exam 5 review questions

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? A. "A tanning bed will supply the ultraviolet light I need." B. "Medicine can prevent the growth of new skin cells." C. "I can never be cured." D. "Stress can cause my flare-ups."

A "A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching.Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? A) "Use pain medication as prescribed to control pain." B) "Clean the pin site when any drainage is noticed." C) "Wear the same clothing that is normally worn." D) "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

A ; The client should be taught the correct use of prescribed pain medication to control pain adequately. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? A) Assess that the cast is dry. B) Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. C) Check the fit of the cast by inserting a tongue blade between the cast and the skin. D) Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

A;

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a.Client admitted from a nursing home with furuncles and folliculitis b.Client with a leg cut and other trauma from a motorcycle crash c.Client with a rash noticed after participating in sporting events d.Client transferred from intensive care with an elevated white blood cell count

A; The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a.Place the client in a single room. b.Administer an antihistamine. c.Assess the client's airway. d.Apply gloves to minimize friction.

A; The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? A. "Avoid sun exposure between 11 a.m. and 3 p.m." B. "Examine your skin quarterly for possible cancerous or precancerous lesions." C. "Keep a total body spot and lesion map." D. "If you feel you must tan, use a tanning bed."

A; "Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time.Skin should be examined at least monthly. A total body spot and lesion map is used for secondary prevention. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching? A. "I may stop using the topical antibiotic when the lesions disappear." B. "I will remove crusts with soap and water before applying the medication." C. "I should contact my provider if I develop a fever or if the lesions spread. D. "I should cover the lesions if necessary to limit exposure to other people."

A; "I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved.Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others.

An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

A; All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.

A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Don't go to fireworks displays. d. Use a soft cotton swab to clean ears.

A; Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the client's fingertip should be placed in the ear canal.

A client has an odorous, purulent wound. How does the nurse best support this client? A. Changes the dressing frequently B. Encourages a diet high in protein C. Suggests whirlpool therapy D. Places room deodorizers in the room

A; Changes the dressing frequently The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client.A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my ears."

A; Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? a. Immediately report headache or stiff neck. b. Keep all follow-up appointments. c. Take the antibiotics with a full glass of water. d. Take the antibiotic on an empty stomach.

A; Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

The client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response? A. "Contact the Guillain-Barré Foundation International for resources." B. "Try inviting several people over so the client won't have to go out." C. "Let your spouse stay alone. Your spouse will get used to it." D. "This behavior is normal."

A; The Guillain-Barré Foundation International (www.gbsi.com) provides resources and information for clients and their families. The client and family should be referred to self-help and support groups for clients with chronic illness, if indicated.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? A) Observation of a large amount of serosanguineous or bloody drainage B) Mild to moderate pain controlled with prescribed analgesics C) Absence of erythema and tenderness at the surgical site D) Ability to flex and extend the right knee

A; A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client should be able to flex and extend the right knee (limb) after surgery.

The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction? A. "I should call 911 if a sudden increase in weakness occurs." B. "I should increase the dose if a sudden increase in weakness occurs." C. "The medication should be taken with a large meal." D. "The medication should be taken on an empty stomach."

A; A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member should call 911 for emergency assistance.

The nurse encourages the ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A. Blinking for "yes" or "no" B. Moving lips to speak C. Using sign language D. Using a laptop to write

A; A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate.

When caring for a client with nephrotic syndrome, which intervention should be included in the plan of care? A. Administering angiotensin-converting enzyme (ACE) inhibitors to decrease protein loss B. Administering heparin to prevent deep vein thrombosis (DVT) C. Providing antibiotics to decrease infection D. Providing transfusion of clotting factors

A; ACE inhibitors can decrease protein loss in the urine. Heparin is administered for DVT, but in nephrotic syndrome it may reduce urine protein and kidney insufficiency. Glomerulonephritis may occur secondary to an infection, but it is an inflammatory process; antibiotics are not indicated for nephrotic syndrome. Clotting factors are not indicated unless bleeding and coagulopathy are present.

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Prostate acid phosphatase (PAP) d. C-reactive protein (CRP)

A; AFP is a glycoprotein that is elevated in testicular cancer. PSA and PAP testing is used in the screening of prostate cancer. CRP is diagnostic for inflammatory conditions.

The client is being evaluated for signs associated with myasthenia crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A. Abdominal cramps, blurred vision, facial muscle twitching B. Bowel and bladder incontinence, pallor, cyanosis C. Increased pulse, anoxia, decreased urine output D. Restlessness, increased salivation and tearing, dyspnea

A; Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs.

The client is admitted with trigeminal neuralgia for a percutaneous sterotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A. Administers pain medication as requested B. Ensures that the client is nothing by mouth (NPO) C. Ensures that the preoperative laboratory work is complete D. Performs a preoperative assessment

A; Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia.

A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important? a. Avoid reading, writing, or close work such as sewing. b. Dim the lights in your house for at least a week. c. Keep the follow-up appointment with the ophthalmologist. d. Remove your eye patch every hour for eyedrops.

A; After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

A; Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

When taking the health history of a client with acute glomerulonephritis (GN), the nurse questions the client about which related cause of the problem? A. Recent respiratory infection B. Hypertension C. Unexplained weight loss D. Neoplastic disease

A; An infection often occurs before the kidney manifestations of acute GN. The onset of symptoms is about 10 days from the time of infection. Hypertension is a result of glomerulonephritis, not a cause. Weight gain, not weight loss, is symptomatic of fluid retention in GN. Cancers are not part of the cause of GN.

A clients chart indicates anisocoria. For what should the nurse assess? a. Difference in pupil size b. Draining infection c. Recent eye trauma d. Tumor of the eyelid

A; Anisocoria is a noticeable difference in the size of a persons pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care? a. Chronic use of sleeping pills b. Impaired near vision c. Slightly shaking hands d. Use of contact lenses

A; Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. This client might need someone else to instill the eyedrops hourly. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? A. Avoiding or reducing skin exposure to sunlight B. Avoiding tanning beds C. Being aware of skin markings and performing skin self-examination D. Wearing SPF 40 sunscreen

A; Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily.Avoiding tanning beds is significant, but is not the most important technique. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? A. Magnetic resonance imaging (MRI) B. Ophthalmoscopy C. Radioisotope scanning D. Snellen chart

A; Because the client has metal in the eye, MRI is an absolute contraindication.Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A) Keep the client's heels off the bed at all times. Correct B) Re-position the client every 3 to 4 hours. C) Administer preventive pain medication before deep-breathing exercises. D) Prohibit the use of antiembolic stockings.

A; Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Re-positioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.

The nurse is caring for a client who has just returned to the surgical unit after a radical nephrectomy. Which assessment information alarms the nurse? A. Blood pressure is 98/56 mm Hg; heart rate is 118 beats/min. B. Urine output over the past hour was 80 mL. C. Pain is at a level 4 (on a 0-to-10 scale). D. Dressing has a 1-cm area of bleeding.

A; Bleeding is a complication of radical nephrectomy; tachycardia and hypotension may indicate impending hypovolemic or hemorrhagic shock. The surgeon should be notified immediately and fluids should be administered, complete blood count should be checked, and blood administered, if necessary. A urine output of 80 mL can be considered normal. The nurse can administer pain medication, but must address hemodynamic instability and possible hemorrhage first. Administering pain medication to a client who has developed shock will exacerbate hypotension. A dressing with a 1-cm area of bleeding is expected postoperatively. The nurse is performing discharge teaching for a client after a nephrectomy for renal cell carcinoma.

The nursing instructor asks the nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A. "Choking, coughing, or eructation may occur in both disorders." B. "Both are disorders of the autonomic nervous system." C. "Facial twitching occurs in both disorders." D. "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."

A; Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects swallowing, chewing, and biting.

Which statement by the nursing student illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. The client's respiratory status and muscle function are affected by both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases exhibit exacerbations and remissions of their signs and symptoms. D. Demyelination of neurons is a cause of both diseases.

A; Both GBS and MG affect respiratory status and muscle function.

Which condition may predispose a client to chronic pyelonephritis? A. Spinal cord injury B. Cardiomyopathy C. Hepatic failure D. Glomerulonephritis

A; Chronic pyelonephritis occurs with spinal cord injury, bladder tumor, prostate enlargement, or urinary tract stones. Weakness of the heart muscle may cause kidney impairment, not an infection. Pyelonephritis may damage the kidney, not the liver. Glomerulonephritis may result from infection, but may not cause infection of the kidney.

The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction? a. I always lose my sunglasses, so I dont wear them. b. I have diabetes and get an annual eye exam. c. I will not share my contact solution with others. d. I will wear safety glasses when I mow the lawn.

A; Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.

A; Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Cloudy urine b. Urinary hesitancy c. Post-void dribbling d. Weak urinary stream

A; Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

The school nurse is counseling a teenage student about how to prevent kidney trauma. Which statement by the student indicates a need for further teaching? A. "I can't play any type of contact sports because my brother had kidney cancer." B. "I avoid riding motorcycles." C. "I always wear pads when playing football." D. "I always wear a seat belt in the car."

A; Contact sports and high-risk activities should be avoided if a person has only one kidney. A family history of kidney cancer does not prohibit this type of activity. To prevent kidney and genitourinary trauma, caution should be taken when riding bicycles and motorcycles. People should wear appropriate protective clothing when participating in contact sports. Anyone riding in a car should wear a seat belt.

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

A; Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important? a. Avoid large crowds and people who are ill. b. Check blood sugars four times a day. c. Use two forms of contraception. d. Wear properly fitting socks and shoes.

A; Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 liters of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."

A; Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss d. Mucositis

A; Doxorubicin (Adriamycin) can cause cardiac problems with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens. DIF: Applying/Application REF: 1477

The nurse reads on a clients chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? a. Bulging eyes b. Drooping eyelids c. Sunken-in eyes d. Yellow sclera

A; Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding? a. This condition will become malignant over time. b. I should refrain from using hormone replacement therapy. c. One cup of coffee in the morning should be enough for me. d. This condition makes it more difficult to examine my breast

A; Fibrocystic breast condition does not increase a womans chance of developing breast cancer. Hormone replacement therapy is not indicated since the additional estrogen may aggravate the condition. Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The client's urine specific gravity is 1.048. c. No blood is observed in the client's urine. d. The client's blood pressure is 152/88 mm Hg.

A; Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. Because eye pressure was too high, the tissue died. b. Glaucoma always leads to permanent blindness. c. The traumatic damage to your eye was too great. d. The infection occurs so quickly it cant be treated.

A; Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? A. Hyperbaric oxygen B. Nutrition therapy C. Topical growth factors D. Vacuum-assisted wound closure

A; Hyperbaric oxygen Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

A client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the nurse's best response? A. "Because the kidneys cannot get rid of fluid, blood pressure goes up." B. "The damaged kidneys no longer release a hormone that prevents high blood pressure." C. "The waste products in the blood interfere with other mechanisms that control blood pressure." D. "This is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products."

A; In chronic kidney disease, fluid levels increase in the circulatory system. The statements asserting that damaged kidneys no longer release a hormone to prevent high blood pressure, waste products in the blood interfere with other mechanisms controlling blood pressure, and high blood pressure is a compensatory mechanism that increases blood flow through the kidneys in attempt excrete waste products are not accurate regarding the relationship between chronic kidney disease and high blood pressure.

An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

A; In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a. The treatment reduces testosterone and prevents bone fractures. b. The medications prevent erectile dysfunction and increase libido. c. There is less gynecomastia and osteoporosis with this drug regimen. d. These medications both inhibit tumor progression by blocking androgens.

A; Lupron, an LH-RH agonist, stimulates the pituitary gland to release luteinizing hormone (LH) to the point that the gland is depleted of LH and testosterone production is lessened. This may decrease the prostate cancer since it is hormone dependent. Lupron can cause osteoporosis, which results in the need for Aredia to prevent bone loss. Erectile dysfunction, decreased libido, and gynecomastia are side effects of the LH-RH medications. Antiandrogen drugs inhibit tumor progression by blocking androgens at the site of the prostate.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? a. "MG is an autoimmune problem in which nerves do not cause muscles to contract." b. "MG is an inherited destruction of peripheral nerve endings and junctions." c. "MG consists of trauma-induced paralysis of specific cranial nerves." d. "MG is a viral infection of the dorsal root of sensory nerve fibers."

A; MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? A) Talking with an amputee close to the client's age who has had the same type of amputation B) Drawing a picture of how the client sees him- or herself C) Talking with a psychiatrist about the amputation D) Engaging in diversional activities to avoid focusing on the amputation

A; Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist should not be necessary. Diversional activities do not help the client deal with loss of the limb.

A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care? a. "I can scratch with a coat hanger." b. "I should feel my fingers for warmth." c. "I will keep the cast clean and dry." d. "I will return to have the cast removed."

A; Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.

When caring for a client with polycystic kidney disease, which goal is most important? A. Preventing progression of the disease B. Performing genetic testing C. Assessing for related causes D. Consulting with the dialysis unit

A; Preventing complications and progression of the disease is the goal. Genetic testing should be done, but this is not a priority. Assessment for related causes is an intervention, not a goal. Not all clients with polycystic kidney disease require dialysis.

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L Total calcium 12 mg/dL Hematocrit 39% Hemoglobin 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase and calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit and hemoglobin are decreased, indicating anemia. d. The elevated hematocrit and hemoglobin indicate dehydration.

A; The alkaline phosphatase (normal value 30 to 120 U/L) and total calcium (normal value 9 to 10.5 mg/dL) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females. DIF: Applying/Application REF: 1470

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."

A; The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

When caring for a client 24 hours after a nephrectomy, the nurse notes that the client's abdomen is distended. Which action does the nurse perform next? A. Check vital signs. B. Notify the surgeon. C. Continue to monitor. D. Insert a nasogastric (NG) tube.

A; The client's abdomen may be distended from bleeding; hemorrhage or adrenal insufficiency causes hypotension, so vital signs should be taken to see if a change in blood pressure has occurred. The surgeon should be notified after vital signs are assessed. An NG tube is not indicated for this client.

