Exam 3

The client scheduled to undergo minor surgery states, The physician will not give me pain medication after surgery because my surgery is only minor. What is the best response by the nurse?

1. You can experience pain after minor surgery, so you can have pain medication. Rationale 1: Clients can experience intense pain after minor surgery, so pain medication may be ordered.

After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. The nurse will monitor the client for the development of a problem associated with the delivery of

1. oxygenated blood to the body. Rationale 1: The mitral valve separates the left ventricle from the left atrium. Problems with this valve will impede the flow of oxygenated blood from the left atrium into the left ventricle for delivery to the body.

A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by

1. the registered nurse. Rationale 1: Because the client is on day 1 in recovery from abdominal surgery, the clients condition might not be stable enough to have unlicensed assistive personnel perform the skill.

The nurse is documenting the use of sequential compression devices in a clients medical record. What should be included in this documentation?

2. Skin integrity 3. Peripheral vascular status 4. Neurovascular status 5. Control unit settings Rationale 2: The nurse should document the clients skin integrity.Rationale 3: The nurse should document the clients peripheral vascular status. Rationale 4: The nurse should document the clients neurovascular status. Rationale 5: The nurse should document the control units settings.

The mother of a newborn tells the nurse, I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesnt breathe regularly, and she sometimes twitches. What advice should the nurse give this mother?

2. These are common behaviors in newborns and are normal. Rationale 2: These are indications of normal REM sleep in the newborn. The mother should be reassured that this is normal.

During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. The nurse documents this murmur as being

3. systolic. Rationale 3: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole.

A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take?

3. Have the client breathe through pursed lips. Rationale 3: The client should be taught to breathe out against pursed lips to increase the time it takes to exhale and to help keep airways open.

The client reports difficulty sleeping. Which environmental intervention should the nurse recommend?

3. Provide white noise with a fan. Rationale 3: Noise should be kept to a minimum. Extraneous noise can be blocked by white noise from a fan, air conditioner, or white noise machine.

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control?

3. Social interactions Rationale 3: Social interactions that are used as nonpharmacologic pain control methods include pet therapy.

The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure?

1. Amount, consistency, color, and odor of sputum 3. Lung sounds before the procedure 4. Lung sounds after the procedure 5. Oxygen saturation after the procedure Rationale 1: The nurse should document the amount, consistency, color, and odor of suctioned sputum. Rationale 3: The nurse should document the clients lung sounds before the procedure. Rationale 4: The nurse should document the clients lung sounds after the procedure. Rationale 5: The nurse should document the clients oxygen saturation after the procedure.

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure?

1. An occlusive dressing Rationale 1: Because this chest tube was put in without a purse-string suture, there is nothing to pull the tissue together once the tube is removed. In order to prevent leakage of air into the chest cavity, an occlusive dressing must be used.

The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard that taking an antacid with this medication will help decrease the incidence of upset stomach. What is the nurses best response?

1. Antacids reduce the absorption and therefore the effectiveness of the NSAID. Rationale 1: It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client?

1. Anxiety Rationale 1: The diagnosis of Anxiety would be appropriate for the client, as the client has past experiences of poor pain control and is anticipating pain.

The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client?

1. Apply suction for 510 seconds. Rationale 1: When conducting nasotracheal suctioning, the nurse should apply suction for 510 seconds.

The parents of a 6-month-old tell the nurse that they are exhausted because their baby wakes up several times every night. What advice should the nurse give these parents?

1. Be certain that the baby is truly awake before picking him up for feeding. Rationale 1: Babies often move and make noises while sleeping that do not indicate wakefulness. The parents should be certain the baby is awake before picking him up to feed, change, or comfort.

The nurse is collecting equipment to assess a clients ankle/brachial index (ABI). What equipment should be taken to the clients bedside?

1. Blood pressure cuff and a Doppler ultrasound device Rationale 1: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement.

Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the health care provider to question the order. What health problems did the client have that caused the nurse to question the medication order?

1. COPD 2. Asthma Rationale 1: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with COPD because they may constrict airways by blocking beta-2 adrenergic receptors. Rationale 2: Beta-adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs can negatively affect people with asthma because they may constrict airways by blocking beta-2 adrenergic receptors.

The nurse is determining a clients ability to transport oxygen from the lungs to body tissues. What factors will influence this ability?

1. Cardiac output 2. Exercise 4. Erythrocyte count 5. Hematocrit Rationale 1: Cardiac output is a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 2: Exercise is a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 4: Erythrocyte count is a factor that affects the rate of oxygen transport from the lungs to the tissues. Rationale 5: Hematocrit level is a factor that affects the rate of oxygen transport from the lungs to the tissues.

A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning?

