Final Exam Adult Health 1

ANS: D. Airborne

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne

ANS: C. A decrease in urine output Rationale: The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Vasopressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insipidus. A decreased urine output is the desired response

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective? A. A decrease in blood sugar B. A decrease in blood pressure C. A decrease in urine output D. A decrease in specific gravity

ANS: A. Send fluid to the laboratory for culture Rationale: Cloudy dialysate indicates infection (peritonitis). Culture of the fluid must be done to determine the microorganism present.

The client with continuous ambulatory peritoneal dialysis (CAPD) has cloudy dialysate. Which of the following is the best initial nursing action? A. Send fluid to the laboratory for culture B. Administer antibiotic C. Do nothing, this is expected D. Stop drainage of fluid

ANS: D. Document the finding as normal Rationale: The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? A. Urge the client to drink more water B. Notify the primary health care provider C. Assess the client's deep tendon reflexes D. Document the finding as normal

ANS: B. pH 7.48

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? A. PaCO 36 B. pH 7.48 C. HCO 21 mEq/L D. O saturation 95%

ANS: C. A continuous passive range-of-motion (ROM) machine.

Which device will assist the patient with a knee replacement to maintain the flexibility of the knee? A. A trochanter roll. B. An abductor pillow. C. A continuous passive range-of-motion (ROM) machine. D. A hemovac drainage device.

ANS: C. 27% Rationale: According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? A. 9% B. 18% C. 27% D. 36%

ANS: B. 22.5% Rationale: Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Since the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18% or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%

ANS: D. Uncompensated respiratory acidosis Rationale: The increased PaCO2 indicates respiratory acidosis, and the low pH indicates that the respiratory acidosis is uncompensated. The PaO2 is normal, indicating that the client is not hypoxemic. The elevated PaCO2 indicates hypercapnia. The HCO3 is normal, indicating that there is no metabolic acidosis.

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? A. Hypoxemia B. Hypocapnia C. Compensated metabolic acidosis D. Uncompensated respiratory acidosis

ANS: D. Diabetes mellitus

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? A. Osteoarthritis B. Glaucoma C. Deafness D. Diabetes mellitus

ANS: D. Serum bicarbonate of 28 mEq/L

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? A. pH 7.26 B. Serum bicarbonate of 21 mEq/L C. pH 7.30 D. Serum bicarbonate of 28 mEq/L

ANS: B. Do not lie down for 2 hours after eating

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? A. Limit caffeine intake to two cups of coffee per day B. Do not lie down for 2 hours after eating C. Follow a low-protein diet D. Take medications with milk to decrease irritation

ANS: C. Ask the client to describe the characteristic of the pain.

A Nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a CPM machine and PCA. The client tell the nurse " I am in so much pain". Which of the following should the nurse take first? A. Remind client to push the button for the PCA device. B. Discuss the activities the client can use to distract from pain. C. Ask the client to describe the characteristic of the pain. D. Pause the CPM machine briefly to apply a cold pack to client's knee

ANS: A. 63% Rationale: Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

A 58-year-old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

ANS: C. Metabolic alkalosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis

ANS: D. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. This type of traction involves pulleys and wheels, not pins and screws

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? A. Allows bony healing to begin before surgery and involves pins and screws B. Provides rigid immobilization of the fracture site and involves pulleys and wheels C. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws D. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

ANS: B. Prepare to assist with ventilation.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Monitor the client's heart rhythm. B. Prepare to assist with ventilation. C. Obtain a urine specimen for drug screening. D. Prepare for gastric lavage.

ANS: C. Respiratory alkalosis, uncompensated Rationale: The client's pH is high, indicating alkalosis. The PaCO2 is abnormal, indicating a respiratory basis. The HCO3 is normal, indicating that compensation has not started. The HCO3 level would decrease with compensation. The primary disturbance is respiratory, as indicated by the decrease in the PaCO2 parameter.

A client's blood gas results are pH 7.48, PaCO2 30 mmHg, HCO3 23 mEq/L. What will the nurse suspect that the client is at risk for? A. Respiratory alkalosis, compensated B. Metabolic alkalosis, uncompensated C. Respiratory alkalosis, uncompensated D. Metabolic alkalosis, compensated

ANS: C, E Rationale: Extrinsic risk factors are external to the patient and related to the physical environment and include lack of support equipment by bathtubs and toilets, height of beds, condition of floors, poor lighting, inappropriate footwear, and improper use of or inadequate assistive devices. Nightlights, railings on the stairway, and the use of a cane are all measures that can ameliorate some extrinsic risk factors.