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? a. I am glad that these tubes will fall out at home when I finally shower. b. I should measure the drainage each day to make sure it is less than an ounce. c. I should be careful how I lie in bed so that I will not kink the tubing. d. If there is a foul odor from the drainage, I should contact my docto

A; The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a days time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the doctor should be contacted immediately. DIF: Applying/Application REF: 1474

A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? A) Check the dorsalis pedis pulses. B) Immobilize the left leg with a splint. C) Administer the prescribed analgesic. D) Place a dressing on the affected area.

A; The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area should both be done after the nurse has assessed the client.

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the client? a. I only have to wash the outside of the catheter once a week. b. I should take extra time to clean the catheter site by pushing the foreskin back. c. The drainage bag needs to be changed at least once a week and as needed. d. I should pour a solution of vinegar and water through the tubing and bag.

A; The first few inches of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a."Wash your hands before touching the client." b."Wear gloves when bathing the client." c."Assess skin for breakdown during the bath." d."Apply lotion to lesions while the skin is wet." e."Use a damp cloth to scrub the lesions."

AB; All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.

A nurse has delegated applying a warm compress to a clients eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.) a. Heating the wet washcloth in the microwave b. Holding the cloth on the client using an Ace wrap c. Turning the cloth so it remains warm on the client d. Using a clean washcloth for the compress e. Washing the hands on entering the clients room

AB; The washcloth should be warmed under running warm water. Microwaving it can lead to burns. Gentle pressure is used to hold the compress in place.

A woman has been using acupuncture to treat the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.) a. Lymphedema b. Bleeding tendencies c. Low white blood cell count d. Elevated serum calcium e. High platelet count

ABC; Acupuncture could be unsafe for the client if there is poor drainage of the extremity with lymphedema or if there was a bleeding tendency and low white blood cell count. Coagulation would be compromised with a bleeding disorder, and the risk of infection would be high with the use of needles. An elevated serum calcium and high platelet count would not have any contraindication for acupuncture. DIF: Remembering/Knowledge REF: 1472

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) A) Occupational therapist B) Physical therapist C) Psychologist D) Respiratory therapist E) Speech therapist

ABC; An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client. The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.

A client, who is a mother of two, has autosomal dominant polycystic kidney disease (ADPKD). Which statement by the client indicates a need for further education about her disease? A. "By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." B. "Even though my children don't have symptoms at the same age I did, they can still have ADPKD." C. "If my children have the ADPKD gene, they will have cysts by the age of 30." D. "My children have a 50% chance of inheriting the ADPKD gene that causes the disease."

A; There is no way to prevent ADPKD, although early detection and management of hypertension may slow the progression of kidney damage. Limiting salt intake can help control blood pressure. Presentation of ADPKD can vary by age of onset, manifestations, and illness severity, even in one family. Almost 100% of those who inherit a polycystic kidney disease (PKD) gene will develop kidney cysts by age 30. Children of parents who have the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease.

The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? A. "It may take your eyes longer to adjust in a darkened room." B. "Most visual changes occur before age 40." C. "When the sclera starts to turn yellow, this means you might have problems with your liver." D. "You probably will have to move reading materials closer to your eyes."

A; The nurse teaches the client that, "It may take your eyes longer to adjust in a dark room." With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments.Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"

A; There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a. There should be no problem with a glass of wine with dinner each night. b. I am so glad that I weaned myself off of coffee about a year ago. c. I need to inform my allergist that I cannot take my normal decongestant. d. My normal routine of drinking a quart of water during exercise needs to change.

A; This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention.

A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important? a. Do not touch or rub the eye until it is no longer numb. b. Monitor the eye for any bleeding for the next day. c. Rinse the eye with warm saline solution at home. d. Use all the eyedrops as prescribed until they are gone.

A; This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

The nurse enters an examination room to help with an eye examination. The client is directed toward the assessment chart shown below: What is the provider assessing? a. Color vision b. Depth perception c. Spatial perception d. Visual acuity

A; This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the clients visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

A; To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A. - Acute compartment syndrome (ACS) B. - Fat embolism syndrome (FES) C. - Congestive heart failure D. - Urinary tract infection (UTI) E. - Osteomyelitis

A; acute compartment syndrome (ACS), fat embolism syndrome (FES), osteomyelitis

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? A. - Check the dorsalis pedis pulses. B. - Immobilize the left leg with a splint. C. - Administer the prescribed analgesic. D. - Place a dressing on the affected area.

A; check the dorsals pedis pulses

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. - Keep the client's heels off the bed at all times. B. - Reposition the client every 3 to 4 hours. C. - Administer preventive pain medication before deep-breathing exercises. D. - Prohibit the use of antiembolic stockings.

A; keep the client's heels off the bed at all times

A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A. - Monitor neuromuscular status for decreased circulation and sensation in the extremity. B. - Apply a heating pad for 15 to 20 minutes four times daily to help with pain. C. - Check the fit of the cast by inserting a tongue blade between the cast and the skin. D. - Keep the cast covered with a soft towel to help it to dry quickly.

A; monitor neuromuscular status for decreased circulation and sensation in the extremity

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider immediately if which change occurs? A. - Observation of a large amount of serosanguineous or bloody drainage B. - Mild to moderate pain controlled with prescribed analgesics C. - Absence of erythema and tenderness at the surgical site D. - Ability to flex and extend the right knee

A; observation of a large amount of serosanguineous or bloody drainage

Which intervention does the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? A. - Talking with an amputee close to the client's age who has a similar amputation B. - Drawing a picture of how the client sees him- or herself C. - Talking with a psychiatrist about the amputation D. - Engaging in diversional activities to avoid focusing on the amputation

A; talking with an amputee close to the client's age who has a similar amputation

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? A. - "Use pain medication as prescribed to control pain." B. - "Clean the pin site when any drainage is noticed." C. - "Wear the same clothing that is normally worn." D. - "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

A; use pain medication as prescribed to control pain

A client with peripheral vascular disease will undergo a Syme amputation. What will the nurse teach this patient when providing education about this procedure? A. - "You will be able to bear weight without needing a prosthesis." B. - "This type of procedure results in more pain than others." C. - "The surgeon will remove both the foot and ankle." D. - "This is an above-the-knee type of amputation."

A; you will be able to bear weight without needing a prosthesis

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

BE; Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you been under a lot of stress lately?" c."Have you recently used a public shower?" d."Have you been out of the country recently?" e."Have you recently had any other health problems?" f."Have you changed any medications recently?"

BEF; Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

The nurse is educating a female client about hygiene measures to reduce her risk for urinary tract infection (UTI). What does the nurse instruct the client to do? A. "Douche—but only once a month." B. "Use only white toilet paper." C. "Wipe from front to back." D. "Wipe with the softest toilet paper available."

C

A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a."Do you spend a great deal of time in the sun?" b."Have you or any family members ever had skin cancer?" c."Which method of contraception are you using?" d."Do you drink alcoholic beverages?"

C; Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a.Administer it over 30 minutes using an IV pump. b.Give the client diphenhydramine (Benadryl) before the drug. c.Assess the IV site at least every 2 hours for thrombophlebitis. d.Ensure that the client has increased oral intake during therapy.

C; Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to "red man syndrome"), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.

A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the client's face.

C; Clients with Ménière's disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière's disease.

The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices

C; Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation. Responding agreeably does not indicate the client will actually follow through.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a "shift to the left" in a client's white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

B; An increase in band cells creates a "shift to the left." A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this client's discharge teaching? (Select all that apply.) a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 liters of fluid each day." c. "The bruising on your back may take several weeks to resolve." d. "Report any blood present in your urine." e. "It is normal to experience pain and difficulty urinating."

ABC; The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.) a. II b. III c. VI d. XII e. X

ABC; The cranial nerves involved with eye function include II, III, IV, V, VI, and VII.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) A. - Occupational therapist B. - Physical therapist C. - Psychologist D. - Respiratory therapist E. - Speech therapist

ABC; occupational therapist, physical therapist, psychologist

A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.) a.Recent prostatectomy b.Long-term hypertension c.Diabetes mellitus d. Hour-long exercise sessions e. Consumption of beer each night

ABCE; Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.) a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. d. Sexual intercourse is allowed. e. Use stool softeners to avoid constipation.

ABCE; The client should be taught to call the physician for increased pain as this might indicate infection or other complication. To avoid increasing intraocular pressure, clients are taught to not lift more than 10 pounds, to avoid bending at the waist, to avoid straining at stool, and to avoid sexual intercourse for a time after surgery.

A client is hesitant to talk to the nurse about genitourinary dysfunction symptoms. What is the nurse's best response? A. "Don't worry, no one else will know." B. "Take your time. What is bothering you the most?" C. "Why are you hesitant?" D. "You need to tell me so we can determine what is wrong."

B; Asking the client what is bothering him or her expresses patience and understanding when trying to identify the client's problem. Telling the client that others will not know is untrue because the client's symptoms will be in the medical record for other health care personnel to see. Asking why the client is hesitant can seem accusatory and threatening to the client. Admonishing the client to disclose his or her symptoms is too demanding; the nurse must be more understanding of the client's embarrassment.

The nurse is administering sulfamethoxazole-trimethoprim (Bactrim) to a client diagnosed with bacterial prostatitis. Which finding causes the nurse to question this medication for this client? a. Urinary tract infection b. Allergy to sulfa medications c. Hematuria d. Elevated serum white blood cells

B; Before administering sulfamethoxazole-trimethoprim, the nurse must assess if the client is allergic to sulfa drugs. Urinary tract infection, hematuria, and elevated serum white blood cells are common problems associated with bacterial prostatitis that require long-term antibiotic therapy.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? a. Review the hemoglobin and hematocrit as ordered. b. Take vital signs and notify the surgeon immediately. c. Release the traction on the three-way catheter. d. Remind the client not to pull on the catheter.

B; Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.

A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

B; Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A) Balanced skin traction B) Buck's traction C) Overhead traction D) Plaster traction

B; Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

Which factor is an indicator for a diagnosis of hydronephrosis? A. History of nocturia B. History of urinary stones C. Recent weight loss D. Urinary incontinence

B; Causes of hydronephrosis or hydroureter include tumors, stones, trauma, structural defects, and fibrosis. Nocturia is a key feature of polycystic kidney disease and pyelonephritis, but it is not associated with hydronephrosis. Recent weight loss and urinary incontinence may be factors in renal cell carcinoma, but are not associated with hydronephrosis.

The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs." C. "An extra supply of medicine should be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."

B; Clients with MG should not take any over-the-counter medications without checking with their health care provider.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will take a laxative every night before going to bed." b. "I must increase my intake of dietary fiber and fluids." c. "I shall only use salt when I am cooking my own food." d. "I'll eat white bread to minimize gastrointestinal gas."

B; Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet.

An emergency department nurse assesses a client with kidney trauma and notes that the client's abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products

B; Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the client's vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. Cover the infected area with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

B; Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection.The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

When assessing a client with acute glomerulonephritis, which finding causes the nurse to notify the provider? A. Purulent wound on the leg B. Crackles throughout the lung fields C. History of diabetes D. Cola-colored urine

B; Crackles indicate fluid overload resulting from kidney damage; shortness of breath and dyspnea are typically associated. The provider should be notified of this finding. Glomerulonephritis may result from infection (e.g., purulent wound); it is not an emergency about which to notify the provider. The history of diabetes would have been obtained on admission. Dark urine is expected in glomerulonephritis.

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the physician will request which medication to aid in the diagnosis of MG? A. Atropine B. Edrophonium chloride (Tensilon) C. Methylprednisolone (Solu-Medrol) D. Morphine sulfate

B; Edrophonium chloride (Tensilon) is used most often for testing for MG because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors.

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. A) 2, 4, 3, 1 B) 3, 4, 1, 2 C) 1, 4, 3, 2 D) 4, 1, 2, 3

B; First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. "I must decrease my intake of fat." b. "I will increase my intake of protein." c. "A decreased intake of carbohydrates will be required." d. "An increased intake of vitamin C is necessary."

B; In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

A client has a grade III open fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A. - Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. B. - Use strict aseptic technique when cleaning the site. C. - Leave the site open to the air to keep it dry. D. - Assist the client to shower daily and pat the wound site dry.

B;

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. - "A callus is quickly deposited and transformed into bone." B. - "A hematoma forms at the site of the fracture." C. - "Cellular and vascular proliferation surround the fracture site." D. - "Granulation tissue reabsorbs the hematoma and deposits new bone."

B;

A nurse assesses a client who has psoriasis. Which action should the nurse take first? a.Don gloves and an isolation gown. b.Shake the client's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the client if she might be pregnant.

B; Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.

After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a."At the next family reunion, I'm going to ask my relatives if they have psoriasis." b."I have to make sure I keep my lesions covered, so I do not spread this to others." c."I expect that these patches will get smaller when I lie out in the sun." d."I should continue to use the cortisone ointment as the patches shrink and dry out."

B; Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this client's discharge teaching? (Select all that apply.) a. "Take your blood pressure every morning." b. "Weigh yourself at the same time each day." c. "Adjust your diet to prevent diarrhea." d. "Contact your provider if you have visual disturbances." e. "Assess your urine for renal stones."

ABD; A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"

ABD; Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness

ABD; Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Irregular blue mole with white specks on the lower leg c.Large cluster of pustules in the right axilla d.Thick, reddened papules covered by white scales

B; This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. A. - 2, 4, 3, 1 B. - 3, 4, 1, 2 C. - 1, 4, 3, 2 D. - 4, 1, 2, 3

B; 3,4,1,2

Which clinical manifestation in a client with pyelonephritis indicates that treatment has been effective? A. Decreased urine output B. Decreased white blood cells in urine C. Increased red blood cell count D. Increased urine specific gravity

B; A decreased presence of white blood cells in the urine indicates the eradication of infection. A decreased urine output, an increased red blood cell count, and increased urine specific gravity are not symptoms of pyelonephritis.

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure the client has a patent airway. c. Prepare to irrigate the clients eye. d. Turn the client on the unaffected side.

B; Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The clients eye may or may not be irrigated.

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.) a. "Do not eat a full meal for 45 minutes after taking the drug." b. "Seek immediate care if you develop trouble swallowing." c. "Take this drug on an empty stomach for best absorption." d. "The dose may change frequently depending on symptoms." e. "Your urine may turn a reddish-orange color while on this drug."