1. Chronic fatigue 3. Pallor 4. Shortness of breath 5. Hypotension Rationale 1: A lack of red blood cells to transport oxygen to tissues can lead to chronic fatigue. Rationale 3: A lack of red blood cells within tissues can cause skin pallor.Rationale 4: A lack of red blood cells to transport oxygen to tissues can cause shortness of breath. Rationale 5: A lack of red blood cells to transport oxygen to tissues can cause hypotension.

The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment?

1. Decreased cough reflex 4. Dry mucous membranes 5. Increased risk of aspiration Rationale 1: The cough reflex decreases during aging. Rationale 4: Mucous membranes are drier with aging.Rationale 5: Increased risk of aspiration occurs in aging because of gastroesophageal reflux disease.

A client has not had uninterrupted sleep for several nights, and is irritable. What other assessment findings should the nurse associate with the clients lack of REM sleep?

1. Depression 2. Confusion 3. Disorientation 4. Impaired memory Rationale 1: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as depression. Rationale 2: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as confusion. Rationale 3: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as disorientation. Rationale 4: In a sleep-deprived client, the loss of REM sleep causes psychological disturbances such as impaired memory.

The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment?

1. Duration 2. Location 3. Intensity 4. Etiology Rationale 1: Pain may be described in terms of duration. Rationale 2: Pain may be described in terms of location. Rationale 3: Pain may be described in terms of intensity. Rationale 4: Pain may be described in terms of etiology

A client with diabetes asks the nurse why his blood glucose level is higher on days when he sleeps less. What should the nurse explain to the client?

1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels will remain elevated, impacting blood glucose. Rationale 1: The cortisol level falls during sleep. With waking, the cortisol level peaks. If the client with diabetes is not getting sufficient rest, the cortisol level will stay elevated, which will impact the control of blood glucose.

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision?

1. Is wide awake around 3 am 2. Takes a nap after lunch every day 4. Goes to sleep before 9 pm most evenings 5. Wakes up and looks at the clock every hour Rationale 1: A hallmark change with age is a tendency toward earlier wake times. Rationale 2: Many older adults report daytime napping, which may contribute to reduced nocturnal sleep. Rationale 4: A hallmark change with age is a tendency toward earlier bedtime. Rationale 5: Older adults may awaken an average of six times during the night.

The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment?

1. Lifestyle 2. Presence of cough 3. Sputum production 4. Pain Rationale 1: A comprehensive nursing history relevant to oxygenation status should include data about lifestyle. Rationale 2: A comprehensive nursing history relevant to oxygenation status should include data about the presence of a cough. Rationale 3: A comprehensive nursing history relevant to oxygenation status should include data about sputum production. Rationale 4: A comprehensive nursing history relevant to oxygenation status should include data about pain.

The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful?

1. Maintain a regular bedtime and wake-up time for all days of the week. Rationale 1: The best intervention is to have the client establish and maintain a regular bedtime and wake-up time for all days of the week.

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions?

1. Massage 2. Acupressure 4. Exercise 5. Nutritional supplements Rationale 1: Massage is a nonpharmacologic intervention that targets the body for pain control. Rationale 2: Acupressure is a nonpharmacologic intervention that targets the body for pain control. Rationale 4: Exercise is a nonpharmacologic intervention that targets the body for pain control. Rationale 5: Nutritional supplements are a nonpharmacologic intervention that target the body for pain control.

The nurse is caring for a client who is using morphine through patient-controlled analgesia (PCA). What medication should the nurse have readily available?

1. Naloxone hydrochloride (Narcan) Rationale 1: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid.

The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this clients sleep history?

1. No questions should be asked. Rationale 1: When the client is critically ill or being admitted for an outpatient procedure, sleep history can be omitted or deferred.

A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client?

1. Nortriptyline 2. Amitriptyline 5. Gabapentin Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 2: Amitriptyline a tricyclic antidepressant used as a coanalgesic to treat pain.Rationale 5: Gabapentin is an anticonvulsant used as a coanalgesic to treat pain.

The health care provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client?

1. Oxymorphone (Opana) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid) Rationale 1: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 3: Oxymorphone (Opana) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 4: Morphine sulfate (morphine) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate. Rationale 5: Hydromorphone hydrochloride (Dilaudid) is an opioid analgesic for severe pain. Because the client rated the pain as 9, which is severe, this medication is appropriate.

A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain?

1. Phantom limb pain Rationale 1: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone.

The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether

1. unlicensed assistive personnel know how to perform a back rub. 3. there any clients who should not have a back rub performed. 5. there any clients who do not want a back rub done by unlicensed assistive personnel. Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for the UAPs comfort and ability. Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications. Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate.

A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this clients respiratory function?