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the patient eliminate which of the following? (Select all that apply.) A. Night-lights B. Railings on the stairway C. Loose carpeting on the floors D. The use of a cane E. Excess clutter

ANS: A, D, E Rationale: The absence of railings on stairways, clutter, and throw rugs can all contribute to falls in the home. Night-lights are recommended to prevent falls as are grab bars positioned beside the toilet in the bathroom.

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. Which of the following are hazards in the home? (Select all that apply.) A. Clutter throughout the home B. Night-lights in all rooms C. Grab bars in bathroom beside toilet D. The absence of railings on the stairway E. A small throw rug outside of the shower stall

ANS: B, C, E Rationale: B, C, E are extrinsic risk factors and A, D are intrinsic factors.

A homecare nurse visits a client in the home to conduct a fall risk assessment. The nurse assesses the client and the home for extrinsic risk factors for falls. Which of the following are extrinsic risk factors? (Select all that apply) A. Unsteady gait B. Inappropriate sized cane C. Cluttered home D. Two different medications that cause orthostatic hypotension E. There are no grab bars in the client's bathroom

ANS: A, B, E, F Rationale: Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is normal finding

A nurse assesses a client who is admitted for treatment to fluid overload. Which sign and symptom does the nurse expect to find? A. Increased pulse rate B. Distended neck veins C. Decreased blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances

ANS: A, B, D Rationale: A continuous passive motion device promotes motion in the knee and prevents scar tissue formation. The nurse should assess the strength of the pulses of both lower extremities to help determine adequate circulation. A pillow should not be placed behind the knee to avoid flexion contractures. The nurse should prevent pressure ulcers on the client's heels by elevating the heels off the bed with a pillow. The nurse should apply cold therapy, not heat therapy, to reduce postoperative swelling.

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.) A. Maintain continuous passive motion device. B. Palpate dorso-pedal pulses. C. Place pillow behind the knee. D. Elevate heels off bed. E. Apply heat therapy to incision.

ANS: B. Cardiac rhythm Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? A. Deep tendon reflexes B. Cardiac rhythm C. Peripheral sensation D. Bowel sounds

ANS: A. Nausea and vomiting Rationale: A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A. Nausea and vomiting B. Extreme thirst C. Flushed skin D. Fever

ANS: B. Increased hematocrit Rationale: An increased hematocrit level is an expected finding related to dehydration

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A. Decreased heart Rate B. Increased hematocrit C. High urine specific Gravity D. Decreased BUN

ANS: B. Dehydration Rationale: Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Polyphagia B. Dehydration C. Bradycardia D. Hyperglycemia

ANS: B, C, D, E Rationale: Skin over the knee that's red may indicate infection and is not an expected finding. Pain when bearing weight due to degeneration of the joint tissue is an expected finding. Joint crepitus due to degeneration of the joint tissue is an expected finding. Swelling of the affected joint due to degeneration of the joint tissue is an expected finding. Limited joint motion is due to degeneration of the joint tissue and is an expected finding.

A nurse is assessing a client who is to undergo a right knee arthroplasty. Which of the following are expected findings? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

ANS: C. Kyphosis Rationale: Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A. Lordosis B. Ankylosis C. Kyphosis D. Scoliosis

ANS: A. Tingling of the extremities Rationale: A serum calcium level of 7.6 mg/dL is below the expected reference range, indicating hypocalcemia. A client who undergoes a total thyroidectomy is at risk for parathyroid injury which can lead to hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysrhythmias

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Tingling of the extremities B. Hypoactive deep tendon reflexes C. Shortened QT intervals D. Constipation

ANS: A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. Rationale: The nurse should remove all wound exudate and any residual antimicrobial ointment or cream toavoid altering the culture results.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora.

ANS: C. Bounding peripheral pulses Rationale: The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses.

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A. Increased urine specific gravity B. Hypoactive bowel sounds C. Bounding peripheral pulses D. Decreased respiratory rate

ANS: C. Polyuria Rationale: Diabetes insipidus is characterized by increased thirst (polydipsia) and increased urination (polyuria). A client who has diabetes insipidus will excrete large quantities of urine with a very low specific gravity

A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria

ANS: A. Chvostek's sign Rationale: The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? A. Chvostek's sign B. Babinski's sign C. Brudzinski's sign D. Kernig's sign

ANS: C. Determine the location of the pain. Rationale: The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client. B. Administer the medication. C. Determine the location of the pain. D. Review the effects of the pain medication.