ABD; Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine will not turn reddish-orange while on this drug.

The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

ABDE; Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.

B; All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African-American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A) "A callus is quickly deposited and transformed into bone." B) "A hematoma forms at the site of the fracture." C) "Calcium and vascular proliferation surround the fracture site." D) "Granulation tissue reabsorbs the hematoma and deposits new bone."

B; In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A) Acute compartment syndrome (ACS) B) Fat embolism syndrome (FES) C) Congestive heart failure D) Urinary tract infection (UTI) E) Osteomyelitis

ABE; ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair, but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

1. The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.) a.Assessing for blood pressure changes when lying, sitting, and arising from the bed b.Immediately reporting any change in the alanine aminotransferase laboratory test c.Teaching the client about the possibility of increased libido with these medications d.Taking the clients pulse rate for a minute in anticipation of bradycardia e.Asking the client to report any weakness, light-headedness, or dizziness

ABE; Both the 5-alpha-reductase inhibitor (5-ARI) and the alpha1-selective blocking agents can cause orthostatic (postural) hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause a decreased libido rather than an increased sexual drive. The alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.

A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this client's dietary teaching? (Select all that apply.) a. "Limit your intake of food high in animal protein." b. "Read food labels to help minimize your sodium intake." c. "Avoid spinach, black tea, and rhubarb." d. "Drink white wine or beer instead of red wine." e. "Reduce your intake of milk and other dairy products."

ABE; Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

ABE; Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors

ABE; The high risk factors for breast cancer are age greater than 65 with the risk increasing until age 80; an increase in breast density because of more glandular and connective tissue; and inherited mutations of BRCA1 and/or BRCA2 genes. Osteoporosis and multiparity are not risk factors for breast cancer. A high postmenopausal bone density and nulliparity are moderate and low increased risk factors, respectively.

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.) a. Peau dorange b. Dense breast tissue c. Nipple retraction d. Mobile mass at two oclock e. Nontender axillary nodes

ACD; In the documentation of a breast mass, skin changes such as dimpling (peau dorange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the face of a clock. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer. DIF: Remembering/Knowledge REF: 1469

Which assessment findings does the nurse expect in a client with kidney cancer? (Select all that apply.) A. Erythrocytosis B. Hypokalemia C. Hypercalcemia D. Hepatic dysfunction E. Increased sedimentation rate

ACDE; Erythrocytosis alternating with anemia and hepatic dysfunction with elevated liver enzymes may occur with kidney cancer. Parathyroid hormone produced by tumor cells can cause hypercalcemia. An elevation in sedimentation rate may occur in paraneoplastic syndromes. Potassium levels are not altered in kidney cancer, but hypercalcemia is present.

A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)

ACDE; Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.

The student learning about vision should remember which facts related to the eyes? (Select all that apply.) a. Aqueous humor controls intraocular pressure. b. Cones work in low light conditions. c. Glaucoma occurs due to increased pressure in the eye. d. Muscles of the iris control light entering the eye. e. Rods work in low light conditions.

ACDE; The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions.

The nurse is caring for a child with the beginning ascending paralysis of Guillain-Barré Syndrome. What nursing actions should be implemented in the care of this child? (Select all that apply.) A. Use play as a means of assessing the child's neurological abilities. B. Assess pulse oximetry measurements daily. C. Listen to lung sounds several times daily. D. Reposition the child every 4 hours. E. Allow the child to eat as long as the cranial nerves are intact. F. Measure each urine watching for decreasing amounts.

ACEF;

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash your hands before and after self-catheterization." b. "Use a large-lumen catheter for each catheterization." c. "Use lubricant on the tip of the catheter before insertion." d. "Self-catheterize at least twice a day or every 12 hours." e. "Use sterile gloves and sterile technique for the procedure." f. "Maintain a specific schedule for catheterization."

ACF; The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? Select all that apply. A. Dysuria B. Enuresis C. Frequency D. Nocturia E. Urgency F. Polyuria

ACde

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination

ADE; Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast self-awareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue. DIF: Applying/Application REF: 1467

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a.Family history of prostate cancer b.Smoking c.Obesity d.Advanced age e.Eating too much red meat f.Race

ADEF; Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors.

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? a. You do not need to worry about lymphedema since you did not have radiation therapy. b. A risk factor for lymphedema is infection, so wear gloves when gardening outside. c. Numbness, tingling, and swelling are common sensations after a mastectomy. d. The risk for lymphedema is a real threat and can be very self-limiting.

B; Infection can create lymphedema; therefore, the client needs to be cautious with activities using the affected arm, such as gardening. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and the presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives. DIF: Applying/Application REF: 1478

An older client has decided to give up driving due to cataracts. What assessment information is most important to collect? a. Family history of visual problems b. Feelings related to loss of driving c. Knowledge about surgical options d. Presence of family support

B; Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the clients perspective on this change.

The nurse anticipates that a client who develops hypotension and oliguria post nephrectomy may need the addition of which element to the regimen? A. Increase in analgesics B. Addition of a corticosteroid C. Administration of a diuretic D. Course of antibiotic therapy

B; Loss of water and sodium occurs in clients with adrenal insufficiency, which is followed by hypotension and oliguria; corticosteroids may be needed. The nurse should use caution when administering analgesics to a hypotensive client; no indication suggests that pain is present in this client. A diuretic would further contribute to fluid loss and hypotension, potentially worsening kidney function. A few doses of antibiotics are used prophylactically preoperatively and postoperatively; additional therapy is used when evidence of infection exists.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How should the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."

B; Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen

B; Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

Which sign or symptom, when assessed in a client with chronic glomerulonephritis (GN), warrants a call to the health care provider? A. Mild proteinuria B. Third heart sound (S3) C. Serum potassium of 5.0 mEq/L D. Itchy skin

B; S3 indicates fluid overload secondary to failing kidneys; the provider should be notified and instructions obtained. Mild proteinuria is an expected finding in GN. A serum potassium of 5.0 mEq/L reflects a normal value; intervention would be needed for hyperkalemia. Although itchy skin may be present as kidney function declines, it is not a priority over fluid excess.

After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will take this medication with food and plenty of water." b. "I shall keep my appointment at the infusion center each week." c. "I'll limit my intake of green leafy vegetables while on this medication." d. "I must not take this medication if I have an infection or am feeling ill."

B; Temsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet.

The nurse refers a client with an amputation and the client's family to which community resource? A) American Amputee Society (AAS) B) Amputee Coalition of America (ACA) C) Community Workers for Amputees (CWA) D) National Amputee of America Society (NAAS)

B; The ACA is an available resource for clients with amputations and supports them and their families. The AAS, CWA, and NAAS do not exist.

After teaching a client with hypertension secondary to renal disease, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I can prevent more damage to my kidneys by managing my blood pressure." b. "If I have increased urination at night, I need to drink less fluid during the day." c. "I need to see the registered dietitian to discuss limiting my protein intake." d. "It is important that I take my antihypertensive medications as directed."

B; The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? A) Thighs have multiple oozing abrasions. B) Serum potassium level is 7 mEq/L. C) The client is describing pain as level 4 (0-to-10 scale). D) Hemoglobin level is 12.0 g/dL.

B; The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further kidney damage or cardiac dysrhythmias. Thighs having multiple oozing abrasions with a pain level of 4 are not unusual for a client with this type of injury. A hemoglobin level of 12.0 g/dL is a normal finding.

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is the most appropriate? a. Breast cancer in men is quite rare. b. It is good that you came to be carefully evaluated. c. Gynecomastia usually comes from overeating. d. When you get older, the male breast always enlarges.

B; The most appropriate statement is the one that is supportive of the client. A breast mass should be carefully evaluated for breast cancer, even if it is not common. Gynecomastia as a symptom can be related to antiandrogen agents, aging, obesity, estrogen excess, or lack of androgens. DIF: Applying/Application REF: 1463

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

B; The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best? a. Inform the provider of the issue. b. Obtain a new bottle of eyedrops. c. Rinse the clients right eye thoroughly. d. Wipe the left eye bottle with alcohol.

B; The nurse has contaminated the clean bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium 128 mEq/L Hemoglobin 14 g/dL Hematocrit 42% Red blood cell count 4.5 What action by the nurse is the most appropriate? a. Consider starting a blood transfusion. b. Slow down the bladder irrigation if the urine is pink. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

B; The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.

A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. Which action should the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

B; The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the client's position will not decrease bleeding.

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by nurse is best? a. Take the clients vital signs and record them in the chart. b. Notify the surgeon about the aspirin ingestion by the client. c. Warn the client that health insurance may not pay for the procedure. d. Teach the client about avoiding twisting above the waist after the operation.

B; The surgeon must be notified immediately since the aspirin could cause increased bleeding during the procedure. Vital signs should be recorded and postoperative teaching should be completed in the preoperative time frame, but these are not the priority since the procedure may be rescheduled. The warning about the clients health insurance is not appropriate at this time. DIF: Applying/Application REF: 1463

The client with advanced Guillain-Barré syndrome (GBS) is no longer able to perform ADLs independently. Which priority problem best identifies measures to prevent pressure ulcers? A. Acute Pain related to paresthesias B. Impaired Physical Mobility related to weakness, paralysis, and ataxia C. Ineffective Airway Clearance related to immobility D. Powerlessness, Anxiety, and Fear related to the inability to perform ADLs and usual role responsibilities

B; This client problem is specific to immobility and includes techniques for the prevention of pressure ulcers.

The RN is working with unlicensed assistive personnel (UAP) in caring for a group of clients. Which action is best for the RN to delegate to UAP? A. Assessing the vital signs of a client who was just admitted with blunt flank trauma and hematuria B. Assisting a client who had a radical nephrectomy 2 days ago to turn in bed C. Helping the provider with a kidney biopsy for a client admitted with acute glomerulonephritis D. Palpating for bladder distention on a client recently admitted with a ureteral stricture

B; UAP would be working within legal guidelines when assisting a client to turn in bed. Although assessment of vital signs is within the scope of practice for UAP, the trauma victim should be assessed by the RN because interpretation of the vital signs is needed. Assisting with procedures such as kidney biopsy and assessment for bladder distention are responsibilities of the professional nurse that should not be delegated to staff members with a limited scope of education.

What is the appropriate range of urine output for the client who has just undergone a nephrectomy? A. 23 to 30 mL/hr B. 30 to 50 mL/hr C. 41 to 60 mL/hr D. 50 to 70 mL/hr

B; Urine output of 30 to 50 mL/hr or 0.5 to 1 mL/kg/hr is considered within acceptable range for the client who is post nephrectomy. Output of less than 25 to 30 mL/hr suggests decreased blood flow to the kidney and the onset or worsening of acute kidney injury. A large urine output, followed by hypotension and oliguria, is a sign of hemorrhage and adrenal insufficiency.

A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A) Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. B) Use strict aseptic technique when cleaning the site. Correct C) Leave the site open to the air to keep it dry. D) Assist the client to shower daily and pat the wound site dry.

B; Using aseptic technique is the best way to prevent infection. Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of a compound fracture must not be exposed to a shower; this practice violates maintaining aseptic technique.

Which statement by a client with diabetic nephropathy indicates a need for further education about the disease? A. "Diabetes is the leading cause of kidney failure." B. "I need less insulin, so I am getting better." C. "My blood sugar may drop really low at times." D. "I must call my provider if the urine dipstick shows protein."

B; When kidney function is reduced, insulin is available for a longer time and thus less of it is needed. Unfortunately, many clients believe this means that their diabetes is improving. It is true that diabetes mellitus is the leading cause of end-stage kidney disease among Caucasians in the United States. Clients with worsening kidney function may begin to have frequent hypoglycemic episodes. Proteinuria, which may be mild, moderate, or severe, indicates a need for follow-up.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? A. - Balanced skin traction B. - Buck's traction C. - Overhead traction D. - Plaster traction

B; buck's traction

A client has Ménière's disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.) a. Broad-spectrum antibiotics b. Chlorpromazine hydrochloride (Thorazine) c. Diphenhydramine (Benadryl) d. Meclizine (Antivert) e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

BCD; Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière's disease. Antibiotics and NSAIDs are not used.

When assessing a client with acute pyelonephritis, which findings does the nurse anticipate will be present? (Select all that apply.) A. Suprapubic pain B. Vomiting C. Chills D. Dysuria E. Oliguria

BCD; Nausea and vomiting are symptoms of acute pyelonephritis. Chills along with fever may also occur, as well as burning (dysuria), urgency, and frequency. Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). Oliguria is related to kidney impairment from severe or long-standing pyelonephritis.

The client has Guillain-Barré syndrome. Which interdisciplinary health care team members will the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in the client with Guillain-Barré syndrome? Select all that apply. A. Certified hospital chaplain B. Family C. Dietitian D. Occupational therapist (OT) E. Social worker

BCD; The nurse should collaborate with the client's family to develop interventions to prevent complications such as pressure ulcers. The family will mostly likely be directly involved in the client's care and should be included. Malnutrition puts the client at greater risk for pressure ulcers. The dietitian should be included to collaborate in preventing pressure ulcers. The occupational therapist (OT) should be included to collaborate in preventing ulcers. The OT can provide assistive devices.

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a.Prepare a room for reverse isolation. b.Assess staff for a history of or vaccination for chickenpox. c.Check the admission orders for analgesia. d.Choose a roommate who also is immune suppressed. e.Ensure that gloves are available in the room.

BCE; Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.

An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

BCE; Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea

BCE; Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily

BD; Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

BDE; After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? Select all that apply. A. Anemia B. Diabetes mellitus C. Hepatitis D. Hypertension E. Multiple sclerosis (MS)

BDE; Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity.Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.) a. Chinese stir fry with vegetables b. Broiled chicken breast c. Chocolate espresso cookies d. Deli turkey sandwich and chips e. Green herbal tea with meals

BE; The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies have caffeine, and the sandwich and chips are high in sodium.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? A. Asks the client if he is squeamish B. Demonstrates how to change the dressing C. Determines whether the client can reach the affected area D. Provides all of the necessary dressing materials

C; Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"

C; Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? A. Oral amoxicillin B. Oral linezolid C. Topical mupirocin D. IV vancomycin

C; Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy.Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? A. "I know that I need to avoid warm climates." B. "I must cover up the affected areas to prevent spread to my family." C. "I should practice good handwashing technique." D. "Psoriasis can be cured with steroids."