2. Conditions that affect transport. Rationale 2: Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the oxygen to all body tissues, and transports CO2 from the cells back to the lungs, where it can be exhaled from the body. Conditions that decrease cardiac output, such as congestive heart failure or hypovolemia, affect tissue oxygenation and also the bodys ability to compensate for hypoxemia.

The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication?

2. Drink 6 to 8 glasses of water per day. Rationale 2: Increasing fluid intake can help prevent constipation.

The nurse is working on a hospital committee tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful?

2. Establish a time at which radios and televisions should be turned off or down. 3. Discontinue use of the paging system after 2100. Rationale 2: Establishing a time at which radios and televisions should be turned off or down will reduce the amount of disturbance to clients. Rationale 3: Discontinuing use of the paging system at 2100 will also reduce noise.

A client is concerned about maintaining a healthy respiratory system. What should the nurse instruct the client to do to promote a healthy respiratory status?

2. Exercise regularly. 3. Do not smoke. 4. Breathe through the nose. Rationale 2: Client teaching to promote healthy breathing includes regular exercise.Rationale 3: Client teaching to promote healthy breathing includes not smoking.Rationale 4: Client teaching to promote healthy breathing includes breathing through the nose.

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

2. Filtration and humidification of inspired air Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse?

2. Have the client concentrate on slowing down respirations. Rationale 2: This client is hyperventilating and should be assisted to slow down respirations. Techniques to slow respirations include counting respirations or having the client match respirations with the nurse, who then slows down the respiratory rate.

The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint?

2. Hemoglobin and hematocrit Rationale 2: Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with client complaints of being tired, listless, and unable to tolerate normal activities.

The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon?

2. Hemoglobin and hematocrit Rationale 2: In order to exhibit cyanosis, the clients blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit.

A clients blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client?

2. Increased respiration rate Rationale 2: Of the three blood gaseshydrogen, oxygen, and carbon dioxidethat can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration.

The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent?

2. Limit or eliminate television. Rationale 2: Preschool children wake up frequently at night, and they might be afraid of the dark or experience night terrors or nightmares. Often, limiting or eliminating TV will reduce the number of nightmares.

The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity?

2. Not to apply suction during the insertion of the catheter Rationale 2: Oral suctioning using a Yankauer suction tube can be delegated to UAP, as this is not a sterile procedure. The nurse needs to review the procedure and important points, such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane.

The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to the UAP?

2. Only oral suctioning Rationale 2: The suctioning of the oral cavity is a nonsterile procedure and can be delegated to the UAP.

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurses next action?

2. Pad the tubing where it contacts the clients ears. Rationale 2: It is necessary to pad the cannula where it contacts the clients ears, as pressure irritation may occur.

The nurse has completed a back massage for a client. What should the nurse document about this procedure?

2. Position to perform the massage 5. Client response Rationale 2: The nurse should document the position in which the massage was performed on the client. Rationale 5: The nurse should document the clients response to the massage.

A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client?

2. Reassess the pain and consider another pain relief measure. Rationale 2: Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. In these circumstances, reassess the pain and consider other relief measures.

A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain?

2. Referred pain Rationale 2: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain.

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

2. Respiratory rate: 8 Rationale 2: A respiratory rate below 8 should be reported immediately.

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client?

2. Rub the knee of the non-casted leg. Rationale 2: The nurse can use contralateral stimulation, which is accomplished by stimulating the skin in an area opposite to the painful area, such as stimulating the left knee if the pain is in the right knee. The nurse should explain the rationale to the client in that nerves are crossed in the spinal cord, and that is why this technique works contralaterally.

A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens easily. What should the nurse suggest to help this client with sleep?

2. Smoke no cigarettes after the evening meal. Rationale 2: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than nonsmokers do. Smokers are usually easily aroused, and often describe themselves as light sleepers. When refraining from smoking after the evening meal, the person usually sleeps better.

What dietary teaching should the nurse provide to the client who has homocysteine elevation?

2. Take a B-complex vitamin supplement daily. Rationale 2: Supplementation with a vitamin that provides folate, vitamin B6, vitamin B12, and riboflavin can reduce homocysteine levels, although results can vary.

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?

2. The client with impairment of vagus nerve conduction Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.

An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication?

2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 5. The lack of pain control will affect mobility and activity tolerance. Rationale 2: If pain is not effectively controlled in the older client, the ability to sleep will be affected. Rationale 3: If pain is not effectively controlled in the older client, irritability can occur Rationale 5: If pain is not effectively controlled in the older client, mobility and activity tolerance will be. affected.

A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose?

2. To decrease afterload Rationale 2: The client likely has developed heart failure secondary to the hypertension, which is an increase in afterload. The nurse would anticipate giving medication to decrease afterload.