ANS: D. Potassium 6.1 mEq/L Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? A. Sodium 152 mEq/L B. Chloride 102 mEq/L C. Magnesium 1.8 mEq/L D. Potassium 6.1 mEq/L

ANS: A, C, D Rationale: You'll have considerably less pain with the traction in place. The traction will help decrease muscle spasms. The weight as a pulling force to keep your leg and hip still.

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of the information should the nurse give the client about this type of traction? (Select all that apply)? A. You'll have considerably less pain with the traction in place. B. You'll have the traction in place for a week or so. C. The traction will help decrease muscle spasms. D. The weight as a pulling force to keep your leg and hip still. E. We have to make sure the weights are just barely touching the floor.

ANS: A, B, C

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply) A. Decreased gastric motility B. Decreased skin elasticity C. Increased pain threshold D. Increased metabolic rate E. Increased cardiac output

ANS: C. Irrigate the indwelling urinary catheter with a syringe Rationale: The nurse should identify that no drainage in the urinary drainage bag indicates an obstruction. The nurse should gently irrigate the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and irrigating fluid to drain

A nurse is collecting data from a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 h our. Which of the following actions should the nurse take? A. Instruct the client to attempt to void around the indwelling urinary catheter B. Increase the rate of irrigation fluid instillation C. Irrigate the indwelling urinary catheter with a syringe D. Prepare to administer a diuretic

ANS: A, C, E Rationale: Washing the surgical incision daily with soap and water decreases the risk of infection. Toes should be externally rotated. This prevents dislocation of the hip prosthesis. The client who uses a straight-backed armchair decreases the chance of bending at a greater than 90° angle, which may cause dislocation of the hip prosthesis. The client who bends at the waist places the hip in a position greater than a 90°angle, which may cause dislocation of the hip prosthesis. The client who uses a toilet riser decreases the chance of bending greater than90° degrees, which may cause dislocation of the hip prosthesis.

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Clean the incision daily with soap and water. B. Turn the toes inward when sitting or lying. C. Sit in a straight-backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.

ANS: C. Opening a sterile package over the middle of the sterile field

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 5 cm (2 in) from the border of the sterile field B. Holding a sterile item at just above the waist level C. Opening a sterile package over the middle of the sterile field D. Opening the sterile tray by first unfolding the flap farthest from his body

ANS: B. Reach around the pack and open the top flap away from the body

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? A. Place the pack on a sterile workforce B. Reach around the pack and open the top flap away from the body C. Open the right flap with the left hand D. Move to the opposite side of the pack to open the fourth flap

ANS: D. Flush the NG feeding tube with 30 mL of water immediately following medication administration Rationale: The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of the bed in a flat position for 30 min following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

ANS: A. Instruct the client to lie prone while in bed Rationale: The nurse should instruct the client to lie in a prone position for 20 to 30 minutes every 3 to 4 hours to avoid developing contractures while in bed

A nurse is providing teaching for a client following a below-the-knee amputation. Which of the following should the nurse include in the teaching? A. Instruct the client to lie prone while in bed B. Ensure the client sleeps on a soft mattress C. Pull up the residual limb while in bed D. Keep the residual limb exposed to air to heal

ANS: B. I will lie on my stomach for 30 minutes a few times a day.

A nurse is reinforcing teaching with a client who had amputation of the left lower leg 3 days ago. Which of the following statements indicates that the client understands how to care for the incision and his left upper leg? A. I should use powder inside my limb sock to keep it cool. B. I will lie on my stomach for 30 minutes a few times a day. C. I should expect some drainage with a strong odor because I had gangrene. D. I will keep elevating my leg on 2 pillows to keep the swelling down

ANS: D. "Your provider might prescribe a central catheter line for long-time antibiotic therapy." Rationale: Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy

A nurse is reinforcing teaching with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? A. "You will need to apply a cold pack to the site three times per day." B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit consumption of high-protein foods." D. "Your provider might prescribe a central catheter line for long-time antibiotic therapy."