C; "I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection.Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

C; A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

C; Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? A. Administer a Snellen test. B. Obtain an informed consent. C. Wash the hands. D. Put on sterile gloves.

C; Always wash hands before touching the external eye structures to prevent infection.A Snellen test may be done but is not the first thing that should be done by the nurse. An informed consent or sterile gloves are not needed for the nurse to examine the client's eye.

A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "Can we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"

C; An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client

C; Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

The nurse receives report on a client with hydronephrosis. Which laboratory study does the nurse monitor? A. Hemoglobin and hematocrit (H&H) B. White blood cell (WBC) count C. Blood urea nitrogen (BUN) and creatinine D. Lipid levels

C; BUN and creatinine are kidney function tests. With back-pressure on the kidney, glomerular filtration is reduced or absent, resulting in permanent kidney damage. Hydronephrosis results from the backup of urine secondary to obstruction; H&H monitors for anemia and blood loss, while WBC count indicates infection. Elevated lipid levels are associated with nephrotic syndrome, not with obstruction and hydronephrosis.

A nurse cares for a client who has pyelonephritis. The client states, "I am embarrassed to talk about my symptoms." How should the nurse respond? a. "I am a professional. Your symptoms will be kept in confidence." b. "I understand. Elimination is a private topic and shouldn't be discussed." c. "Take your time. It is okay to use words that are familiar to you." d. "You seem anxious. Would you like a nurse of the same gender to care for you?"

C; Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the client's symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

C; Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "If I think I am pregnant, I will stop the drug." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."

C; Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin? a. On a scale from 0 to 10, what is the rating of your chest pain? b. Are you allergic to any food or medications? c. Have you taken any drugs like Viagra recently? d. Are you light-headed or dizzy right now?

C; Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the client's vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation

C; Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.

A nurse provides phone triage to a pregnant client. The client states, "I am experiencing a burning pain when I urinate." How should the nurse respond? a. "This means labor will start soon. Prepare to go to the hospital." b. "You probably have a urinary tract infection. Drink more cranberry juice." c. "Make an appointment with your provider to have your infection treated." d. "Your pelvic wall is weakening. Pelvic muscle exercises should help."

C; Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

A 25-year-old client has recently been diagnosed with testicular cancer and is scheduled for radiation therapy. Which intervention by the nurse is best? a. Ask the client about his support system of friends and relatives. b. Encourage the client to verbalize his fears about sexual performance. c. Explore with the client the possibility of sperm collection. d. Provide privacy to allow time for reflection about the treatment.

C; Sperm collection is a viable option for a client diagnosed with testicular cancer and should be completed before radiation therapy, chemotherapy, or radical lymph node dissection. The other options would promote psychosocial support but are not the priority intervention.

The client arrives to the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A. Bell's palsy B. Guillain-Barré syndrome C. Myasthenia gravis (MG) D. Trigeminal neuralgia

C; Sudden-onset ptosis, diplopia, and dysphagia are classic symptoms of MG. Laboratory studies and a Tensilon test most likely will be done to confirm the diagnosis.

A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching? a. Beta carotene, lutein, and zeaxanthin are good supplements. b. I might qualify for a retinal transplant one day soon. c. Since Im going blind, sunglasses are not needed anymore. d. Vitamin A has been shown to slow progression of RP.

C; Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.

C; Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of mental illness is not an appropriate action. DIF: Applying/Application REF: 1469

A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells.

C; Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide (Lupron) does this. Chemotherapy agents such as ixabepilone (Ixempra) interfere with cancer cell division, and doxorubicin (Adriamycin) inhibits DNA synthesis in susceptible cells. DIF: Remembering/Knowledge REF: 1477

A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center? a. "Avoid having teeth pulled for 1 year." b. "Brush your teeth with a soft toothbrush." c. "Do not use harsh chemicals on your face." d. "Inform your dentist of this procedure."

C; The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.

During discharge teaching for a client with kidney disease, what does the nurse teach the client to do? A. "Drink 2 liters of fluid and urinate at the same time every day." B. "Eat breakfast and go to bed at the same time every day." C. "Check your blood sugar and do a urine dipstick test." D. "Weigh yourself and take your blood pressure."

D; Regular weight assessment monitors fluid restriction control, while blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction. Fluid intake and urination, and breakfast time and bedtime, do not need to be at the same time each day. Clients with diabetes, not kidney disease, should regularly check their blood sugar and perform a urine dipstick test.

A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol LA) d. Allopurinol (Zyloprim)

D; Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Phenazopyridine is given to clients with urinary tract infections. Propantheline is an anticholinergic. Tolterodine is an anticholinergic with smooth muscle relaxant properties.

A client says, "I have problems reading signs when I am driving." Which test does the nurse use to best assess this client's problem? A. Confrontation test B. Ishihara chart C. Rosenbaum Pocket Vision Screener or a Jaeger card D. Snellen chart

D; The Snellen chart test best assesses the client's distance vision, which is the type of vision used while driving.The confrontation test assesses the client's visual field. The Ishihara chart assesses the client's color vision. The Rosenbaum Pocket Vision Screener or Jaeger card assesses the client's near vision.

A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? a. Administering an antispasmodic for bladder spasms b. Managing pain through patient-controlled analgesia c. Applying ice to a swollen scrotum and penis d. Helping the client transfer from the bed to the chair

D; The UAP could aid the client in transferring from the bed to the chair and with ambulation. The nurse would be responsible for medication administration, assessment of swelling, and the application of ice if needed.

A client who is using eye drops in both eyes develops a viral infection in one eye and asks the nurse what to do. What is the nurse's best response? A. "As long as you don't touch the eyes with the dropper, it will be OK." B. "Just wash your hands between eyes and put drops in the uninfected eye first." C. "The other eye will probably get infected anyway." D. "You will need to use a separate bottle of drops for each eye."

D; The best response is that the client will need a separate bottle of eye drops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled "right" and "left" to use in the correct eyes.There is still a risk of transmitting the infection when the dropper is kept from contacting the eye or when hands are washed. With proper technique, transmission of infection to the other eye can be prevented.

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? A) Bleeding B) Head injury C) Pain D) Respiratory distress

D; The client should first be assessed for respiratory distress, and any oxygen interventions instituted accordingly. Bleeding is the second assessment priority, head injury is the third assessment priority, and pain is the fourth assessment priority in this case.

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Include support people, such as the male partner, in the decision making.

D; The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often makes the decisions for care of the female. Women with a high risk for breast cancer can consider prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have more complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in the remaining mammary tissue. DIF: Applying/Application REF: 1468

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, "I am anxious about having an ileal conduit. What is it like to have this drainage tube?" How should the nurse respond? a. "I will ask the provider to prescribe you an antianxiety medication." b. "Would you like to discuss the procedure with your doctor once more?" c. "I think it would be nice to not have to worry about finding a bathroom." d. "Would you like to speak with someone who has an ileal conduit?"

D; The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge. Medications for anxiety will not promote a positive self-image and a positive attitude, nor will discussing the procedure once more with the physician or hearing the nurse's opinion.

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the client's record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the client's abdomen and vital signs.

D; The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the client's abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

A young adult with testicular cancer is admitted for unilateral orchiectomy and retroperitoneal lymph node dissection. Which nursing action is best for the nurse to delegate to unlicensed assistive personnel (UAP)? a) Encourage the client to cough and deep-breathe after surgery. b) Discuss reproductive options with the client and significant other. c) Teach about the availability of a gel-filled silicone testicular prosthesis. d) Evaluate the client's understanding of chemotherapy and radiation treatment. (Chp 72, elsevier resources)

a; Although teaching about routine postoperative client actions such as coughing and deep-breathing should be done by licensed nurses, reminding clients to perform these activities can be delegated to UAP. Client education and evaluation are more complex skills that should be done by licensed nurses. (Chp 72, elsevier resources)

A client is struggling with body image after breast cancer surgery. Which behavior indicates to the nurse that the client is maladaptive? a) Avoiding eye contact with staff b) Saying, "I feel like less of a woman" c) Requesting a temporary prosthesis immediately d) Saying, "This is the ugliest scar ever" (Chp. 70, elsevier resources)

a; Avoiding eye contact may be an indication of decreased self-image. The client stating that she feels like less of a woman or that her scar is ugly illustrates an expected emotional state; by verbalizing her frustration, the client suggests a willingness to discuss and express feelings. Requesting a prosthesis can be a sign of healing and working through body image changes. (Chp. 70, elsevier resources)

Which type of hearing loss is most likely to be reversible when treated appropriately? a. Conductive hearing loss b. Sensorineural hearing loss c. Mixed conductive sensorineural hearing loss d. Central hearing loss

a; Conductive hearing loss

An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? a. Continues further assessment b. Irrigates the ear c. Prescribes antibiotics for probable otitis media d. Tests hearing acuity

a; Continues further assessment

The nurse is performing an otoscopic examination of a client's ear and notes greenish white drainage. What does the nurse do next? a. Disposes of the otoscope tip and washes the hands before examining the other ear b. Reports the finding to the health care provider immediately c. Sends a specimen for culture d. Suctions out the drainage

a; Disposes of the otoscope tip and washes the hands before examining the other ear

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? a. "I wear foam ear inserts at works where it is noisy." b. "I listen to music with foam ear inserts." c. "My ears ring after a rock concert, but it goes away." d. "The machinery is loud at work, but I get used to it."

a; I wear foam ear inserts at works where it is noisy

A client is receiving chemotherapy treatment for breast cancer and asks for additional support for managing the associated nausea and vomiting. Which complementary therapy does the nurse suggest? a) Ginger b) Journaling c) Meditation d) Yoga (Chp. 70, elsevier resources)

a; It has long been believed that ginger helps alleviate nausea and vomiting. Current studies are being done on the effect of ginger on chemotherapy-induced nausea. Journaling is good for reducing anxiety, stress, and fear. Meditation helps reduce stress, improve mood, improve quality of sleep, and reduce fatigue. Yoga has been shown to improve physical functioning, reduce fatigue, improve sleep, and improve one's overall quality of life. (Chp. 70, elsevier resources)

Which statement about breast reconstruction surgery is correct? a) Many women want breast reconstruction using their own tissue immediately after mastectomy. b) Placement of saline- or gel-filled prostheses is not recommended because of the nature of the surgery. c) Reconstruction of the nipple-areola complex is the first stage in the reconstruction of the breast. d) The surgeon should offer the option of breast reconstruction surgery once healing has occurred after a mastectomy. (Chp. 70, elsevier resources)

a; Many women want autogenous reconstruction after mastectomy. Saline- or gel-filled prostheses are recommended as breast expanders in breast augmentation surgery, not for reconstructive surgery. Reconstruction of the nipple-areola complex is the last stage in breast reconstruction surgery. Breast reconstruction surgery should be discussed before mastectomy takes place. (Chp. 70, elsevier resources)

The nurse is caring for a client with erectile dysfunction who has not had success with other treatment modalities. The nurse anticipates that the health care provider will recommend which treatment for this client? a) Penile implants b) Penile injections c) Transurethral suppository d) Vacuum constriction device (Chp 72, elsevier resources)

a; Penile implants (prostheses), which require surgery, are used when other modalities fail. Devices include semi-rigid, flexible, or hydraulic inflatable and multi-component or one-piece instruments. Penile injections are tried before using the option of last resort. Transurethral suppository is tried before using the option of last resort. A vacuum constriction device is easy to use, and is often the first option that is tried. (Chp 72, elsevier resources)

Which client has the highest risk for breast cancer? a) Older adult woman with high breast density b) Nullipara older adult woman c) Obese older adult male with gynecomastia d) Middle-aged woman with high breast density (Chp. 70, elsevier resources)

a; People at high increased risk for breast cancer include women age 65 years and older with high breast density. Nullipara women are at low increased risk for breast cancer. Men are not at high increased risk for breast cancer, but obesity can cause gynecomastia. Being middle-aged does not indicate a high increased risk for breast cancer. (Chp. 70, elsevier resources)

When is the best time for the nurse to begin discharge planning and a community-based plan of care for a client with prostate cancer? a) Before surgery b) After surgery c) 2 days before being discharged d) The day of discharge (Chp 72, elsevier resources)

a; Planning should begin as early as possible, on admission and before surgery. After surgery is not the correct time to begin planning. Planning should begin earlier than 2 days before discharge. (Chp 72, elsevier resources)

The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? a) Adolescent with an erection for "10 or 11 hours" who is reporting severe pain b) Young adult with a swollen, painful scrotum who has a recent history of mumps infection c) Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria d) Older adult with a history of benign prostatic hyperplasia and palpable bladder distention (Chp 72, elsevier resources)

a; The client who has had an erection for "10 or 11 hours" has symptoms of priapism, which is considered a urologic emergency because the circulation to the penis may be compromised and the client may not be able to void with an erect penis. The client with a swollen, painful scrotum; the client with hematuria; and the client with a history of benign prostatic hyperplasia do not require the nurse's immediate attention since these are not medical emergencies. (Chp 72, elsevier resources)

After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? (Select all that apply.) a) Antispasmodic drugs b) Emergency surgery c) Forced fluids d) Increased intermittent irrigation e) Monitoring for anemia (Chp 72, elsevier resources)

ae; Although not a common occurrence, bleeding may occur in the postoperative period. Venous bleeding is more common than arterial bleeding. The surgeon may apply traction on the catheter for a few hours to control the venous bleeding. Traction on the catheter is uncomfortable and increases the risk for bladder spasms, so analgesics or antispasmodics are usually prescribed. Hemoglobin and hematocrit should be monitored and trended for indications of anemia. Emergency surgery and increased intermittent irrigation would be indicated for an arterial bleed, which would be a brighter red color. Forced fluids are indicated after the catheter is removed. (Chp 72, elsevier resources)