A client has been taking medication for back pain for several months, and has seen several different health care providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting

2. addiction. Rationale 2: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving.

The nurse is planning a time schedule for a clients twice-daily postural drainage. Which time schedule would be best?

3. 0700 and 2000 Rationale 3: Postural drainage should be scheduled to avoid hours shortly after meals because the treatment may induce vomiting and can be very tiring for the client. Of the options offered, the one that takes into consideration the meal schedule and is most widely distributed is 0700 and 2000.

The nurse seeing a client stop breathing realizes that there is how much time before the onset of permanent damage?

3. 4 to 6 minutes Rationale 3: After 4 to 6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage.

Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective?

3. A humidifier prevents my lungs from getting too dry. Rationale 3: The purposes of humidifiers are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration

The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. What action should the nurse take?

3. Accept the declination but tell the client to call if he changes his mind. Rationale 3: Some clients are eager to have a back rub, but others are not comfortable with the close physical contact this intervention requires. Respect the clients decision, but keep the offer open if he changes his mind.

After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client?

3. Administer an opioid for moderate pain. Rationale 3: If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate, then a step 2 regimen is appropriate. At the second step, an opioid for moderate pain or a combination of opioid and nonopioid medicine is provided with or without coanalgesic medications.

The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurses first action?

3. Assess pain using a scale of 1 to 10. Rationale 3: Assessment should always occur before implementation.

A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place?

3. Auscultate for bilateral breath sounds. Rationale 3: The end of the endotracheal tube should sit just above the bifurcation of the trachea into the two mainstem bronchi. If the tube is in the correct position, the nurse should be able to hear equal bilateral breath sounds.

The postmyocardial infarction client asks the nurse about return to exercise. What information should the nurse give this client?

3. Avoid exercise when the weather is hot or cold. Rationale 3: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart. Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the hearts workload.

The hospitalized client requests a bedtime snack. Which food should the nurse offer this client?

3. Cereal with milk Rationale 3: The nurse should offer the client a light carbohydrate (cereal) and milk.

The client is taking meperidine (Demerol) and experiencing pruritus. Which medication should the nurse expect the physician to order?

3. Diphenhydramine hydrochloride (Benadryl) Rationale 3: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

The 70-year-old client tells the nurse, I can go to sleep without a problem, but then I wake up in a couple of hours and cant go back to sleep. What nursing action would help promote rest and sleep in this client?

3. Evaluate if the client perceives sleeplessness to be a serious problem. Rationale 3: The first intervention is to determine what the pattern of sleeplessness means to the client. Many older clients will nap off and on through the day and night and spend wakeful times engaged in activity, even if the active times are not during traditional active hours.

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?

3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties Rationale 3: Because these ties are soiled, it is likely that they must be removed before new ties are attached. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem?

3. Have the child empty the bladder prior to going to bed. Rationale 3: Night terrors are partial awakenings that are sometimes related to excessive tiredness or a full bladder. Having the child empty the bladder before going to bed might be helpful.

A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health?

3. Have the client alternately flex and extend the feet several times a day. Rationale 3: Alternating flexion and extension of the feet will help keep clots from forming in the extremities. Active contraction and relaxation of the calf muscles is also used for this purpose.

The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurses greatest concern is that this client might develop which health problem?

3. Hypoxemia Rationale 3: Although injury to the heart muscle might affect any or all of the body systems, at this point the nurse is most concerned that the client will develop hypoxemia. The status of the respiratory system is closely linked to and dependent upon the cardiovascular system.

The client who has obstructive sleep apnea is being treated with a nasal continuous positive airway pressure (CPAP) device, but has just been prescribed modafinil (Provigil). What client statement indicates that teaching about these therapies has been effective?

3. I will continue using my CPAP machine at night. Rationale 3: Provigil is a medication that is for the treatment of narcolepsy, not sleep apnea. It will not prevent sleep apnea, so the client must continue to use the CPAP machine as it was used prior to the Provigil.

A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client?

3. If the medication is taken to treat pain, you will not become addicted to it. Rationale 3: Clients are unlikely to become addicted to an analgesic provided to treat pain.

A hospitalized client is being woken up every hour during the night for care and procedures. The nurse realizes that the lack of NREM sleep can have which physiological effect?

3. Increase susceptibility to infection Rationale 3: The loss of NREM sleep causes immunosuppression, slows tissue repair, lowers pain tolerance, triggers profound fatigue, and increases susceptibility to infection.

The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the physician?

3. Increased troponin Rationale 3: Of these options, the most important finding to discuss with the physician is the increase in troponin, which may help diagnose myocardial infarction.

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?

3. Ineffective Airway Clearance Rationale 3: The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is crackles in both lung bases.

From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time?