ANS: D. Fasting blood glucose 95 mg/dL Rationale: The nurse should identify that a fasting blood glucose of 95 mg/dL is within the expected reference range of 70 to 110 mg/dL, which indicates that the client has the diabetes under control

A nurse is reviewing laboratory results for a client who has diabetes mellitus. Which of the following results indicates that the client is controlling the diabetes? A. HbA1c 8.5% B. Postprandial blood glucose 190 mg/dL C. Casual blood glucose 205 mg/dL D. Fasting blood glucose 95 mg/dL

ANS: D. Bronchitis 2 weeks ago Rationale: A recent infection can cause micro-organisms to migrate to the surgical area and causethe prosthesis to fail.

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age of 78 B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago

ANS: D. WBC count Rationale: An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN B. Potassium C. RBC count D. WBC count

ANS: A. Begin a program of brisk walking Rationale: Weight-bearing exercises help maintain bone mas and prevent osteoporosis. Walking is generally a safe activity for older clients

A nurse is talking with an older adult client who is at risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide? A. Begin a program of brisk walking B. Take 800 mg of calcium per day C. Drink plenty of sparkling water D. Drink 8 oz of red wine each day

ANS: A, B, C, E Rationale: Expected physiologic changes of aging include more difficulty seeing due to greater sensitivity to glare, decreased cough reflex, decreased bladder capacity, dehydration of intervertebral disc.

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.) A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased bladder capacity D. Decreased systolic blood pressure E. Dehydration of intervertebral disc

ANS: A, B, E Rationale: Inactivity, Family history, and Cigarette smoking

A nurse is teaching a group of women about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? (Select all that apply) A. Inactivity B. Family history C. Obesity D. Hyperlipidemia E. Cigarette smoking

ANS: B. The area surrounding the insertion site feels warm to the touch

A nurse is working with a licensed practical nurse to care for a client who is receiving a continuous IV fusion which of the following findings reported by the LPN indicates to the nurse or the client has phlebitis at the IV insertion site. A. The infusion rate has stopped but the tubing is not kinked B. The area surrounding the insertion site feels warm to the touch C. There is fluid leaking around the insertion site D. There is no blood return when the tubing is aspirated

ANS: D. 31.5% Rationale: R arm = 4.5%(anterior) + 4.5%(posterior) = 9% whole arm. Anterior Torso = 18. Anterior Face: 4.5%. To get the answer: 9+18+4.5 = 31.5%

An adult client was burned in a car fire. The client sustained a circumferential burn to the right arm, the anterior torso, and half of the anterior face. What percent of the body was burned using the rule of nines? A. 15.75% B. 27% C. 29.25% D. 31.5%

ANS: A. "Lipping" of the bottle with its solution. Rationale: Before pouring the solution into the container, the nurse pours a small amount into a waste receptacle, which cleans the lip of the bottle. This is referred to as "lipping" the bottle. Wiping the rim of the bottle introduces the possibility of contamination from the cloth or towel. Pouring the water straight into the container does not take into account that the edge of the bottle may not be clean. Handing the bottle over without making sure it is clean would introduce the possibility of infection to the sterile nurse.

During surgery, the physician requests more sterile water. What action must the nurse perform before pouring the solution into the sterile container? A. "Lipping" of the bottle with its solution. B. Wiping the rim of the bottle C. Pouring the water straight into the container

ANS: D. Headache, deteriorating level of consciousness, and twitching. Rationale Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity.

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: A. Hypertension, tachycardia, and fever. B. Hypotension, bradycardia, and hypothermia. C. Restlessness, irritability, and generalized weakness. D. Headache, deteriorating level of consciousness, and twitching.

ANS: A. 22%-23% Rationale: The anterior thorax, which includes the chest and abdomen, is 18% of the total body surface area. Therefore, the entire chest and half of the abdomen would be 13.5%. The anterior right area adds another 4.5%, bringing the total to 18%. The anterior section of the right thigh adds another 4.5%, bringing the total body surface area involved in this injury to approximately 22% to 23%. (pg. 523, Physiological Integrity)

The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, the entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines? A. 22%-23% B. 30%-31% C. 39%-40% D. 48%-49%

ANS: A. Lying recumbent following meals Rationale: Lying recumbent following meals or at night will cause reflux and pain. Relief is usually achieved with the intake of small, bland meals, use of H2 receptor antagonists and antacids, and elevation of the thorax after meals and during sleep

The client with a hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with hiatal hernia? A. Lying recumbent following meals B. Taking in small, frequent, bland meals C. Raising the head of the bed on 6-inch blocks D. Taking H2-receptor antagonist medication

ANS: A. Instruct the client to push the residual limb against a pillow Rationale: Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual against harder and harder surfaces is done in preparation for prosthesis training.