A client is having a radical prostatectomy. Which preoperative teaching specific to this surgery does the nurse emphasize? a) Incentive spirometry b) Kegel exercises c) Pain control d) Penile implants (Chp 72, elsevier resources)

b; Kegel perineal exercises may reduce the severity of urinary incontinence after radical prostatectomy. The client is taught to contract and relax the perineal and gluteal muscles in several ways. Incentive spirometry and pain control are important for everyone who undergoes surgery; neither is specific to radical prostatectomy. Penile implants are not important to discuss during preoperative teaching; however, they may be necessary to discuss later. (Chp 72, elsevier resources)

A client has been diagnosed with breast cancer. Which client-chosen treatment option requires the nurse to discuss with the client the necessity of considering additional therapy? a) Chemotherapy b) Complementary and alternative medicine (CAM) c) Hormonal therapy d) Neoadjuvant therapy (Chp. 70, elsevier resources)

b; No proven benefit has been found with using CAM alone as a cure for breast cancer. The nurse must ensure that the client's choices can be safely integrated with conventional treatment for breast cancer. Chemotherapy is usually used for stage II or higher breast cancer and may or may not be used as a single treatment option. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth; it may or may not be used with other treatment options. A large tumor is sometimes treated with chemotherapy, called neoadjuvant therapy, to shrink the tumor before it is surgically removed; an advantage of this therapy is that cancers can be removed by lumpectomy rather than mastectomy. (Chp. 70, elsevier resources)

Which technique is correct when instilling ear drops? a. Maintain the head in the same position for 2 minutes after instillation. b. Place the medication bottle in a bowl of warm water before instillation. c. Rinse the ear canal with hydrogen peroxide before instillation. d. Check to see whether the eardrum is intact before instillation.

b; Place the medication bottle of warm water before instillation

A client who recently had a mastectomy requests a volunteer to visit her home to help with recovery. Which community resource does the nurse recommend? a) National Breast Cancer Coalition b) Reach to Recovery c) Susan G. Komen for the Cure d) Young Survival Coalition (Chp. 70, elsevier resources)

b; The American Cancer Society's program Reach to Recovery provides volunteers who visit clients in the hospital or at home. They bring personal messages of hope; informational materials on breast cancer recovery; and a soft, temporary breast form. The National Breast Cancer Coalition is an organization dedicated to ending breast cancer through action and advocacy. Susan G. Komen for the Cure is an organization that supports breast cancer research. The Young Survival Coalition is an organization dedicated to educating the medical, research, breast cancer, and legislative communities about breast cancer, as well as serving as a point of contact for young women living with breast cancer. None of these other community resources provide volunteers to visit the home. (Chp. 70, elsevier resources)

Which action can the same-day surgery charge nurse delegate to an experienced unlicensed assistive personnel (UAP) who is helping with the care of a client who is having a breast biopsy? a) Assess anxiety level about the surgery. b) Monitor vital signs after surgery. c) Obtain data about breast cancer risk factors. d) Teach about postoperative routine care. (Chp. 70, elsevier resources)

b; Vital sign assessment is included in UAP education and usually is part of the job description for UAP working in a hospital setting. Nursing assessment, obtaining data, and client teaching are not within the scope of practice for UAP and should be done by licensed nursing staff. (Chp. 70, elsevier resources)

The nurse in the urology clinic is providing teaching for a female client with cystitis. Which instructions does the nurse include in the teaching plan? Select all that apply. A. Cleanse the perineum from back to front after using the bathroom. B. Try to take in 64 ounces (2 liters) of fluid each day. C. Be sure to complete the full course of antibiotics. D. If urine remains cloudy, call the clinic. E. Expect some flank discomfort until the antibiotic has worked.

bcd

The nurse is instructing a client on how to perform breast self-examination (BSE). Which techniques does the nurse include in teaching the client about BSE? (Select all that apply.) a) Instruct the client to keep her arm by her side while performing the examination. b) Ensure that the setting in which BSE is demonstrated is private and comfortable. c) Ask the client to remove her shirt. The bra may be left in place. d) Ask the client to demonstrate her own method of BSE. e) Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts. (Chp. 70, elsevier resources)

bd; The setting should be private and comfortable to promote an environment conducive to learning and to prevent potential client embarrassment. Before teaching breast palpation, ask the client to demonstrate her own method, so that the nurse can assess the client's understanding of BSE. For better visualization, the arm should be placed over the head. The client should undress completely from the waist up. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts. (Chp. 70, elsevier resources)

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) a. "You might experience a lot of bruising and swelling around the eye." b. "You will receive a medication to help you relax. Then you will receive eye drops to dilate your pupils and paralyze the lens." c. "You will need to wear a patch on your eye for several weeks after the surgery." d. "Bring sunglasses with you on the day of your procedure." e. "Several different types of eye drops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." -

bde

A 32-year-old female with a urinary tract infection (UTI) reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100°F (37.8°C). Which drug does the primary health care provider prescribe? A. Nitrofurantoin (Macrodantin) after intercourse B. Estrogen (Premarin) C. Trimethoprim/sulfamethoxazole (Bactrim) D. Phenazopyridine (Pyridium) with intercourse

c

A client has a bilateral corneal disorder and must instill anti-infective eye drops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? a. "I must apply the drops throughout the night" b. "I must wash my hands, before, between, and after eye applications" c. "I have two bottles of eye drops in case I run out" d. "I won't be able to wear my contacts for a while" -

c

A client has recently been diagnosed with 20/200 vision bilaterally and tells the nurse he is "legally blind." How does the nurse best offer increased support? a. Tells the client to find a support group b. Provides instructions in a loud, clear voice c. Refers the family to local services for the blind d. Writes instructions down in very large print -

c

The certified Wound, Ostomy, and Continence Nurse or enterostomal therapist teaches a client who has had a cystectomy about which care principles for the client's postdischarge activities? A. Nutritional and dietary care B. Respiratory care C. Stoma and pouch care D. Wiping from front to back (asepsis)

c

The nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective? A. "I must avoid drinking carbonated beverages." B. "I need to douche vaginally once a week." C. "I need to drink 2½ liters of fluid every day." D. "I will not drink fluids after 8 PM each evening."

c

The nurse is teaching a client about administering eye drops to treat open-angle glaucoma. Which statement by the client indicates a need for further instruction? a. "I must wait 10 to 15 minutes between different eye drop medications." b. "These eye drops will not cure my glaucoma." c. "I must press on the inside of my eye to prevent washout." d. "It is important to not skip a dose." -

c

Which nursing activity illustrates proper aseptic technique during catheter care? A. Applying Betadine ointment to the perineal area after catheterization B. Irrigating the catheter daily C. Positioning the collection bag below the height of the bladder D. Sending a urine specimen to the laboratory for testing

c

The nurse is assigned care for a client who has undergone a modified radical left mastectomy for breast cancer. When delegating care, which statement by the nursing assistant would require further teaching by the nurse? a) "I will report urine intake and output to you." b) "If the client appears to be in pain, I will tell you right away." c) "It is important for me to take blood pressure on the client's left arm." d) "When ambulating, I will assist the client to stand straight with arms hanging at the side." (Ignatavicius & Workman, p. 1474)

c;

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? a. The eardrum is red, thick appearing, and immobile. b. The lymph nodes are swollen and painful to touch. c. The client reports a headache and a stiff neck. d. The client's oral temperature is 100.1° F (37.8° C).

c; The client reports a headache and a stiff neck

With which male client does the nurse conduct prostate screening and education? a) Young adult with a history of urinary tract infections b) Client who has sustained an injury to the external genitalia c) Adult who is older than 50 years d) Sexually active client (Chp 72, elsevier resources)

c; A man who is 50 years or older is at higher risk for prostate cancer. A history of urinary tract infections, injury to the external genitalia, and sexual activity are not risk factors for prostate cancer. (Chp 72, elsevier resources)

Which assessment finding causes the nurse to suspect that a client may have testicular cancer? a) Hematuria b) Penile discharge c) Painless testicular lump d) Sudden increase in libido (Chp 72, elsevier resources)

c; A painless lump or swelling in the testicles is the most common manifestation of testicular cancer. Hematuria is not a symptom of testicular cancer, but could be indicative of other conditions such as bladder cancer. Penile discharge is not a symptom of testicular cancer, but could be indicative of another condition. A sudden increase in libido is not a symptom of testicular cancer. (Chp 72, elsevier resources)

The potential problem of grief is most relevant to a client after which procedure? a) Cystoscopy b) Transurethral microwave therapy c) Radical prostatectomy d) Sperm banking (Chp 72, elsevier resources)

c; A radical prostatectomy may lead to erectile dysfunction, which could present a potential problem of grief at loss of function. Cystoscopy, a test to view the interior of the bladder, the bladder neck, and the urethra, does not affect sexuality. Transurethral microwave therapy is a minimally invasive procedure involving high temperatures that heat and destroy excess prostate tissue, and does not affect sexuality. The process of sperm banking would not result in a diagnosis of altered self-image; however, the diagnosis leading to the necessity of sperm banking might cause this. (Chp 72, elsevier resources)

A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? a) Allow the client to bring up the topic first. b) Remind the client to avoid sexual intercourse for 2 months after the surgery. c) Suggest that the client wear a bra or camisole during intercourse. d) Teach the client that birth control is a priority. (Chp. 70, elsevier resources)

c; Clients may prefer to lay a pillow over the surgical site or wear a bra or camisole to prevent contact with the surgical site during intercourse. The client may be embarrassed to discuss the topic of sexuality, so the nurse must be sensitive to possible concerns and approach the subject first. Sexual intercourse can be resumed after surgery whenever the client is comfortable. Sexually active clients receiving chemotherapy or radiotherapy must use birth control because of the therapy's teratogenic effects, but this is not necessary for clients who have had surgery only. (Chp. 70, elsevier resources)

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? a. Antihistamines b. Antipyretics c. Diuretics d. Nicotinic acid

c; Diuretics

The nurse is instructing a client with breast cancer who will be undergoing chemotherapy about the side effects of doxorubicin (Adriamycin). Which side effect does the nurse instruct the client to report to the health care provider? a) Diaphoresis b) Dysphagia c) Edema d) Hearing loss (Chp. 70, elsevier resources)

c; Doxorubicin is an anthracycline, and clients must be instructed to be aware of and to report cardiotoxic effects, including edema, shortness of breath, chronic cough, and excessive fatigue. Diaphoresis (profuse sweating), dysphagia (difficulty swallowing), and hearing loss are not associated side effects of doxorubicin. (Chp. 70, elsevier resources)

A premenopausal client diagnosed with breast cancer will be receiving hormonal therapy. The nurse anticipates that the health care provider will request which medication for this client? a) Anastrozole (Arimdex) b) Fulvestrant (Faslodex) c) Leuprolide (Lupron) d) Trastuzumab (Herceptin) (Chp. 70, elsevier resources)

c; Leuprolide is used in premenopausal women whose main estrogen source is the ovaries and who may benefit from luteinizing hormone-releasing hormone agonists that inhibit estrogen synthesis. Anastrozole is an aromatase inhibitor that is used in postmenopausal women whose main source of estrogen is not the ovaries, but rather body fat. Fulvestrant is a second-line hormonal therapy for postmenopausal women with advanced breast cancer. Trastuzumab is not a hormone and is used for targeted therapy for breast cancer. (Chp. 70, elsevier resources)

Which method is a common complementary and alternative therapy for benign prostatic hyperplasia (BPH)? a) Acupuncture b) Calcium supplements c) Serenoa repens d) Yoga (Chp 72, elsevier resources)

c; Serenoa repens (saw palmetto), a plant extract, is often used by men with early to moderate BPH. They believe that this agent relieves their symptoms and prefer this treatment over prescription drugs or surgery. (It should be noted, however, that studies on the effectiveness of Serenoa repens have not shown that it is effective.) Acupuncture, calcium, and yoga are not common alternative therapies for BPH. (Chp 72, elsevier resources)

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What does the nurse do next? a. Administer an antiemetic. b. Call the health care provider. c. Stop irrigation immediately. d. Use less water to irrigate.

c; Stop the irrigation immediately

Which option for prevention and early detection of breast cancer is the option of choice for a client with a high genetic risk? a) Breast self-examination (BSE) beginning at 20 years of age b) Hormone replacement therapy (HRT) combining estrogen and progesterone c) Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 d) Prophylactic mastectomy (Chp. 70, elsevier resources)

c; The American Cancer Society recommends that high-risk women (>20% lifetime risk) have an MRI and mammogram every year beginning at age 30. BSE is an option for everyone, not just those at high genetic risk for breast cancer. Use of HRT containing both estrogen and progestin increases risk; risk diminishes after 5 years of discontinuation. With a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue. (Chp. 70, elsevier resources)

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? Select all that apply. a. Acetaminophen (Tylenol) b. Beta blockers c. Erythromycin d. Ibuprofen (Advil) e. Insulin f. Furosemide (Lasix)

cdf;

A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the primary health care provider before the ESWL procedure begins? A. "Blood in my urine has become less noticeable, so maybe I don't need this procedure." B. "I have been taking cephalexin (Keflex) for an infection." C. "I previously had several ESWL procedures performed." D. "I take over-the-counter naproxen (Aleve) twice a day for joint pain."

d

A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection. Which nursing action can the home health RN delegate to the home health aide (unlicensed assistive personnel [UAP])? A. Assisting the client in developing a schedule for when to take prescribed antibiotics B. Inserting a straight catheter as necessary if the client is unable to empty the bladder C. Teaching the client how to use the Credé maneuver to empty the bladder more fully D. Using a bladder scanner (with training) to check residual bladder volume after the client voids

d

A client who is 6 months pregnant comes to the prenatal clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client? A. Discharges the client to her home for strict bedrest for the duration of the pregnancy B. Instructs the client to drink a minimum of 3 liters of fluids, especially water, every day to "flush out" bacteria C. Recommends that the client refrain from having sexual intercourse until after she has delivered her baby D. Refers the client to the clinic nurse practitioner for immediate follow-up

d

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? a. Inability to differentiate colors b. Burning in the eye c. Increased sensitivity to light d. Gradual vision changes -

d

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? a. Addressing the client in a loud, clear voice b. Allowing the client's seeing-eye dog in the unit c. Keeping the client bedridden for safety d. Making all health care team members aware of the client's visual limitations -

d

The nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates a correct understanding of these procedures? A. "If I restrict my oral intake of fluids, the adjustment will be easier." B. "I must go to the restroom more often because my urine will be excreted through my anus." C. "I need to wear loose-fitting pants so the urine can flow into my ostomy bag." D. "I will have to drain my pouch with a catheter."