3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility Rationale 3: The diagnosis of Ineffective Health Maintenance would be applicable, as the client is experiencing chronic arthritic pain and is fatigued. Rationale 4: The diagnosis of Insomnia would be applicable, as the client is experiencing increased pain perception at night, affecting sleep. Rationale 5: The diagnosis of Impaired Physical Mobility would be applicable, as the client is experiencing arthritic pain in the hips and knees.

A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effects on the client?

3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects Rationale 3: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing toxicity. Rationale 4: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing side effects.

The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take?

3. Note this normal finding in the infants medical record. Rationale 3: An irregular heart rate of 140 is common and normal in an infant of this age. The finding should be recorded in the medical record.

The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching?

3. Obesity 4. Smoking 5. Hypertension Rationale 3: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include obesity. Rationale 4: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include smoking. Rationale 5: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include hypertension.

A client is complaining of having the same type of pain that he experienced prior to being diagnosed with cancer. The nurse realizes that which process will influence this clients perception of pain?

3. Perception Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows.

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement?

3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction. Rationale 3: The nurse should provide 2 to 3 breaths at 1.5 times the clients normal tidal volume prior to and after insertion of the suction catheter.

The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication?

3. Pulmonary embolism Rationale 3: The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development.

The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should the nurse use to administer the medication?

3. Rectal Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client?

3. Respiratory rate Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids.

A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this clients pain intensity?

3. Severe pain Rationale 3: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10.

A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain?

3. Somatic pain Rationale 3: Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain.

The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor?

3. The automaticity of cardiac cells Rationale 3: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. The most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

The nurse is working with a client to develop an expected outcome for the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this clients situation?

3. The client will report getting sufficient sleep to provide energy for daily activities. Rationale 3: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities.

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?

3. The nurse should view the sputum for quality and quantity. Rationale 3: There is no good rationale for having the client expectorate the sputum except for the nurse to view it for quality and quantity.

The nurse determines that UAP can apply sequential compression devices to a client when what is observed?

3. The tubing is not kinked. Rationale 3: The tubing should not be kinked.

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

3. Turn the clients head to the side.' Rationale 3: The nurse should turn the clients head to the side to allow drainage of oral secretions.

A client repeatedly asks the nurse How much longer until I can get more pain medication? Once the medication is provided, the client stops asking for it. The nurse identifies the clients behavior as being

3. pseudoaddiction. Rationale 3: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might clock watch, and might display other inappropriate drug-seeking behaviors. To differentiate between pseudoaddiction and addiction, if the clients negative behavior resolves when the pain is treated effectively, the client is exhibiting pseudoaddiction.

A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to

3. remove irritants from the trachea or bronchi. Rationale 3: The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus that traps pathogens and microscopic particulate matter. These foreign particles are then swept upward toward the larynx and throat by cilia. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi.

A client is working two jobs, caring for aged parents, and maintaining a household for the family. The nurse realizes that this emotional stress will have what impact on the clients sleep?

4. Less deep sleep and more awakenings during the night Rationale 4: Stress is considered by most sleep experts to be the number one cause of short-term sleeping difficulties. A person preoccupied with personal problems might be unable to relax sufficiently to get to sleep. Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings.

The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client?

4. Lower blood pressure 5. Lower heart rate Rationale 4: One physiological change that occurs during sleep is a drop in arterial blood pressure. Rationale 5: One physiological change that occurs during sleep is a decrease in heart rate.

The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client?

4. Presence of a productive cough Rationale 4: Expectorants break up mucus, making it more liquid and easier to cough out.

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage?

4. Prone 5. Side-lying Rationale 4: The prone position is recommended for a back rub. Rationale 5: The side-lying position can be used if a client cannot assume the prone position for a back rub.

A clients pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time?

4. Provide opioid analgesic as prescribed. Rationale 4: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If a client reports severe pain, a more potent pain relief measure is indicated.

The nurse is planning morning care for a client who has sequential compression devices in place. How should the nurse instruct the UAP who will be giving the bath?

4. Put the devices on as quickly as possible after the bath. Rationale 4: The nurse should remind the UAP that the devices are being used to support circulation and should be off the client for as short a period of time as possible. The UAP who knows the correct removal and application process may remove and apply these devices.

The client who has sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

4. Risk for Injury related to somnambulism Rationale 4: The priority is Risk for Injury related to somnambulism because it reflects the most dangerous situation for the client.

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?

4. Tape the tracheostomy obturator to the head of the bed. Rationale 4: The obturator should be taped to the head of the bed so that it will be readily available if the client tracheostomy tube should become dislodged.

The client is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to the client?

