getting the client back in bed. □ 4. Give the client a muscle relaxant.
118. 2. Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep him or her on bed rest. A muscle relaxant is not indicated. CN: Management of care; CL: Synthesize
32. A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history, the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's wort for a "bit of depression," and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply. □ 1. Instruct the client that the wine with meals can be beneficial for cardiovascular health. □ 2. Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. □ 3. Instruct the client to increase the protein in his diet and eat less frequently. □ 4. Advise the client of the need for additional testing for HIV. □ 5. Encourage the client to obtain sufficient rest.
2, 4, 5. Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their HCPs before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than do those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue. CN: Physiologic adaptation; CL: Synthesize
Which symptom indicates that a client has developed a complication after a cystoscopy? □ 1. dizziness □ 2. chills □ 3. pink-tinged urine □ 4. bladder spasms
2. Chills could indicate the onset of acute infection that can progress to septic shock. Dizziness would not be an anticipated symptom after a cystoscopy. Pink-tinged urine and bladder spasms are common after cystoscopy. CN: Reduction of risk potential; CL: Analyze
When providing client teaching about continuous bladder irrigation following prostate surgery, what should the nurse tell the client? 1. The catheter is disconnected from the drainage tubing one time per shift to enable manual irrigation of the bladder. 2. The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder. 3. The fluid drips into the bladder at a slow rate to prevent the effects of overhydration and hyponatremia. 4. The catheter is clamped off approximately 4 hours after returning to the nursing unit.
2. Continuous bladder irrigation is performed when urinary surgery results in hematuria. It is accomplished using an indwelling foley catheter with three lumens. One port is for the balloon, a second port allows irrigant inflow, and a third port enables outflow. The purpose of the irrigation is to achieve clear outflow and to prevent clot formation within the bladder. Manual irrigation is used as an intermittent type of bladder irrigation and is not the same as CBI. CBI involves irrigation of the bladder, and is not an intravascular infusion. The rate is often initially fast to achieve a clear outflow. Stopping and clamping the irrigant inflow is done only under a doctors order and is typically not done until one day after the procedure.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.
2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.
Which health promotion activity should the nurse suggest that the client with cirrhosis add to the daily routine at home? □ 1. Supplement the diet with daily multivitamins. □ 2. Abstain from drinking alcohol. □ 3. Take a sleeping pill at bedtime. □ 4. Limit contact with other people whenever possible.
2. General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. It is not necessary to take multivitamins if the client is obtaining adequate nutrition. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people. CN: Health promotion and maintenance; CL: Synthesize
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? □ 1. Have a preference for foods high in salt. □ 2. Eat food on only half of the plate. □ 3. Forget the names of foods. □ 4. Be unable to swallow liquids.
2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
A client is undergoing a total prostatectomy for prostate cancer. The client asks questions about his sexual function. What should the nurse tell the client? "Loss of the prostate gland means that you will: □ 1. be impotent." □ 2. be infertile and there will be no ejaculation." □ 3. have no loss of sexual function and drive." □ 4. have erectile capability immediately after surgery."
2. Loss of the prostate gland interrupts the flow of semen, so there will be no ejaculation fluid. The sensations of orgasm remain intact. The client needs to be advised that return of erectile capability is often disrupted after surgery, but within 1 year, 95% of men have returned to normal erectile function with sexual intercourse. CN: Physiological adaptation; CL: Synthesize
A nurse assesses a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? SATA 1. Generalized seizures 2. Nuchal rigidity 3. Postive Brudzinski's sign 4. Postive Kernig's sign 5. Babinski's reflex 6. Photophobia
2. Nuchal rigidity 3. Postive Brudzinski's sign 4. Postive Kernig's sign 6. Photophobia
A client has prostatic hypertrophy. What should the nurse assess when conducting a focused assessment of the client's ability to urinate? □ 1. voiding at less frequent intervals □ 2. difficulty starting the flow of urine □ 3. painful urination □ 4. increased force of the urine stream
2. Signs and symptoms of prostatic hypertrophy include difficulty starting the flow of urine, urinary frequency and hesitancy, decreased force of the urine stream, interruptions in the urine stream when voiding, and nocturia. The prostate gland surrounds the urethra, and these symptoms are all attributed to obstruction of the urethra resulting from prostatic hypertrophy. Nocturia from incomplete emptying of the bladder is common. Straining and urine retention are usually the symptoms that prompt the client to seek care. Painful urination is generally not a symptom of prostatic hypertrophy. CN: Physiological adaptation; CL: Analyze
The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. What should the nurse tell the client? □ 1. "This drug is part of your chemotherapy program." □ 2. "This drug has been found to decrease metastatic breast cancer." □ 3. "This drug will act as an estrogen in your breast tissue." □ 4. "This drug will prevent hot flashes since you cannot take hormone replacement."
2. Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect. CN: Pharmacological and parenteral therapies; CL: Synthesize
Which is an initial sign of Parkinson's disease? □ 1. rigidity □ 2. tremor □ 3. bradykinesia □ 4. akinesia
2. The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.
What is a risk factor for women who have human papillomavirus (HPV)? □ 1. sterility □ 2. cervical cancer □ 3. uterine fibroid tumors □ 4. irregular menses
2. Women who have HPV are much more likely to develop cervical cancer than women who have never had the disease. Cervical cancer is now considered a sexually transmitted disease. Regular examinations, including Papanicolaou tests, are recommended to detect and treat cervical cancer at an early stage. Girls and women as well as boys and men (around ages 9 to 26 depending on the vaccine) should receive a vaccine to prevent HPV. HPV does not cause sterility, uterine fibroid tumors, or irregular menses. CN: Health
The nurse should monitor the client with acute pancreatitis for which complication? □ 1. heart failure □ 2. duodenal ulcer □ 3. cirrhosis □ 4. pneumonia
20. 4. The client with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis. CN: Reduction of risk potential; CL: Analyze Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 475). Wolters Kluwer Health. Kindle Edition.
A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? □ 1. Sit quietly with the client until the episode is over. □ 2. Ignore the behavior. □ 3. Attempt to divert the client's attention. □ 4. Tell the client that this behavior is unacceptable.
3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.
The nurse notices that a client with Parkinson's disease is frequently coughing when eating. Which intervention should the nurse consider? □ 1. Have the client hyperextend the neck when swallowing. □ 2. Tell the client to place the chin firmly against the chest when eating. □ 3. Thicken all liquids before offering to the client. □ 4. Place the client on a clear liquid diet.
3. Clients with Parkinson's disease can experience dysphagia. Thickening liquids assists with swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase risk of aspiration. Pressing the chin firmly on the chest makes swallowing more difficult. The chin should be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult for evaluation of the client's ability to swallow.
What is the expected outcome of thrombolytic drug therapy for stroke? □ 1. increased vascular permeability □ 2. vasoconstriction □ 3. dissolved emboli □ 4. prevention of hemorrhage
3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching? □ 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." □ 2. "It is safer for me to take acetaminophen for pain instead of aspirin." □ 3. "I should avoid constipation to decrease chances of bleeding." □ 4. "If I get enough rest and follow my diet, it's possible for my cirrhosis to be cured."
3. Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen, which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease. CN: Reduction of risk potential; CL: Evaluate
50. The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? □ 1. peripheral edema □ 2. ascites □ 3. anorexia □ 4. jaundice
3. Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats. Peripheral edema, ascites, and jaundice are later signs of liver failure and portal hypertension. CN: Physiological adaptation; CL: Analyze
The unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? □ 1. providing passive range-of-motion exercises to the left extremities during the bed bath □ 2. elevating the foot of the bed to reduce edema □ 3. pulling up the client under the left shoulder when getting the client out of bed to a chair □ 4. putting high top tennis shoes on the client after bathing
3. Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? □ 1. Ask what medications the client is taking. □ 2. Complete a history and health assessment. □ 3. Identify the time of onset of the stroke. □ 4. Determine if the client is scheduled for any surgical procedures.
3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
A client, who had a transurethral resection of the prostate (TURP), has a three-way indwelling urinary catheter with continuous bladder irrigation. In which circumstance should the nurse increase the flow rate of the continuous bladder irrigation? When drainage: □ 1. is continuous but slow. □ 2. appears cloudy and dark yellow. □ 3. becomes bright red. □ 4. of urine and irrigating solution stops.