d

The nurse is teaching the importance of a low purine diet to a client admitted with urolithiasis consisting of uric acid. Which statement by the client indicates that teaching was effective? A. "I am so relieved that I can continue eating my fried fish meals every week." B. "I will quit growing rhubarb in my garden since I'm not supposed to eat it anymore." C. "My wife will be happy to know that I can keep enjoying her liver and onions recipe." D. "I will no longer be able to have red wine with my dinner."

d

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? a. "My child should look down at the floor during instillation." b. "My child should rub the eye gently after instillation to increase absorption." c. "I will press gently on the inner canthus for 1 minute." d. "I will place the ointment in the lower lid." -

d

Which client is most in need of immediate examination by an ophthalmologist? a. A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes b. A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes c. A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged d. A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights -

d

The nurse is caring for four clients. Which client does the nurse recognize as having the highest risk for development of breast cancer? a) 45-year-old male with gynecomastia b) 40-year-old female whose father had colon cancer c) 50-year-old male whose mother had ovarian cancer d) 65-year-old female with history of a prior episode of breast cancer (Ignatavicius & Workman, p. 1467)

d;

The nurse is teaching a client about taking sildenafil (Viagra) for erectile dysfunction. Which statement by the client indicates a need for further teaching? a) "I should have sex within an hour after taking the drug." b) "I should avoid alcohol when on the drug or it might not work well." c) "I can expect to maybe get a stuffy nose or headache when I take the drug." d) "If I have chest pain during sex, I should take a nitroglycerin tablet." (Ignatavicius & Workman, p. 1513)

d;

A newly admitted client who is diabetic and has pyelonephritis and prescriptions for intravenous antibiotics, blood glucose monitoring every 2 hours, and insulin administration should be cared for by which staff member? A. RN whose other assignments include a client receiving chemotherapy for renal cell carcinoma B. RN who is caring for a client who just returned after having renal artery balloon angioplasty C. RN who has just completed preoperative teaching for a client who is scheduled for nephrectomy D. RN who is currently admitting a client with acute hypertension and possible renal artery stenosis

C; The client scheduled for nephrectomy is the most stable client; the RN caring for this client will have time to perform the frequent monitoring and interventions that are needed for the newly admitted client. The client receiving chemotherapy will require frequent monitoring by the RN. The client after angioplasty will require frequent vital sign assessment and observation for hemorrhage and arterial occlusion. The client with acute hypertension will need frequent monitoring and medication administration.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A) Ensure that weights are attached to the bed frame or placed on the floor. B) Ensure that pins are not loose, and tighten as needed. C) Inspect the skin at least every 8 hours. D) Remove the traction weights only for bathing.

C; The client's skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A) Surgical repair of the rotator cuff B) Prescribed exercises of the affected arm C) Immobilizer for the affected arm D) Patient-controlled analgesia with morphine

C; The conservative treatment for this client is to place the injured arm in an immobilizer. Surgical intervention is not considered conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

The client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention will the nurse perform first? A. Calls the Rapid Response Team to intubate B. Instructs the client on how to cough effectively C. Raises the head of the bed to 45 degrees D. Suctions the client

C; The head of the client's bed should be raised to 45 degrees because this allows increased lung expansion, which improves the client's ability to breathe.

The nurse is examining a womans breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask? a. When was your last mammogram at the clinic? b. How many cans of caffeinated soda do you drink in a day? c. Do the small lumps seem to change with your menstrual period? d. Do you have a first-degree relative who has breast cancer?

C; The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast conditions, but research has not found that it has a significant impact. Questions related to the clients last mammogram or breast cancer history are not related to the nurses assessment. DIF: Applying/Application REF: 1462

After receiving change-of-shift report on the urology unit, which client does the nurse assess first? A. Client post radical nephrectomy whose temperature is 99.8° F (37.6° C) B. Client with glomerulonephritis who has cola-colored urine C. Client who was involved in a motor vehicle crash and has hematuria Correct D. Client with nephrotic syndrome who has gained 2 kg since yesterday

C; The nurse should be aware of the risk for kidney trauma after a motor vehicle crash; this client needs further assessment and evaluation to determine the extent of blood loss and the reason for the hematuria because hemorrhage can be life-threatening. Although slightly elevated, the low-grade fever of the client who is post radical nephrectomy is not life-threatening in the same way as a trauma victim with bleeding. Cola-colored urine is an expected finding in glomerulonephritis. Because of loss of albumin, fluid shifts and weight gain can be anticipated in a client with nephrotic syndrome.

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A. Inability to tolerate everyday activities related to severe fatigue B. Inability to communicate verbally related to vocal weakness C. Potential for aspiration related to difficulty with swallowing D. Inability to care for self related to muscle weakness

C; The potential for aspiration is the highest priority client problem because the client's ability to maintain airway patency is compromised.

Which of the following nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern

C; The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. Complete blood count b. Culture and sensitivity c. Prostate-specific antigen d. Cystoscopy

C; The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.

When caring for a client who had a nephrostomy tube inserted 4 hours ago, which is essential for the nurse to report to the health care provider? A. Dark pink-colored urine B. Small amount of urine leaking around the catheter C. Tube that has stopped draining D. Creatinine of 1.8 mg/dL

C; The provider must be notified when a nephrostomy tube does not drain; it could be obstructed or dislodged. Pink or red drainage is expected for 12 to 24 hours after insertion and should gradually clear. The nurse may reinforce the dressing around the catheter to address leaking urine; however, the provider should be notified if there is a large quantity of leaking drainage, which may indicate tube obstruction. A creatinine level of 1.8 mg/dL is expected in a client early after nephrostomy tube placement (due to the minor kidney damage that required the nephrostomy tube).

A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.

C; This increased IOP indicates glaucoma. The nurses main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving immunoglobulin (IVIG). Which client finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99° F (37° C)

C; This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy.

A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best? a. Doing this allows time for absorption. b. I am keeping the drops in the eye. c. This prevents systemic absorption. d. I am stopping you from rubbing your eye.

C; This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? A) "Avoid contact sports." B) "Avoid rigorous exercise." C) "Wear helmets when riding a motorcycle." D) "Avoid driving in inclement weather."

C; Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what many health care professionals recommend to maintain health.

Which proper technique does the nurse use for eye drop instillation? A. Instilling the drops into the inner canthus B. Opening the eye by raising the upper eyelid C. Placing the eye drop in the lower lid pocket D. Touching the bottle tip to the eyeball

C; To instill eye drops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled.Instilling drops into the inner canthus causes the medication to enter the punctum and be absorbed systemically. The upper eyelid is larger than the lower eyelid and is used to protect the eye and keep the cornea moist; it should not be used to create a pocket to instill medication. Touching the bottle tip to any part of the eye could potentially contaminate the eye.

A client who is near blind is admitted to the hospital. What action by the nurse is most important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

C; Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A. - Surgical repair of the rotator cuff B. - Prescribed exercises of the affected arm C. - Activity limitations for the affected arm D. - Patient-controlled analgesia with morphine

C; activity limitations for the affected arm

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A. - Ensure that weights are placed on the floor. B. - Ensure that pins are not loose and tighten as needed. C. - Inspect the skin at least every 8 hours. D. - Remove the traction weights only for bathing.

C; inspect the skin at least every 8 hours

A client undergoes a surgical amputation of a lower extremity after a motor vehicle crash. The client's vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client? A. - Fitting the client with a prosthetic device B. - Inspecting the limb stump daily for signs of skin breakdown C. - Positioning and range-of-motion of the affected extremity D. - Teaching the client and family how to apply shrinker stockings

C; positioning and range-of-motion of the affected extremity

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? A. - "Avoid contact sports." B. - "Avoid rigorous exercise." C. - "Wear helmets when riding a motorcycle." D. - "Avoid driving in inclement weather."

C; wear helmets when riding a motorcycle

A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.) a. As long as I dont wipe my eyes, I can share my towel. b. Eye irrigations should be done with warm saline or water. c. I will throw away all my eye makeup when I get home. d. I wont touch the tip of the eyedrop bottle to my eye. e. When the infection is gone, I can use my contacts again.

CD; Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the clients eyes is possible. The client should discard all eye makeup being used at the time the infection started. When instilling eyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. The client should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when the infection first manifests also need to be discarded.

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? Select all that apply. A. Cab driver B. College student C. Lifeguard D. Racquetball player E. Registered nurse

CD; Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury.Cab drivers may require eyewear for corrective purposes but are not at high risk and in need of protective eyewear. College students are generally not at high risk. Although an RN would need eye protection at certain times, RNs do not routinely require protective eyewear for general work.

A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

CD; The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

What does the nurse teach a client to do to decrease the risk for urinary tract infection (UTI)? A. Limit fluid intake. B. Increase caffeine consumption. C. Limit sugar intake. D. Drink about 3 liters of fluid daily.

D

Which client does the nurse manager on the medical unit assign to an experienced LPN/LVN? A. A 42-year-old with painless hematuria who needs an admission assessment B. A 46-year-old scheduled for cystectomy who needs help in selecting a stoma site C. A 48-year-old receiving intravesical chemotherapy for bladder cancer D. A 55-year-old with incontinence who has intermittent catheterization prescribed

D

Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? A. Encouraging them to drink fluids B. Irrigating all catheters daily with sterile saline C. Recommending that catheters be placed in all clients D. Periodically reevaluating the need for indwelling catheters

D

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A) "My spouse will be the only person to change my dressing." B) "I can't believe that this has happened to me. I can't stand to look at it." C) "I do not want any visitors while I'm in the hospital." D) "It will take me some time to get used to this."

D;

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A) Cyclobenzaprine (Flexeril) B) Ibuprofen (Advil) C) Meperidine (Demerol) D) Patient-controlled analgesia (PCA) with morphine

D;

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a."I'll apply cortisone cream to reduce the inflammation." b."I'll apply a clean dressing after squeezing out the pus." c."I'll keep my arm down at my side to prevent spread." d."I'll cleanse the area prior to applying antibiotic cream."

D; Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.

A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a.Viral infection - Clindamycin (Cleocin) b.Bacterial infection - Acyclovir (Zovirax) c.Yeast infection - Linezolid (Zyvox) d.Fungal infection - Ketoconazole (Nizoral)

D; Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

A nurse is irrigating a client's ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort? a. Have the client tilt the head back. b. Re-position the client on the other side. c. Slow the rate of the irrigation. d. Stop the irrigation immediately.

D; During ear irrigation, if the client becomes nauseated, stop the procedure. The other options are not helpful.

A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing

D; The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct.

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A) "Simple fracture involves a break in the bone, with skin contusions." B) "Compound fracture does not extend through the skin." C) "Simple fracture is accompanied by damage to the blood vessels." D) "Compound fracture involves a break in the bone, with damage to the skin."

D; A compound fracture involves a break in the bone with damage to the skin. A simple fracture does not extend through the skin. A compound fracture is accompanied by damage to blood vessels.

During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99 F (37.2 C) d. Dusky color of the flap

D; A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse should notify the surgeon to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but should be monitored. DIF: Applying/Application REF: 1476

Which statement by the client indicates that teaching has been effective? A. "Because renal cell carcinoma usually affects both kidneys, I'll need to be watched closely." B. "I'll eventually require some type of renal replacement therapy." C. "I'll need to decrease my fluid intake to prevent stress to my remaining kidney." D. "My remaining kidney will provide me with normal kidney function now."

D; After a nephrectomy, the second kidney is expected to eventually provide adequate kidney function, but this may take days or weeks. Renal cell carcinoma typically only affects one kidney. Renal replacement therapy is not the typical treatment for renal cell carcinoma. Fluids should be maintained to flush the remaining kidney.

A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)? a. Aid in the draining of the cysts by needle aspiration. b. Teach the client to wear a supportive bra to bed. c. Administer diuretics to decrease breast swelling. d. Obtain a cold pack to temporarily relieve the pain.

D; All of the options would be comfort measures for a client with a fibrocystic breast condition. The UAP can obtain the cold or heat therapy. Only the nurse should aid the health care provider with a needle aspiration, teach, and administer medications. DIF: Applying/Application REF: 1462

The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? A) Inspect the abdomen for tenderness and bowel sounds. B) Auscultate lung sounds. C) Assess the level of consciousness and ability to follow commands. D) Assess sensation of the right upper extremity.

D; Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus. Inspecting the abdomen and auscultating lung sounds of the client with multiple fractures are not part of a focused neurovascular assessment. Because the client does not have a head injury, assessing the client's level of consciousness and ability to follow commands is not part of a focused neurovascular assessment.

Which staff member does the charge nurse assign to a client who has benign prostatic hyperplasia and hydronephrosis and needs an indwelling catheter inserted? A. RN float nurse who has 10 years of experience with pediatric clients B. LPN/LVN who has worked in the hospital's kidney dialysis unit until recently C. RN without recent experience who has just completed an RN refresher course D. LPN/LVN with 5 years of experience in an outpatient urology surgery center

D; Catheterization of a client with an enlarged prostate, a skill within the scope of practice of the LPN/LVN, would be performed frequently in a urology center. The pediatric nurse would have little exposure to prostatic obstruction and adult catheterization. Dialysis clients do not typically have catheters inserted, so the LPN/LVN from the kidney dialysis unit would not be the best staff member to assign to the client.

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, "Will my children develop this disease?" How should the nurse respond? a. "No genetic link is known, so your children are not at increased risk." b. "Your sons will develop this disease because it has a sex-linked gene." c. "Only if both you and your spouse are carriers of this disease." d. "Each of your children has a 50% risk of having ADPKD."

D; Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this client's teaching? a. "Since you only have one kidney, a salt and fluid restriction is required." b. "Your therapy will include hemodialysis while you recover." c. "Medication will be prescribed to control your high blood pressure." d. "You need to avoid participating in contact sports like football."

D; Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

A client is in the preoperative holding area waiting for cataract surgery. The client says Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix. What action by the nurse is most important? a. Ask the client when the last dose was. b. Check results of the prothrombin time (PT) and international normalized ratio (INR). c. Document the information in the chart. d. Notify the surgeon immediately.

D; Clopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notified immediately. The nurse should find out when the last dose of the drug was, but the priority is to notify the provider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.

Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? a) Recent radical mastectomy client requiring chemotherapy administration b) Modified radical mastectomy client needing discharge teaching c) Stage III breast cancer client requesting information about radiation and chemotherapy d) Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy (Chp. 70, elsevier resources)

d; A nurse working in the ICU would be familiar with postoperative monitoring and care of clients with Jackson-Pratt drains. The recent radical mastectomy client requires chemotherapy, so it is more appropriate to assign her to nurses who are familiar with teaching, monitoring, and providing chemotherapy for clients with breast cancer. The modified radical mastectomy client who requires discharge teaching, and the stage III breast cancer client requiring information about radiation and chemotherapy are more appropriate to assign to nurses who are familiar with breast cancer. (Chp. 70, elsevier resources)

A client with testicular cancer is worried about sterility and the ability to conceive children later. Which resource does the nurse refer the client to before surgery takes place? a) American Cancer Society b) American Fertility Society c) RESOLVE: The National Infertility Association d) Sperm bank (Chp 72, elsevier resources)

d; After radiation therapy or chemotherapy has been started, the client is at increased risk for producing mutagenic sperm, which may not be viable or may result in fetal abnormalities. If the client is interested in having children, he should be encouraged to arrange for semen storage as soon as possible after diagnosis. Sperm collection should be completed before radiation therapy or chemotherapy is started. The client is referred to the American Cancer Society for more generalized information on testicular cancer. The American Fertility Society and RESOLVE: The National Infertility Association are appropriate referrals if permanent sterility occurs and sperm storage has not been feasible. (Chp 72, elsevier resources)

The issue that is often foremost in the minds of men who have been diagnosed with prostate cancer and must be addressed by the nurse is the alteration of which factor? a) Comfort because of surgical pain b) Mobility after treatment c) Nutrition because of radiation side effects d) Sexual function after treatment (Chp 72, elsevier resources)

d; Altered sexual function is one of the biggest concerns of men after cancer treatment. Comfort, mobility, and nutrition are important, but are typically not the foremost concern in the minds of men with prostate cancer. (Chp 72, elsevier resources)

A large-breasted client reports discomfort, backaches, and fungal infections because of her excessive breast size. The nurse provides information to the client about which breast treatment option? a) Augmentation b) Compression c) Reconstruction d) Reduction mammoplasty (Chp. 70, elsevier resources)

d; Breast reduction mammoplasty surgery removes excess breast tissue and repositions the nipple and remaining skin flaps to produce the best cosmetic effect. Breast augmentation surgery enhances the size, shape, or symmetry of breasts. Breast compression is not a treatment. Breast reconstruction surgery is typically performed for women after a mastectomy. (Chp. 70, elsevier resources)

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? a. Dry, flaky cerumen b. Pain on movement of the tragus c. Ringing in the ears d. Dizziness

d; Dizziness

Hormone treatment for prostate cancer works by which action? a) Decreases blood flow to the tumor b) Destroys the tumor c) Shrinks the tumor d) Suppresses growth of the tumor (Chp 72, elsevier resources)

d; Hormone therapy, particularly antiandrogen drugs, inhibits tumor progression by blocking the uptake of testicular and adrenal androgens at the prostate tumor site. Antiandrogens may be used alone or in combination with luteinizing hormone-releasing hormone agonists for a total androgen blockade (hormone ablation). Hormone treatment for prostate cancer does not decrease blood flow to the tumor, destroy the tumor, or shrink the tumor. (Chp 72, elsevier resources)

The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching? a. "I dry my ears using my fingertip and a towel." b. "I may irrigate my ears with tap water." c. "I should not use an ear candle to soften the wax." d. "I use a cotton swab to remove earwax."

d; I use a cotton swab to remove earwax

The nurse is educating a group of young men about testicular self-examination (TSE). Which statement by a member of the group indicates teaching has been effective? a) "I will examine my testicles right before taking a shower." b) "I should squeeze each testicle in my hand to feel any lumps." c) "I should only report any large lumps to my health care provider." d) "I will look and feel for any lumps or changes to my testes." (Chp 72, elsevier resources)

d; With early detection by monthly TSE and treatment, testicular cancer can be successfully cured. In TSE, the client should look and feel for any lumps or changes to the testes. Any lumps that are detected should be immediately reported. A TSE should be performed immediately following a shower. The client should gently roll each testicle between the thumb and forefinger. All lumps should be reported to the provider, no matter the size. (Chp 72, elsevier resources)

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase inhibitor (ChE). The nurse plans to contact the physician if the client is taking which medication? A. Acetaminophen (Tylenol) B. Furosemide (Lasix) C. Ibuprofen (Advil, Motrin, others) D. Procainamide (Pronestyl)

D; Procainamide (Pronestyl) should be avoided because it may increase the client's weakness.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, "What can I do to help prevent these infections?" How should the nurse respond? a. "Test your urine daily for the presence of ketone bodies and proteins." b. "Use tampons rather than sanitary napkins during your menstrual period." c. "Drink more water and empty your bladder more frequently during the day." d. "Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled."

C; Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client's sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? A. Bilateral eye patches B. Contact lenses C. Nothing; this is normal D. Reading glasses

C; Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment.Bilateral eye patches inhibit the client's vision. Contact lenses are used to correct under refraction of the eye. Reading glasses are used to correct over refraction of the eye.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

C; Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. Checking the amount of urine in the urine catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

C; Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions. DIF: Applying/Application REF: 1473

Which information suggests that a client with diabetes may be in the early stages of kidney damage? A. Elevation in blood urea nitrogen (BUN) B. Oliguria C. Microalbuminuria D. Painless hematuria

C; In the early stages of diabetic nephropathy, micro-levels of albumin are first detected in the urine. Progressive kidney damage occurs before dipstick procedures can detect protein in the urine. BUN may change in response to protein and fluid intake. Oliguria is a later finding in kidney disease and may also be present in dehydration. Painless hematuria often occurs with kidney cancer.

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

C; Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable masses throughout the breast tissue could be a fibrocystic breast condition. A firm, defined mobile mass in the lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local abscess or ductal ectasia. DIF: Applying/Application REF: 1469

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each of my three children for 12 months. b. It looks as though I need to start working out at the gym more often. c. I am glad that we can still have wine with every evening meal. d. When I have menopausal symptoms, I must avoid hormone replacement therapy.

C; Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for breast cancer prevention. DIF: Applying/Application REF: 1465

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, which should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. The disease is inherited as an autosomal, sex-linked, recessive gene. C. Muscle function will gradually return, and recovery is possible in most children. D. The disease results from an apparently toxic reaction to certain medications.

C; Most patients regain full muscle strength. The return of function is in reverse order of onset.

What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago? a. Placing the head of bed at 30 degrees b. Elevating the left arm on a pillow c. Administering morphine for pain at a 4 on a 0-to-10 scale d. Supporting the left arm while initially ambulating the client

C; Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of pain by the client. The UAP could position the bed to 30 degrees and elevate the clients arm on a pillow to facilitate lymphatic fluid drainage return. The clients arm should be supported while walking at first but then allowed to hang straight by the side. The UAP could support the arm while walking the client. DIF: Applying/Application REF: 1474

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? A. Snellen eye examination result is 20/50 for a client who normally wears corrective lenses but does not have them at the time of the examination. B. When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. C. The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. D. When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

D; Cloudiness in the cornea and pain from a light shined into the pupil is an abnormal finding that requires further assessment and possible intervention and/or referral.A Snellen eye examination result of 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination is normal given the client's baseline and considering that he or she wears corrective lenses. It can be a normal finding for the client to exhibit nystagmus when looking to the left lower and upper fields during assessment of the six cardinal positions of gaze of the left eye. It is normal for the pupil to exhibit miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil.

The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

D; Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the clients behavior, which statement by the nurse would be the most appropriate? a. The urine incontinence should not prevent you from socializing. b. You seem depressed and should seek more pleasant things to do. c. It is common for men at your age to have changes in mood. d. Nocturia could cause interruption of your sleep and cause changes in mood.

D; Frequent visits to the bathroom during the night could cause sleep interruptions and affect the clients mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity.

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? A. Anisocoria B. Presbyopia C. Diabetic retinopathy D. Glaucoma

D; Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best? a. Advise the client to restrict fluids. b. Assess the client for signs of infection. c. Have the client add table salt to food. d. Instruct the client on a magnesium supplement.

D; Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed.

When caring for a client with hemorrhage secondary to kidney trauma, the nurse provides volume expansion. Which element does the nurse anticipate will be used? A. Fresh-frozen plasma B. Platelet infusions C. 5% dextrose in water D. Normal saline solution (NSS)

D; Isotonic solutions and crystalloid solutions are administered for volume expansion; 0.9% sodium chloride (NSS) and 5% dextrose in 0.45% sodium chloride may be used. Clotting factors, contained in fresh-frozen plasma, are given for bleeding, not for volume expansion. Platelet infusions are administered for deficiency of platelets. A solution hypotonic to the client's blood, 5% dextrose, is administered for nutrition or hypernatremia, not for volume expansion.

Which goal for a client with diabetes will best help to prevent diabetic nephropathy? A. Heed the urge to void. B. Avoid carbohydrates in the diet. C. Take insulin at the same time every day. D. Maintain glycosylated hemoglobin (HbA1c).

D; Maintaining long-term control of blood glucose will help prevent the progression of diabetic nephropathy. Voiding when the client has the urge prevents the backflow of urine and infection. The diabetic diet is composed of carbohydrates, proteins, and fats. Although taking insulin at the same time each day may indirectly help control blood glucose, it is not the best option.

The client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse? A. "I'll need artificial tears at least four times a day." B. "I will eat a soft diet." C. "My eye must be taped or patched at bedtime." D. "Narcotics will be needed for pain relief."

D; Mild analgesics, not narcotics, are used for pain associated with Bell's palsy.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Have any new lesions genetically tested. D. Perform a total skin self-examination monthly with a partner.

D; Perform a total skin self-examination monthly with a partner. Perform a total skin self-examination monthly with a partner. The nurse teaches the client that performing a monthly total skin self-examination with another person is the best secondary preventive measure.If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. Genetic testing of lesions is performed to determine whether targeted therapy will be effective.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the client's urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the client's pulse.

D; The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Assess the client for shortness of breath. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the provider.

D; The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

When preparing a client for nephrostomy tube insertion, it is essential for the nurse to monitor which factor before the procedure? A. Blood urea nitrogen (BUN) and creatinine B. Hemoglobin and hematocrit (H&H) C. Intake and output (I&O) D. Prothrombin time (PT) and international normalized ratio (INR)

D; The procedure will be cancelled or delayed if coagulopathy in the form of prolonged PT/INR exists because dangerous bleeding may result. Nephrostomy tubes are placed to prevent and treat kidney damage; monitoring BUN and creatinine is important, but is not essential before this procedure. H&H is monitored to detect anemia and blood loss; this would not occur before the procedure. This client should be on I&O during the entire hospitalization; it is not necessary only before the procedure, but throughout the admission.

A client with pyelonephritis has been prescribed urinary antiseptic medication. What purpose does this medication serve? A. Decreases bacterial count B. Destroys white blood cells C. Enhances the action of antibiotics D. Provides comfort Correct

D; Urinary antiseptic drugs such as nitrofurantoin (Macrodantin) are prescribed to provide comfort for clients with pyelonephritis. Antibiotics, not antiseptics, are used to decrease bacterial count and treat pyelonephritis infection; the action of antibiotics is not enhanced with antiseptics. White blood cells, along with antibiotics, fight infection.

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? a. Ability to chew and swallow without aspiration b. Eating 75% of meals and between-meal snacks c. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month

D; Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.

A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? A. - "Simple fracture involves a break in the bone, with skin contusions." B. - "An open fracture does not extend through the skin." C. - "Simple fracture has an increased risk for infection and emboli." D. - "An open fracture involves a break in the bone, with damage to the skin."

D; an open fracture involves a break in the bone, with damage to the skin

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. - Removing the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. - Assessing for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. - Teaching a client with a right ankle fracture how to use crutches when transferring and ambulating. D. - Checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

D; checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. - "My spouse will be the only person to change my dressing." B. - "I can't believe that this has happened to me. I can't stand to look at it." C. - "I do not want any visitors while I'm in the hospital." D. - "It will take me some time to get used to this."

D; it will take me some time to get used to this

The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated? A. - Elevate the extremity. B. - Apply an ice pack to the extremity. C. - Reposition the extremity and recheck in 15-20 minutes. D. - Notify the provider of these findings.

D; notify the provider of these findings

An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A. - Cyclobenzaprine (Flexeril) B. - Ibuprofen (Advil) C. - Meperidine (Demerol) D. - Patient-controlled analgesia (PCA) with morphine

D; patient-controlled analgesia (PCA) with morphine

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? A. - Skin to evaluate lacerations and abrasions. B. - Lungs for bilateral normal breath sounds C. - Pain score and level of alertness D. - Urine dipstick for the presence of red blood cells.