4. The client reports a decrease in morning headache. Rationale 4: The fact that the client experiences a decrease in morning headache indicates the client is sleeping better

The 50-year-old who is postmenopausal asks the nurse about the use of estrogen replacement therapy to protect the heart. How should the nurse respond?

4. The use of estrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks. Rationale 4: There is some concern about the risk of administering this therapy and the development of other health problems such as cancers. The choice to use this therapy should be made only after careful consideration of these benefits and risks.

The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the clients potential to develop

4. stroke. Rationale 4: Transient ischemic attacks may result from atherosclerosis of the cerebral vessels. Continued development of this atherosclerosis may result in stroke.

A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing

4. the gate control theory of pain. Rationale 4: In the gate control theory, signals of noxious stimuli are carried to the dorsal horn, where they are modified according to the balance of the substantia gelatinosa. By using ice, the substantia gelatinosa is calmed, reducing the pain.

After an assessment, the nurse determines that a clients sequential compression devices need to be removed. What should the nurse document about this clients status in the medical record?

2. Client complains of numbness, tingling, and leg pain with the sequential compression devices. Rationale 2: The nurse should remove the devices if the client complains of numbness, tingling, or leg pain.

The nurse who is assessing a clients chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?

2. Collaborate with the clients physician. Rationale 2: Subcutaneous emphysema, which is air in the subcutaneous tissues, can result from a poor seal at the chest tube insertion site. The nurse should collaborate with the clients physician regarding this finding.

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a clients medical record. What should this documentation include?

.1. Lung sounds before and after suctioning 2. Characteristics of suctioned sputum 3. Integrity of the skin around the stoma 5. Flow rate of oxygen Rationale 1: The nurse should document lung sounds before and after suctioning.Rationale 2: The nurse should document the characteristics of the suctioned sputum.Rationale 3: The nurse should document the integrity of the skin around the stoma.Rationale 4: The nurse does not need to document the side on which the tracheostomy tie knot is located. Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time?

1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) Rationale 1: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as acetaminophen (Tylenol). Rationale 2: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as ibuprofen (Motrin). Rationale 3: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as naproxen (Naprosyn).

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion?

1. Enrolled in online classes 2. Raising two children ages 4 and 8 3. Experiences chronic pain from sciatica 5. Works one job steady night turn and another part-time late afternoon Rationale 1: The National Sleep Foundation reports that certain adults, such as students, are vulnerable for not getting enough sleep. Rationale 2: A womans sleep pattern is more commonly affected by the birth of a child. However, both parents of infants and young children experience fatigue related to interrupted sleep or sleep deprivation. Rationale 3: The National Sleep Foundation reports that certain adults, such as those experiencing chronic pain, are vulnerable for not getting enough sleep. Rationale 5: The National Sleep Foundation reports that certain adults, such as shift workers, are vulnerable for not getting enough sleep. Adults working long hours or multiple jobs may find their sleep less refreshing.

The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant?

1. FLACC scale Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old.

The client has been prescribed zolpidem (Ambien) for the short-term management of insomnia. What information should the nurse include when teaching the client about this medication?

1. For best results, take the medication just prior to bedtime. Rationale 1: Zolpidem (Ambien) has a rapid onset of action, so for best results and decreased sedation while awake, the client should take the medication just prior to bedtime.

The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication?

1. Gastrointestinal (GI) distress Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion.

The client reports difficulty sleeping and awakening several times during the night. What intervention should the nurse recommend for the client when unable to sleep?

1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy. Rationale 1: The bed should be used only for sleep or sexual activity, so it is associated with sleep. The client should get up, go into a different room, and pursue some relaxing activity until drowsiness returns.

A client complains of not being able to stay awake during the day even after sleeping throughout the night. What should the nurse suggestion to this client?

1. Go to your physician for a physical examination. Rationale 1: Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances. The nurse should suggest that the client be evaluated by a physician.

A client tells the nurse about having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem?

1. How often does this happen? 2. How much coffee do you drink each day? 3. How do you feel when you wake up in the morning? 5. What have you done to deal with this sleeping problem? Rationale 1: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How often does this happen? Rationale 2: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How much coffee do you drink each day? Rationale 3: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How do you feel when you wake up in the morning? Rationale 5: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include What have you done to deal with this sleeping problem?

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate that this client needs further instruction?

1. I will replace my cotton blankets with polyester ones. Rationale 1: Polyester blankets and fabrics tend to produce static electricity, which can cause sparks and can cause oxygen-saturated fabrics to burn more readily.

A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep?

1. Illness Rationale 1: The need to urinate during the night disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep.

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?

1. Increased hematocrit Rationale 1: Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the bodys attempt to increase oxygen-carrying capacity by increasing erythrocyte production.

A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?

1. Ineffective Tissue Perfusion Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level.

The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this clients plan of care?