3. The decision by the surgeon to insert a catheter after TURP or prostatectomy depends on the amount of bleeding that is expected after the procedure. During continuous bladder irrigation after a TURP or prostatectomy, the rate at which the solution enters the bladder should be increased when the drainage becomes brighter red. The color indicates the presence of blood. Increasing the flow of irrigating solution helps flush the catheter well so that clots do not plug it. There would be no reason to increase the flow rate when the return is continuous or when the return appears cloudy and dark yellow. Increasing the flow would be contraindicated when there is no return of urine and irrigating solution. CN: Pharmacological Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 544). Wolters Kluwer Health. Kindle Edition.
The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? □ 1. Ask the family to stay with the client. □ 2. Contact the health care provider, and request a prescription for soft wrist restraints. □ 3. Increase the frequency of client observation. □ 4. Administer a sedative.
3. The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.
A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one physician in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. 4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.
3. The tape and television are competing, even conflicting stimuli. Crime events portrayed on television could be misinterpreted as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely disturbing.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation? 1. Ensuring adequate fluid intake on the day of the test. 2. Preparing the client for the possibility of bladder spasms during the test. 3. Checking the client's history for allergy to iodine. 4. Determining when the client last had a bowel movement.
3.A client scheduled for an IVP should be assessed for allergies to iodine and shellfish. Clients with such allergies may be allergic to the IVP dye and be at risk for an anaphylactic reaction. Adequate fluid intake is important after the examination. Bladder spasms are not common during an IVP. Bowel preparation is important before an IVP to allow visualization of the ureters and bladder, but checking for allergies is most important.
What is the priority nursing intervention in the postictal phase of a seizure? □ 1. Reorient the client to time, person, and place. □ 2. Determine the client's level of sleepiness. □ 3. Assess the client's breathing pattern. □ 4. Position the client comfortably.
32. 3. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent. CN: Reduction of risk potential; CL: Synthesize Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 569). Wolters Kluwer Health. Kindle Edition.
What nursing assessments should be documented at the beginning of the ictal phase of a seizure? □ 1. heart rate, respirations, pulse oximeter, and blood pressure □ 2. last dose of anticonvulsant and circumstances at the time □ 3. type of visual, auditory, and olfactory aura the client experienced □ 4. movement of the head and eyes and muscle rigidity
34. 4. During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure. CN: Physiological adaptation; CL: Analyze Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 569). Wolters Kluwer Health. Kindle Edition.
The nurse should teach clients about which potential risk factor for the development of colon cancer? □ 1. chronic constipation □ 2. long-term use of laxatives □ 3. history of smoking □ 4. history of inflammatory bowel disease
4. A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 456). Wolters Kluwer Health. Kindle Edition.
A woman tells the nurse, "There has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer? □ 1. pain □ 2. leg edema □ 3. urinary and rectal symptoms □ 4. light bleeding or watery vaginal discharge
4. In its early stages, cancer of the cervix is usually asymptomatic, which underscores the importance of regular Pap smears. A light bleeding or serosanguineous discharge may be apparent as the first noticeable symptom. Pain, leg edema, urinary and rectal symptoms, and weight loss are late signs of cervical cancer. CN: Physiological adaptation; CL: Apply
The nurse is providing preoperative instructions to a client who is having a transurethral resection of the prostate. What should the nurse tell the client? □ 1. "You will have a central venous access inserted just prior to the procedure." □ 2. "Plan on being in the hospital anywhere from 5 to 7 days following the procedure." □ 3. "You will be taught care of the incision and suture line prior to your discharge home." □ 4. "Expect blood in your urine in the first couple of days following the procedure."
4. Transurethral resection of the prostate (TURP) is a common surgical procedure used to treat male clients with benign prostate enlargement. The surgery commonly results in blood from the surgery in the urine for the first few days, and the client should not be concerned; the urine will become clear within 2 to 3 days. Central venous access is not expected for this type of surgery. Peripheral IV access can be expected. Clients are instructed to anticipate hospitalization for 1 to 3 days. Because the procedure is performed transurethrally (via the urethra), there is no outward incision. CN: Physiological adaptation; CL: Synthesize Billings, Diane; Hensel, Desiree. Lippincott Q&A Review for NCLEX-RN (Lippincott's Review For NCLEX-RN) (p. 543). Wolters Kluwer Health. Kindle Edition.