The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? A. Instruct the client to push the residual limb against a pillow B. Demonstrate how to apply an elastic bandage around the residual limb C. Encourage the client to apply vitamin B12 to the surgical incision D. Teach the client to elevate the residual limb at least three times a day

ANS: B. "Lying on your stomach will help prevent contractures." Rationale: The prone position will help stretch the hamstring muscles, which will help prevent flexion contractures leading to problems when fitting the client for a prosthesis.

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? A. "This position will help your lungs expand better." B. "Lying on your stomach will help prevent contractures." C. "Many times this will help decrease pain in the limb." D. "The position will take pressure off your backside."

ANS: C. Female gender Rationale: A nonmodifiable risk factor is a factor the client cannot do anything to alter or change. About 50% of all women will experience an osteoporosis-related fracture.

The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a non-modifiable risk factor? A. Calcium deficiency B. Tobacco use C. Female gender D. High alcohol intake

ANS: A. Excessive thirst Rationale: The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger).

The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which of the following symptoms reported by the patient is considered one of the classic clinical manifestations of diabetes? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision

ANS: C. Infiltration

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred. A. Infection B. Phlebitis C. Infiltration D. Thrombosis

ANS: 6, 2, 3, 1, 5, 4, 7. Correct Order: 1. Assess area of skin to be used as puncture site 2. Identify patient using two identifiers 3. Check code on test strip vial 4. Clean puncture site with antiseptic solution 5. Gently squeeze fingertips until drop of blood appears 6. Wick blood drop into test strip 7. Read results and document in medical record Rationale: Blood glucose should be monitored every 6 hours for a patient receiving TPN. The skill begins with assessment of the patient's skin to identify an appropriate puncture site. The final step is documentation of the results in the patient's medical record.

The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. 1. Clean puncture site with antiseptic solution. 2. Identify patient using two identifiers. 3. Check code on test strip vial. 4. Wick blood drop into test strip. 5. Gently squeeze fingertip until drop of blood appears. 6. Assess area of skin to be used as puncture site. 7. Read results and document in medical record.

ANS: A. Phlebitis of the vein

The nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced: A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. Allergic reaction to the IV catheter material

ANS: C. Lower the height of the solution bag to slow the instillation rate. Rationale: This is the correct choice. This is the first action the nursing assistant should take. Some cramping is often experienced by patients receiving an enema, but the cramping should not be painful or severe. Lowering the height of the enema bag to slow the instillation rate of the solution is a simple initial action that will quickly lessen the patient's cramping and promote his ability to receive and retain the enema solution.

Which action do you tell the nursing assistant to do first if the patient reports cramping during an enema? A. Place the patient on the bedpan to evacuate the enema solution immediately. B. Remind the patient that cramping can occur during enema administration. C. Lower the height of the solution bag to slow the instillation rate. D. Clamp the bag and stop the enema

ANS: A, B, C Rationale: These are the correct answers because they affect the client's vision, factors affecting sensations in the legs and feet, and a history of falls. There is no research to connect the risk of falls with either of the skin conditions mentioned. Tai Chi improves balance, which decreases risk for falls.

Which assessment finding is a contributor to an older adult's risk for falls? (Select all that apply) A. Client is awaiting cataract surgery on right eye B. Client's type 2 diabetes is poorly controlled with diet and exercise alone C. Client reports a fall in the last year D. Client has a history of contact dermatitis and psoriasis E. Client attends Tai Chi classes

ANS: C. "Push the button when you first feel pain instead of waiting until pain is severe." Rationale: Clients should be instructed to push the button to release medication when the pain begins rather than waiting until the pain becomes so great that the dose given by the pump cannot control the pain. No one should push the button for the client. Clients should not be instructed to bear the pain as long as possible before using PCA.

Which instruction is the most accurate for the nurse to give a client who has a patient-controlled analgesia device (PCA) after abdominal surgery? A. "Instruct your visitors to press the button for you when you are sleeping." B. "Push the button every 15 minutes whether you feel pain at that time or not." C. "Push the button when you first feel pain instead of waiting until pain is severe." D. "Try to go as long as you possibly can before you press the button."

ANS: A. The client has lost one inch in height Rationale: The loss of height occurs as vertebral bodies collapse

Which sign/symptoms indicate to the nurse the client has developed osteoporosis? A. The client has lost one inch in height B. The client has lost 12 pounds in the last year C. The client's hands are painful to the touch D. The client's serum uric acid level is elevated