1. Insert an oropharyngeal airway. 2. Provide nasal care every 2 to 4 hours. 3. Provide oral hygiene every 2 to 4 hours. 5. Move the tube to opposite sides of the mouth every 8 hours. Rationale 1: For an oral endotracheal tube, use an oropharyngeal airway to prevent the client from biting down on the oral endotracheal tube. Rationale 2: For an oral endotracheal tube, provide nasal care every 2 to 4 hours. Rationale 3: For an oral endotracheal tube, provide oral hygiene every 2 to 4 hours. Rationale 5: For an oral endotracheal tube, move the tube to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa.

A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?

4. Kussmauls Rationale 4: Kussmauls respirations are a type of hyperventilation that accompanies metabolic acidosis. They represent the bodys attempt to compensate for the acidosis by blowing off carbon dioxide.

The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices?

1. Place in the dorsal recumbent or semi-Fowlers position. 2. Place a sleeve under each leg with the opening at the knee. 3. Wrap the sleeve securely around the leg, securing the Velcro tabs. 5. Connect the sleeves to the control unit and adjust the pressure as needed. 4. Turn on the control unit and adjust the alarms and pressures as needed. Rationale 1: When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowlers position. Rationale 2: The second step is to place a sleeve under each leg with the opening at the knee. Rationale 3: The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs. Rationale 4: The fifth step is to turn on the control unit and adjust the alarms and pressures as needed. Rationale 5: The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed.

The nurse is completing the admission assessment on a client who has obstructive sleep apnea. Which findings should the nurse expect when assessing this client?

1. Reddened uvula 2. Large soft palate 3. Obesity Rationale 1: Clients with obstructive sleep apnea are likely to have a reddened uvula. Rationale 2: Clients with obstructive sleep apnea are likely to have an enlarged soft palate. Rationale 3: Clients with obstructive sleep apnea are likely to be obese.

An older client is prescribed diazepam (Valium). What should the nurse monitor in this client?

1. Respirations Rationale 1: Medications such as diazepam (Valium) can decrease the rate and depth of respirations. Older clients are at high risk of respiratory depression. The nurse must carefully monitor respiratory status in this client.

The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client?

1. Talk with the client about pain. 2. Provide privacy .3. Present choices for dealing with pain. 4. Encourage distraction with music or television. Rationale 1: Nursing interventions to assist with pain management for an adolescent client include talking with the client about the pain. Rationale 2: Nursing interventions to assist with pain management for an adolescent client include providing privacy. Rationale 3: Nursing interventions to assist with pain management for an adolescent client include presenting choices for dealing with the pain.Rationale 4: Nursing interventions to assist with pain management for an adolescent client include encouraging distraction with music or television.

A client experiencing pain after surgery says Something must be wrong because the pain is so severe. What is the best response for the nurse to make to the client?

1. The amount of tissue disrupted from the surgery is not related to the degree of pain you feel. Rationale 1: Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. The amount of tissue damaged or disrupted is not related to the amount of pain experienced.

A client asks why sequential compression devices have been prescribed. How should the nurse respond to the client?

1. They stimulate the blood return that would occur with walking. Rationale 1: Sequential compression devices simulate the blood flow that results from walking.

A client is diagnosed with chronic low back pain syndrome. The nurse realizes that which analgesic delivery route might be beneficial for this client?

1. Topical Rationale 1: Topical medications work directly at the point of application on the body. They are useful for painful procedures such as lumbar punctures or bone marrow biopsies, or for injections. These products can also offer effective pain relief for chronic pain syndromes such as low back pain.

A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process?

1. Transduction Rationale 1: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane.

A client complains of difficulty breathing. What will the nurse most likely assess in this client?

1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth Rationale 1: Use of accessory muscles is an assessment finding associated with difficulty breathing. Rationale 2: Increased respiratory depth is an assessment finding associated with difficulty breathing. Rationale 3: Increased respiratory rate is an assessment finding associated with difficulty breathing. ationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present in conditions such as asthma. Respiratory rate is generally increased.

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint?

1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth Rationale 1: Use of accessory muscles often is an assessment finding indicating difficulty breathing. Rationale 2: Depth is often assessed when determining difficulty breathing. The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present. Rationale 3: Rate is assessed when determining difficulty breathing. Rate is generally increased. Rationale 4: The depth of respirations can be deeper (tidal volume greater than 500 mL of air) or more shallow if partial obstruction is present.

A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in

1. Ventilation. Rationale 1: Atelectasis affects lung compliance, which is a condition that needs to be present for adequate ventilation.

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the clients pain was influenced by which type of distraction?

1. Visual Rationale 1: Visual distraction includes watching television.

The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this childs blood pressure?