D; urine dipstick for the presence of red blood cells

A client has purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first a. put on gloves b. obtain an informed consent c. administer a Snellen test d. instill antibiotic drops -

a

A client has sustained damage to the optic nerve (cranial nerve II) after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? a. Identifying food on the client's plate using the clock method b. Daily eye assessment of the six cardinal positions of gaze c. Artificial tears d. Ensuring that the client wears sunglasses when the curtains are open or when the room light is on -

a

A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first? A. Administer morphine sulfate 4 mg IV. B. Begin an infusion of metoclopramide (Reglan) 10 mg IV. C. Obtain a urine specimen for urinalysis. D. Start an infusion of 0.9% normal saline at 100 mL/hr.

a

A client who was previously diagnosed with a urinary tract infection (UTI) and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen, the client states, "I only took the first dose because after that, I felt better." How does the nurse respond? A. "Not completing your medication can lead to return of your infection." B. "That means your treatment will be prolonged with this new infection." C. "This means you will now have to take two drugs instead of one." D. "What you did was okay however, let's get you started on something else."

a

The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows a correct understanding of what the nurse has taught? A. "I need to be drinking at least 1.5 to 2.5 liters of fluids every day." B. "It is a good idea for me to reduce germs by taking a tub bath daily." C. "Trying to get to the bathroom to urinate every 6 hours is important for me." D. "Urinating 1000 mL on a daily basis is a good amount for me."

a

The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement? a. Instill antibiotic drops into the eyes. b. Apply a warm pack to the eyes. c. Contact the recipient family. d. Elevate the lower extremities. -

a

The nurse is questioning a female client with a urinary tract infection (UTI) about her antibiotic drug regimen. Which statement by the client indicates a need for further instruction? A. "I take my medication only when I have symptoms." B. "I always wipe front to back." C. "I don't use bubble baths and other scented bath products." D. "I try to drink 3 liters of fluid a day."

a

A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which response by the nurse is best? a) "Tell me what you mean when you say you don't know how this could have happened to you." b) "Do you have a family history that might make you more likely to develop breast cancer?" c) "Would you like me to help you find more information about how breast cancer develops?" d) "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it." (Chp. 70, elsevier resources)

a; The client's statement that he or she does not know how this could have happened may indicate shock and denial or a request for more information. To provide appropriate care, further assessment is needed about the client's psychosocial status. The first action by the nurse in this situation is to obtain more data by asking open-ended questions. The nurse needs to further assess the client's emotional status before asking about family history of cancer or obtaining information for the client. (Chp. 70, elsevier resources)

The nurse is teaching post-mastectomy exercises to a client. Which statement made by the client indicates that teaching has been effective? a) "For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." b) "In rope turning, I'll hold the rope with my arms flexed." c) "In rope turning, I'll start by making large circles." d) "With hand wall climbing, I'll walk my hands up the wall and back down until they are at waist level." (Chp. 70, elsevier resources)

a; To perform the pulley exercise properly, the client should drape a 6-foot-long rope over a sturdy structure. In rope turning, the client holds the end of the rope and steps back from the door until the arm is almost straight out in front. The client starts with small circles and gradually increases to larger circles as the client becomes more flexible. With hand wall climbing, the client walks the hands up the wall and then back down until they are at shoulder level. (Chp. 70, elsevier resources)

A client with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the client about this type of pharmacologic management? (Select all that apply.) a) Avoid drugs used to treat erection problems. b) Be careful when changing positions. c) Keep all appointments for follow-up laboratory testing. d) Hearing tests will need to be conducted periodically. e) Take the medication in the afternoon. (Chp 72, elsevier resources)

abc; Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage, so it is important to keep appointments for follow-up laboratory testing. These drugs do not affect hearing. Alpha-adrenergic blockers should be taken in the evening to decrease the risk of problems related to hypotension. (Chp 72, elsevier resources)

Which clients are at high risk for developing hearing problems? Select all that apply. a. Airline mechanic b. Client with Down syndrome c. Drummer in a rock band d. Teenager listening to music using ear buds e. Telephone operator

abcd;

A client with a urinary tract infection is prescribed trimethoprim/sulfamethoxazole (Bactrim). What information does the nurse provide to this client about taking this drug? Select all that apply. A. "Be certain to wear sunscreen and protective clothing." B. "Drink at least 3 liters of fluids every day." C. "Take this drug with 8 ounces (236 ml) of water." D. "Try to urinate frequently to keep your bladder empty." E. "You will need to take all of this drug to get the benefits."

abce

What information will the nurse provide to a client who is scheduled for extracorporeal shock wave lithotripsy? Select all that apply. A. "Your urine will be strained after the procedure." B. "Be sure to finish all of your antibiotics." C. "Immediately call the primary health care provider if you notice bruising." D. "Remember to drink at least 3 liters of fluid a day to promote urine flow." E. "You will need to change the incisional dressing once a day."

abd

Which clients with long-term urinary problems does the nurse refer to community resources and support groups? Select all that apply. A. A 32-year-old with a cystectomy B. A 44-year-old with a Kock pouch C. A 48-year-old with urinary calculi D. A 78-year-old with urinary incontinence E. An 80-year-old with dementia

abd

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (Select all that apply.) Select all that apply. a. Announce name and purpose when entering the client's room. b. Orient the client to the location of the call light, and keep it in that place. c. Speak in a loud, clear voice. d. Orient the client to the room surroundings and equipment. e. Explain food positions on the tray using a clock face as the example. -

abde

A client with prostate cancer asks the nurse for more information and counseling. Which resources does the nurse suggest? (Select all that apply.) a) American Cancer Society's Man to Man program b) Us TOO International c) American Prostate Cancer Society d) National Prostate Cancer Coalition e) Client's church, synagogue, or place of worship (Chp 72, elsevier resources)

abde; The American Cancer Society's Man to Man program helps the client and partner cope with prostate cancer by providing one-on-one education, personal visits, education presentations, and the opportunity to engage in open and candid discussions. Us TOO International is a prostate cancer support group that is sponsored by the Prostate Cancer Education and Support Network. The National Prostate Cancer Coalition provides prostate cancer information. The client's church, synagogue, or place of worship is a community support service that may be important for many clients. There is no such organization as the American Prostate Cancer Society. (Chp 72, elsevier resources)

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) Select all that apply. a. Blowing the nose frequently b. Bending over to tie shoes c. Sitting with legs elevated d. Sleeping on more than two pillows e. Lifting objects weighing more than 10 pounds (4.5 kg) -

abe

Which clients with an indwelling urinary catheter does the nurse reassess to determine whether the catheterization needs to be continued or can be discontinued? Select all that apply. A. Three-day postoperative client B. client in the step-down unit C. Comatose client with careful monitoring of intake and output (I&O) D. Incontinent client with perineal skin breakdown E. Incontinent older adult in long-term care

abe

A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? (Select all that apply.) a) Administer antispasmodic medications. b) Encourage the client to urinate around the catheter if pressure is felt. c) Perform intermittent urinary catheterization every 4 to 6 hours. d) Place the client in a supine position with his knees flexed. e) Assist the client to mobilize as soon as permitted. (Chp 72, elsevier resources)

ae; Antispasmodic drugs can be administered to decrease the bladder spasms that may occur due to catheter use. Assisting the client to a chair as soon as permitted postoperatively will help to decrease the risk of complications from immobility. An indwelling catheter and continuous bladder irrigation are in place for about 24 hours after TURP. The client should not try to void around the catheter, which causes the bladder muscles to contract and may result in painful spasms. Intermittent urinary catheterization is not necessary. Typically, the catheter is taped to the client's thigh, so he should keep his leg straight. (Chp 72, elsevier resources)

A client has recently had cataract surgery. The nurse will instruct the client to notify the health care provider immediately if which symptom occurs? a. Itching of the eye b. Reduction in vision c. Increased tearing d. Swollen eyelid -

b

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? a. "I will be sure to pick up all clutter and loose carpets from the floor." b. "I will rearrange the furniture for better flow before my spouse gets home." c. "I will get some books on tape for entertainment." d. "I will place a nonslip mat in the bathtub." -

b

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? a. Suggesting a seeing-eye animal companion b. Building on the remaining vision c. Teaching Braille d. Keeping the floor free of clutter -

b

The nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification? A. "A small-lumen catheter will help prevent injury to my urethra." B. "I will use a new, sterile catheter each time I do the procedure." C. "My family members can be taught to help me if I need it." D. "Proper handwashing before I start the procedure is very important."

b

The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? A. A 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4°F (37.4°C) B. A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours C. A 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy D. A 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

b

What is the action of miotic drugs that constrict the pupils in the client with glaucoma? a. Increase the production of vitreous humor b. Enhance aqueous circulation to site of absorption c. Vasoconstrict the blood vessels in the eye d. Decrease the inflammatory process -

b

A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick. What is the nurse's best action? a) notify the charge nurse as soon as possible b) increase the rate of bladder irrigation c) document the assessment in the medical record d) prepare the patient for a blood transfusion (Ignatavicius & Workman, p. 1506)

b;

A client had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning. What is the nurse's priority for care? a) assess the client's pain level and provide pain management b) ensure that the client's urinary catheter is draining clear yellow urine c) observe the client's incision for redness, swelling, and drainage d) apply oxygen therapy via nasal cannula at 2 L/min (Ignatavicius & Workman, p. 1515)

b;

A client with prostate cancer asks why he must have surgery instead of radiation, even if his cancer is the least-invasive type. What is the nurse's best response? a) "It is because your cancer growth is large." b) "Surgery is the most common intervention to cure the disease." c) "Surgery slows the spread of cancer." d) "The surgery is to promote urination." (Chp 72, elsevier resources)

b; Because some localized prostate cancers are resistant to radiation, surgery is the most common intervention for a cure. The size of the tumor is not likely to be why the client is having surgery. A bilateral orchiectomy (removal of both testicles) is palliative surgery that slows the spread of cancer by removing the main source of testosterone. A transurethral resection of the prostate is done to promote urination for clients with advanced disease; it is not used as a curative treatment. (Chp 72, elsevier resources)

Why is prostate cancer screening often emphasized to the African-American population in the United States? a) Metastasis of prostate cancer is higher. b) Prostate cancer occurs at an earlier age. c) Prostate-specific antigen (PSA) is not sensitive to prostate disease. d) Clinical presentation is different. (Chp 72, elsevier resources)

b; In the United States, prostate cancer affects African-American men the most and at an earlier age. There is no difference in prostate cancer metastasis, PSA sensitivity, or clinical presentation of prostate cancer in the African-American population as compared to other populations. (Chp 72, elsevier resources)

Which assessment finding indicates to the nurse that a client is at high risk for a malignant breast lesion? a) A 1-cm freely mobile rubbery mass discovered by the client b) Ill-defined painful rubbery lump in the outer breast quadrant c) Backache and breast fungal infection d) Nipple discharge and dimpling (Chp. 70, elsevier resources)

d; Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion. On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses usually discovered by the woman herself; their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter. Although the immediate fear is breast cancer, the risk of its occurring within a fibroadenoma is very small. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition; the lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common. (Chp. 70, elsevier resources)

What is the proper technique for assessing an adult client's ear with an otoscope? a. Hold the otoscope right side up when inserting it into the ear canal. b. Maintain distance between the otoscope and the client's head. c. Place the otoscope in the nondominant hand. d. Pull the pinna up and back with the nondominant hand.

d; Pull the pinna up and back with the non dominant hand

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? a. Provide further assessment. b. Suggest a quiet environment. c. Suggest temporary removal of a hearing aid. d. Refer the client to the American Tinnitus Association.

d; Refer the client to the American Tinnitus Association

A client who has just been discharged from the hospital after a modified radical mastectomy is referred to a home health agency. Which nursing action is most appropriate to delegate to an experienced home health aide? a) Assessing the safety of the home environment b) Developing a plan to decrease lymphedema risk c) Monitoring pain level and analgesic effectiveness d) Reinforcing the guidelines for hand and arm care (Chp. 70, elsevier resources)

d; Reinforcement of previously taught information about hand and arm care should be done by all caregivers. Assessment, developing a care plan, and monitoring pain level and analgesic effectiveness are not within the scope of practice of a home health aide and should be done by licensed nursing staff. (Chp. 70, elsevier resources)

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? a. "I may need to use a cane." b. "I should keep my grandkids' toys out of the hallway." c. "Moving more slowly may help the vertigo subside." d. "Taking my medication will allow me to drive my car again."

d; Taking my medication will allow me to drive my car again

A client receiving external beam radiation therapy calls the nurse to report rectal urgency, cramping, and passing of mucus and blood. What is the nurse's best response? a) "This is an emergency. Go directly to the emergency department." b) "This is normal and will resolve as soon as the treatment stops." c) "Avoid caffeine and continue drinking plenty of water and other fluids." d) "Limit spicy or fatty foods, caffeine, and dairy products." (Chp 72, elsevier resources)

d; The client's symptoms indicate that he is experiencing radiation proctitis, a common complication of external beam radiation therapy. The nurse's instructions to limit spicy or fatty foods, caffeine, and dairy products describe what the client should do to alleviate these symptoms. The client's symptoms do not indicate an emergency, but they should be reported to the health care provider. The client's symptoms should resolve 4 to 6 weeks after the treatment stops. Avoiding caffeine and drinking water and other fluids describe what the client should do if he is experiencing radiation cystitis, which he is not. (Chp 72, elsevier resources)

Which statement about the early detection of breast masses is correct? a) Clinical breast examinations should be done yearly starting at age 20. b) Detection of breast cancer before or after axillary node invasion yields the same survival rate. c) Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. d) The goal of screening for breast cancer is early detection. (Chp. 70, elsevier resources)

d; The purpose of screening is early detection of cancer before it spreads. It is recommended that the clinical breast examination be part of a periodic health assessment at least every 3 years for women in their 20s and 30s, and every year for asymptomatic women who are at least 40 years of age. Detection of breast cancer before axillary node invasion increases the chance of survival. The American Cancer Society recommends screening with mammography annually beginning at age 40. (Chp. 70, elsevier resources)

The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which statement by the client indicates a need for further teaching? a) "Hormonal therapy is only used to prevent the growth of cancer. It won't get rid of it." b) "I might have chemotherapy before surgery." c) "If I get radiation, I am not radioactive to others." d) "Radiation will remove the cancer, so I might not need surgery." (Chp. 70, elsevier resources)

d; Typically, radiation therapy follows surgery to kill residual tumor cells. Radiation therapy plays a critical role in the therapeutic regimen and is an effective treatment for almost all sites where breast cancer can metastasize. The purpose of radiation therapy is to reduce the risk for local recurrence of breast cancer. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Chemotherapy drugs destroy breast cancer cells that may be present anywhere in the body; they are typically administered after surgery for breast cancer, although neoadjuvant chemotherapy may be given to reduce the size of a tumor before surgery. The client receiving radiation therapy is radioactive only if the radiation source is dwelling inside the breast tissue. (Chp. 70, elsevier resources)