After receiving a change-of-shift report at 0700, the nurse should assess which client first? □ 1. a 23-year-old with a migraine headache who has severe nausea associated with retching □ 2. a 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching □ 3. a 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast □ 4. a 63-year-old with multiple sclerosis who has an oral temperature of 101.8°F (38.8°C) and flank pain
4. Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon but do not have needs as urgent as this client.
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? □ 1. pulse □ 2. respirations □ 3. blood pressure □ 4. temperature
48. 3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure. CN: Reduction of risk potential; CL:
When teaching a client about ovarian cancer, the nurse should include which information in the teaching plan? Select all that apply. □ 1. details about the prognosis □ 2. staging and grading of ovarian cancer □ 3. need for routine colonoscopy beginning at age 30 □ 4. procedures for diagnosis if there is a pelvic mass □ 5. symptoms occurring early in the disease process
88. 2, 4. Client teaching emphasizes the importance of regular gynecologic examinations. If a pelvic mass is found, completely explain the procedures for diagnosis. Explain presurgical and postsurgical instructions, and explain the terminology particular to staging and grading of cancer, when appropriate. Refer all questions about the prognosis to the health care provider (HCP) . Routine colonoscopies are typically begun at age 50 unless family history warrants otherwise. Ovarian tumors are commonly occult until symptoms of advanced disease are present.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack).Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance
ANSWER: 1, 2,4 Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.----------------------------------------------Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that hemiparesis indicates weakness on one side of the body and focusing on the subject will direct you to the correct option. Also, noting the word complete in the question will assist you in answering correctly. Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that hemiparesis indicates weakness on one side of the body and focusing on the subject will direct you to the correct option. Also, noting the word complete in the question will assist you in answering correctly.
A 50-year-old patient is preparing to begin breast cancer treatment with tamoxifen (Nolvadex). What point should the nurse emphasize when teaching the patient about her new drug regimen? A. "You may find that your medication causes some breast sensitivity." B. "It's important that you let your care provider know about any changes in your vision." C. "You'll find that this drug often alleviates some of the symptoms that accompany menopause." D. "It's imperative that you abstain from drinking alcohol after you begin taking tamoxifen."
B. "It's important that you let your care provider know about any changes in your vision."Tamoxifen has the potential to cause cataracts and retinopathy. The drug is likely to exacerbate rather than alleviate perimenopausal symptoms. Breast tenderness is not associated with tamoxifen, and it is not necessary for the patient to abstain from alcohol.
A nurse educating a patient about cancer prevention teaches the patient that warning signs of cancer include which of the following? SATA A. Weight gain B. Migraine headaches C. Pain D. Nagging cough E. Unusual Bleeding or Discharge
C, D, E Warning signs of cancer include pain, nagging cough, and unusual bleeding or discharge. Weight loss is usually a sign of cancer, and headaches- not migraines- can be a sign of cancer.
After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of the disease and the treatment plan when the client makes which statement? □ 1. "I'll live longer, but ultimately the disease will cause death." □ 2. "My symptoms will be controlled, and eventually I will be cured." □ 3. "I'll be able to control the disease and enjoy a healthy lifestyle." □ 4. "I won't be so tired, but I can expect occasional periods of muscle weakness."
With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a normal lifestyle, and achieve a normal life expectancy. Myasthenia gravis can be controlled and need not be a fatal disease. Myasthenia gravis can be controlled, not cured. Episodes of increased muscle weakness should not occur if treatment is well managed.
The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which of the following? Select all that apply. a) Tachycardia. b) Thirst. c) Rapid respirations. d) Decreased urine output. e) Widening pulse pressure. f) Dry, flushed skin.
a, b, c, d Decreased urine output.• Tachycardia.• Rapid respirations.• Thirst.Explanation:The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to find are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and flushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.
When planning care for a client with myasthenia gravis, the nurse understands that the client is at the highest risk for which health problem? a. aspiration b. bladder dysfunction c. hypertension d. sensory loss
a. Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is not sensory deficit.
When caring for a client with bph, what should the nurse do? SATA a. provide privacy and time for the client to void b. monitor intake and output c. catheterize the client for postvoid residual urine d. ask the client if he has urinary retention e. test the urine for hematuria
a. b. d. e. Because of the hx of bph, the nurse should provide privacy and time for the client to void. The nurse should also monitor intake and output, assess the client for urinary retention, and test the client for urinary retention.