1. Yes, blood pressure is measured for all children over the age of 3 years. Rationale 1: Blood pressure measurements should be included for all children over the age of 3 years.

The nurse is preparing to massage a clients back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage.

2, 5, 4, 6,1, 3 To perform a back massage, the nurse should: (1) pour a small amount of lotion into the palms of the hands and hold for a minute to warm; (2) with the palms, begin in the sacral area using smooth, circular strokes; (3) move the hands up the center of the back; (4) move the hands to the scapulae and massage this region using circular strokes; (5) move the hands down the sides of the back; and (6) massage the areas over the right and left iliac crests.

The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication?

2. 4 hours Rationale 2: The duration of action for most opiates is 4 hours.

A client tells the nurse that because of work and life responsibilities, sleep has become optional. What is the best response the nurse should make to this client?

2. A lack of sleep can affect hormone levels and bodily functions. Rationale 2: Different biological functions occur during sleep that become altered with the lack of sleep. The nurse should explain what is affected by a lack of sleep.

A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control?

2. Address the clients fear of pain with walking. Rationale 2: Nurses can use the gate control theory to stop nociceptor firing by applying topical therapies and addressing the clients mood to reduce fear and anxiety.

The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client?

2. Apply tape over all injection ports on the tubing. 4. Label the tubing, infusion bag, and pump with the word epidural. 5. Post a sign above the clients bed indicating that an epidural is being used. Rationale 2: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter. Rationale 4: Label the tubing, the infusion bag, and the front of the pump with tape marked epidural to prevent confusion with similar-looking IV lines Rationale 5: Post a sign above the clients bed indicating that an epidural is in place.

A client questions why a medication that is used to treat Parkinsons disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do?

2. Assure the client that medications used to treat Parkinsons disease are also used to treat PLMD. Rationale 2: Medications that are commonly prescribed for the treatment of Parkinsons disease are also prescribed for the treatment of PLMD.

The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which intervention should the nurse include in this plan of care?

2. Be certain the client has the prescription for modafinil (Provigil) filled. Rationale 2: The medication modafinil (Provigil) is prescribed to control the daytime drowsiness associated with narcolepsy.

The nurse finds a client pulseless and breathless. The clients skin is pale and cool, but not cyanotic. Because of this finding, what should the nurse suspect?

2. Cardiac arrest occurred prior to respiratory arrest. Rationale 2: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest.

The nurse notes a widely bizarre pattern on the clients cardiac monitor. What is the nurses priority action?

2. Check the clients pulse. Rationale 2: The nurse should always remember to verify any changes on the cardiac monitor by assessing the client (in this case, checking the pulse). The cardiac monitor reports electrical activity that may not directly reflect the mechanical activity occurring in the heart.

A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing?

4. Acute pain Rationale 4: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the clients degree of effective gas exchange?

4. Arterial blood gas Rationale 4: Blood for partial pressures or blood gases is usually obtained from arterial blood.

A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should take which action?

4. Avoid hyperventilation and increase the oxygen to 100% for several breaths. Rationale 4: The nurse should avoid hyperventilation and should increase the oxygen to 100% for several breaths prior to initiating suction. Hyperventilating a client who has copious secretions can force the secretions deeper into the respiratory tract.

A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?

4. Both medications have the possible side effect of increased heart rate. Rationale 4: Both of these medications have the possible side effect of increased heart rate.

A client with a terminal illness without an advance directive stops breathing, and does not have a heartbeat. What should the nurse do?

4. Call a code. Rationale 4: If there is no do-not-resuscitate order, all clients who arrest will have resuscitation efforts begun.

A clients blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations?

4. Carotid bodies Rationale 4: Special neural receptors sensitive to decreases in O2 concentration are located outside the central nervous system in the carotid bodies, just above the bifurcation of the common carotid arteries, and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation.

During tracheal suctioning, the nurse notes that the client heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?

4. Complete the suction episode as quickly as possible. Rationale 4: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible.

A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client?

4. Decreased cardiac output Rationale 4: Cardiac output equals stroke volume x heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. At the rate of 170, the compensatory increase in heart rate is no longer helpful in increasing cardiac output. This leads to a decrease in cardiac output.

The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition?

4. Decreased hair on the legs Rationale 4: When peripheral arterial blood flow is reduced, the amount of oxygen to support hair growth is decreased and there is a reduction of hair distribution on the legs.

The nurse, seeing a client asleep, turns off the television in the room. The client opens her eyes and says I was watching that. I wasnt sleeping. The nurse realizes that the client was demonstrating which stage of NREM sleep?

4. I Rationale 4: Stage I is the stage of very light sleep, and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened, and might deny that she was sleeping.

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse?

4. Increase the liter flow of oxygen being delivered. Rationale 4: To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen.