HESI Practice

Captopril

- Excessive hypotension and hyperkalemia may occur. - Monitor patient for first-dose hypotension (first-dose syncope). - Skipping doses or discontinuing the drug can result in rebound hypertension. - Angioedema, a rare adverse effect, can develop suddenly and can be life-threatening.

Safety Alert: Thrombolytic Therapy

- Minor or major bleeding can occur with thrombolytic drugs. - Place two or three IV lines before thrombolytic therapy is started. - If signs and symptoms of major bleeding occur (e.g., drop in BP, increase in HR, sudden change in the patient's mental status, blood in the urine or stool), stop the drug and notify the HCP.

IRON

- Some preparations of IV iron have a risk of an allergic reaction, and the patient should be monitored accordingly. - Oral iron should be taken about 1 hr before meals. - Vitamin C (ascorbic acid) enhances iron absorption.

The nurse is performing an assessment with a client using the Glasgow Coma Scale. Which result would indicate the best neurological status for the client? 2. 5. 13. 20.

13: The higher the Glasgow Coma Scale number, the better neurological status is present. The scale sum ups the score in three areas; Eyes Open; Best verbal response and Best motor response. The overall total scores range from 3-15.

Which nursing actions should be implemented to reduce the risk of the development of acute respiratory distress syndrome (ARDS)? A. Practicing scrupulous infection control guidelines. B. Implementing a restricted intake and documenting all output. C. Placing a cllient with active tuberculosis client in a negative pressure room. D. Adhering to aspiration precautions for clients with impaired swallowing and gag reflex. E.Raising the head of the bed to 30-45° for clients receiving enteral feedings.

A,D &E: Both aspiration and systemic infections increase a client's chances of developing acute respiratory distress syndrome (ARDS). To reduce the risk of a client aspirating while receiving enteral feedings, the nurse should raise the head of the bed 30 to 45 degrees. If the client has impaired swallow or reduced gag reflex, aspirations precautions should be put in place and followed. To help decrease the risk of a systemic infection, the nurse should adhere to scrupulous infection control guidelines.

Which factors should the nurse teach a group of clients to help slow down the rate of progression of atherosclerosis? A. Abstinence of smoking or use of tobacco. B. Moderate- Vigorous aerobic exercise 2Xs a week for 30 minutes. C. Healthy eating habits of mostly whole grains, fruits and vegetables. D. Diet that consists of equal amounts of fish, poultry and red meats. E. No more than 2 glasses/women and 3 glasses/men of alcohol per day.

A & C: The progression rate of atherosclerosis can be slow down if a client abstains from smoking and the use of tobacco products; participates in moderate-vigorous aerobic exercise 3-4Xs per week for an average of at least 40 minutes each session; consumes a healthy diet that is mostly whole grains, fruits and vegetables, along with non-fried fish and poultry. The consumption of red meat should be limited in a healthy diet. Moderation of alcohol consumption should be no more than one glass for woman or 2 glasses for a man daily.

A client is status-post liposuction procedure on their hips and thighs. Which post-op complications should the nurse assess for in this client? A. Emboli. B. Infection. C. Hematoma. D. Fat necrosis. E. Depigmentation.

A, B, & C: Post-op complications that can occur with the liposuction plastic procedure can be collection of blood pooling in the tissues,forming a hematoma; release of fat emboli during the suctioning of the adipose tissue; episodes of severe pain, and complications of an infection from the invasive procedure.

The nurse is presenting a class at the community center about the prevention of colorectal cancer. Which statements should the nurse include in their teaching? A.Decrease the consumption of fat, refined carbohydrates and low in animal fat. B. After the age of 50, a colonoscopy should be done every 10 years. C. Increase the consumption vegetables such as broccoli, cabbage and sprouts. D. Exercise a minimum of three to four times a week. E. Fecal occult blood testing should be done yearly, starting at the age of 30.

A, B, C, D: The nurse should include in the class on colorectal cancer: decrease the amount of fat, refined carbohydrates and animal fat in their diets. Clients should be told to consumed more baked and broiled foods, high fiber and plants that come from a stem or stalk such as broccoli, cabbage, cauliflower and sprouts. These types of plants have been shown to help protect the intestinal mucosa from colon cancer. The class should also include the importance of not being sedentary, avoidance of smoking and excessive alcohol. After the age of 50, the participants should be told that they should have a colonoscopy every 10 years; or a double-contrast barium enema or sigmoidoscopy with fecal occult blood testing every five years.

The nurse is caring for a client who has a fiberglass long leg cast on the right leg. Which nursing actions should be implemented in the cast care of this client? A. Smelling the cast and feeling for the presence of hot spots on the cast. B. Checking neurovascular status of the right exposed foot and toes every four hours. C. Using a soft cotton-tipped 6-inch swab to help scratch beneath the cast. D. Placing the nurse's finger in the client's cast while performing cast care. E. Covering the perineal area of the cast with plastic before client uses the fracture bedpan.

A, B, D, E: Cast care should include ensuring the cast is not too tight, by placing a finger between the client's skin and cast; by protecting the cast from being soiled by placing a protective plastic covering in the perineal area before the client uses a bedpan; by smelling for a foul odor coming from the cast; by palpating for hot spots on the cast every shift; and by performing neurovascular checks distal to the cast every four hours. Nothing should be placed in the cast to facilitate scratching beneath the cast.

Which statements should the nurse include in health promotion education for a client diagnosed with atherosclerosis? A. The development of atherosclerosis began years ago before any signs and symptoms were noticeable. B. At this point, a sedentary life style has already caused irreversible damage, so it doesn't matter what you do. C. Performance of moderate-vigorous aerobic exercise 3 to 4 times a week will help slow the progression of disease. D. You should not smoke because the cigarette's carbon monoxide will cause additional injury and worsen your disease. E. Your diet should consist of high proteins such as steak and eggs and limited consumption of dairy such as Greek yogurt and beans.

A, C, & D: The development of atherosclerosis can begin years ago before clinical signs and symptoms are present in the client. The rate of the progression of the disease can be slowed by down by moderate-vigorous aerobic exercise 3 to 4 times per week for a minimum of 40 minutes. Carbon monoxide from cigarette smoking causes damage to the arterial wall worsening the disease. The client should be encouraged to eat more fresh fruits and vegetables and increase fiber intake. Clients should limit their consumption of foods high in saturated fats such as red meats and eggs.

A nurse reviewing a client's physical assessment notes from a health care provider noted that their digital rectal exam examined of the client revealed to be stony hard with palpable irregularities present. These assessment findings are a clinical sign and symptom of which condition? A. Prostate cancer. B. Testicular cancer. C. Rectal hemorrhoids. D. Benign prostatic hyperplasia.

A: A digital rectal exam is usually done for palpation of the prostate gland. A prostate gland which palpates to be stony hard and with irregularities noted is usually indicative of prostate cancer.

While auscultating the abdomen of a thin older-adult client, the nurse detects a pulsatile mass. What is the correct action for the nurse to take? A. Notify the physician. B. Call an emergency code. C. Document the findings. D. Roll the patient onto his right side.

A: A pulsatile mass in a thin elderly male is suspicious for an abdominal aortic aneurysm. Due to the potential for leakage or rupture, the nurse should notify the physician immediately.

The nurse is reviewing the history of a client who presents with upper abdominal pain. Which entry in the client's history may cause the nurse to suspect acute pancreatitis? A.Excessive alcohol consumption. B.Lethargy. C. Constipation. D. Kidney stones.

A: Acute pancreatitis is an inflammatory condition that can be caused by toxic factors, such as excessive alcohol consumption. The client may experience vomiting, diarrhea, melena, and restlessness associated with pain.

When caring for a client with acute coronary syndrome, which action should the nurse take to reduce the risk of further injury? A. Be prepared to begin antithrombin therapy. B. Begin discharge education on diet. C. Increase the client's physical activity. D. Stop intravenous fluids.

A: Administering antithrombin therapy is administered to help dissolve any clots that may be blocking an artery which is causing the chest pain and discomfort caused by ischemia of the impeded blood flow as the result of the blood clots.

The nurse is providing care to a client with adrenal insufficiency. Which action should the nurse be prepared to take? A. Replace cortisol. B. Manage hypertension. C. Encourage the client to take in oral fluids. D. Diurese the client.

A: Adrenal insufficiency is a condition in which the adrenal glands produce an inadequate amount of cortisol, a hormone which plays a key role in maintaining homeostasis. In collaboration with the medical team, the nurse should be prepared to administer hydrocortisone to increase the client's cortisol levels.

The nurse is reviewing a client's electronic medical record and notes the client has arcus senilis. What is the anticipated outcome from this condition? A. Change in appearance of eyes. B. Gradual onset of ataxia. C. Rapidly progressing dementia. D. Intermittent stiffness in hand joints.

A: Arcus senilis is seen in the eyes as an opaque, bluish white ring within the outer edge of the cornea that is caused by years of buildup of fat deposits. It can start to form and become visible when a client is in their 40s and may encircle the cornea by the time they are in their 80s. The presence of arcus senilis does not affect the client's vision.

Which is a side effect of aspirin? A. Tinnitus. B. Lethargy. C. Increased appetite. D. Hyperpigmentation.

A: Aspirin (acetylsalicylic acid) is used to treat pain, fever, and inflammation. Tinnitus and hearing loss are possible side effects of aspirin.

A client comes to the emergency department with severe and gnawing epigastric pain. The client reports accidently doubling the warfarin sodium dose for the last three days. What should the nurse expect to find upon assessment? A. Melena. B. Ascites. C. Jaundice. D. Vascular spiders.

A: Bleeding can occur at any point in the gastrointestinal system. Abnormally high doses of warfarin sodium, an anticoagulant, can cause bleeding to occur in otherwise healthy clients. Upon assessment, the nurse should expect to find melena, or blackened stool.

The nurse is preparing a client for a plastic surgery procedure that will excise bulging fat and redundant skin from the periorbital area. What is the name of this procedure? A. Blepharoplasty. B. Dermabrasion C. Rhinoplasty. D. Liposuction.

A: Blepharoplasty is a procedure that removes the appearance of bags under the eyes by removing bulging fat and redundant skin from the periorbital area.

The nurse is caring for a client who recently had a myocardial infarction. Which is the first action the nurse should take when a client begins exhibiting signs of cardiogenic shock? A. Prepare to administer ionotropic agents. B. Encourage the client to breath slowly. C. Place the client in prone position. D. Give the client aspirin.

A: Cardiogenic shock occurs when the heart is no longer able to pump effectively, resulting in decreased perfusion. The nurse's first action should be to administer ionotropic agents.

Which diet modification is most important for the nurse to include when counseling a client with heart failure? A. Reduce sodium intake. B. Increase protein intake. C. Increase vegetables intake. D. Reduce carbohydrate intake.

A: Chronic diseases such as congestive heart failure require that a client make dietary changes to manage the disease. It is important that a client with congestive heart failure be aware of sources of dietary sodium, as sodium may exacerbate the effects of congestive heart failure.

A client with a history of deep vein thrombosis presents to the emergency department with acute onset shortness of breath, tachycardia, and tachypnea. What should the nurse do first? A. Activate the emergency response team. B. Intubate the client. C. Document the findings. D. Start a large bore IV.

A: Client with deep vein thrombosis who develops a sudden onset of respiratory distress is indicative of a life-threatening pulmonary embolism. The emergency response team would need activation to manage this condition

The clinic nurse is assessing the blood pressure of a client diagnosed hypertension. How should the nurse assess this client's blood pressure? A. Obtain blood pressure readings from both the client's arms. B. Take a blood pressure with the client sitting down and then standing up. C. Compare the blood pressure readings from the upper extremities and lower extremities. D. A blood pressure should be taken in the same arm at the beginning and at the end of the check-up.

A: Clients diagnosed with hypertension have a high incidence of atherosclerosis. It is best to obtain a blood pressure from both arms of the client and record in the client's electronic medical record documenting the blood pressure reading for each arm.

A nurse is reviewing a female client's laboratory test results history and noticed the client tested positive for the BRCA2. A client who tests positive for this has increased chance of developing which condition? A. Breast cancer. B. Cervical cancer. C. Pelvic inflammatory disease. D. Endometrial uterine cancer.

A: Clients who test positive for the BRCA2 gene are at an increased rate of 60-88% for developing breast cancer. If a client does not develop breast cancer, this mutated gene can be passed onto to their present and/or future male or female offspring.

While monitoring a client with adrenal insufficiency, the nurse notices that the client's vital signs are beginning to deteriorate. Which action should the nurse take? A. Call the physician. B. Complete a full physicial assessment. C. Encourage the client to ambulate. D. Decrease the rate of intravenous fluids.

A: Clients with adrenal insufficiency should be monitored closely. If deterioration of the client's vital signs or hemodynamics occurs, the nursing priority is to immediately alert the physician.

Which is a complication of administering sedatives to the client with liver failure? A. Encephalopathy. B. Moderate to severe hypoglycemia. C. Anaphylaxis. D. Hepatic necrosis.

A: Common drugs can be hepatotoxic in a client with liver failure. The nurse should be aware that sedatives can contribute to encephalopathy and should be avoided, if possible, in clients with this condition.

A client's admitted to the intensive care unit diagnosed with stage 5 chronic kidney disease assessment includes crackles in the lungs, periorbital edema, anuric, muscle cramps and paresthesia. The nurse should anticipate the health care provider to prescribe which treatment? A.Renal dialysis. B. Nitroglycerin. C. Albuterol inhalation. D. Furosemide intravenously.

A: Diuretics can be used in clients with chronic kidney disease stages 1-4. Clients who have advance to stage 5, diuretics will not work; these clients will need to receive renal dialysis treatment to remove the excess fluids from their system.

The nurse is providing fluid resuscitation to a client. Which complications should a nurse monitor for when providing fluid resuscitation? A. Pulmonary. B. Gastrointestinal. C. Tissue perfusion. D. Neurological.

A: Fluid resuscitation is imperative to the client with hypovolemic shock. While providing care to a client who is undergoing fluid resuscitation, the nurse should monitor the client's breath sounds for fluid overload resulting in pulmonary edema. This should be done at each increment of 250ml of fluid infused.

A male client has been diagnosed with uncomplicated gonorrhea. Which combination of drugs should the nurse anticipate that the client will need? A. Ceftriaxone and azithromycin. B. Cefepime and azithromycin. C. Cefazolin and Augmentin. D. Cephalexin and Augmentin.

A: Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae bacteria. A combination therapy of ceftriaxone and azithromycin is used to treat uncomplicated gonorrhea.

The nurse is working with the medical team to stabilize a client who is in shock. The nurse knows the physician will likely order a fluid challenge. Which action should the nurse take first? A. Establish two IV catheters. B. Begin warming IV fluids. C. Encourage the client to take fluids in orally. D. Obtain orthostatic blood pressures.

A: IV access is needed to provide fluid resuscitation to clients in shock. The nurse's first action is to establish two IV catheters, one in a peripheral vein and one in a central vein.

The nurse is administering IV fluid resuscitation to an elderly client diagnosed with sepsis. The nurse should be alert for which possible complication of this treatment? A. Shortness of breath. B. Facial droop C. Decreased urine output D. Confusion

A: IV fluid resuscitation is administered to clients experiencing extreme dehydration or sepsis. When administering IV fluid resuscitation to an elderly client, the nurse should monitor for symptoms of fluid overload, which include shortness of breath and respiratory compromise.

Ibuprofen is an nonsteroidal anti-inflammatory drugs (NSAIDS) which is commonly used for muscle strains and aches. Which should the nurse recognize as a serious side effect of ibuprofen? A. Nephrotoxicity. B. Xerostomia. C. Hallucination. D. Convulsions.

A: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation. NSAIDs have nephrotoxic effects and should be avoided in patients with kidney disease.

When formulating a nutrition plan for a client diagnosed with renal failure, which food should the nurse recommend that the client avoid? A. Bananas. B. Green beans. C. Carrots. D. Cucumbers.

A: In clients with renal failure, there is a need to modify dietary intake of foods that contain potassium, phosphorous, and sodium. Bananas are high in potassium, so they should be avoided by patients with reduced kidney function.

The nurse is caring for a client with exacerbation of asthma who is not responding to breathing treatments and medications. Which emergency intervention should the nurse be prepared for? A. Intubation and mechanical ventilation. B. Emergency tracheostomy. C. Bedside thoracotomy. D. Bronchoscopy.

A: Maintaining the client's airway is the nursing priority in clients with exacerbation of asthma. Interventions, such as intubation and mechanical ventilation, are performed to help restore normal breathing patterns.

The nurse is caring for a client who takes metoprolol. The nurse should monitor the client for which side effect? A. Low heart rate. B. Unexplained weight loss. C. Hypersalivation. D. Mania.

A: Metoprolol belongs to a class of antihypertensive medications known as beta blockers, which lower heart rate and blood pressure. Use of beta blockers can cause an abnormally low heart rate. The client's blood pressure should be take periodically during initial treatment and an apical/radial pulse should be taken before administration and the medication should be held and healthcare provider notified if any significant or pulse rate less than 60 beats per minute.

The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care? A. The client will remain free of infection. B. The client will maintain cool, dry skin. C. The client will remain hypotensive. D. The client will return to baseline activity level by day 3.

A: Multiple organ dysfunction syndrome (MODS) occurs as a result of uncontrolled inflammation in the body. The nurse should list an expected outcome that the client will remain free of infection.

Which examination tool is used to diagnose myopia? A. Snellen chart. B. Ophthalmoscope. C. Slit lamp. D. Digital retina camera.

A: Myopia (nearsightedness) is a common type of refractive error. It is diagnosed during a comprehensive eye exam, often with an eye chart called a Snellen chart.

A client has been diagnosed with an ankle sprain. The nurse should anticipate that the client will need which medication? A. Naproxen sodium. B. Hydrocortisone. C. Ciprofloxacin. D. Chloroquine.

A: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium, are recommended for treatment of sprains.

The nurse is assessing a client with a deep puncture wound, accompanied with swelling and erythema noted at the base of frontal (L) knee; the area is hot to touch; and the client complains of constant, throbbing pain which increases with movement. Client's current temperature is 101.6°F (38.7°C) and their leukocytes are double the normal value and the erythrocyte sedimentation rate (ESR) reflects a normal value. The presenting clinical signs and symptoms are indicative of which condition? A. Osteomyelitis. B. Ewing's sarcoma. C. Rheumatoid arthritis. D. Compartment syndrome.

A: Osteomyelitis is an infection in the bony tissue. Osteomyelitis can be caused by bacteria, viruses or fungi. Invasion of one of these stimulate an inflammatory response which leads to vascular leakage and edema. Ischemia and necrosis of the bone occurs as a result. Acute osteomyelitis presents with fevers above 101°F (38.3°C); swelling around the affected area; erythema; tenderness and bone pain which is constant, localized, pulsating which increases with movement. Puncture wounds provide a mechanism of direct entry for the invasion of pathogenic organisms.

A serum sample is obtained from a client who is being evaluated for crushing chest pain which radiates up to their jaw and down their left arm that started an hour ago. Which abnormal lab value would the nurse anticipate to be present indicating an acute coronary syndrome/myocardial infarction? A. Troponin. B. Myoglobulin. C. Creatine kinase-MB. D. High density lipoprotein.

A: Presence of high levels of cardiac markers (troponin, myoglobulin, creatine kinase-MB) can confirm a diagnosis of acute coronary syndrome/myocardial infarction. The troponin is the first of the markers that is a definitive indication of injury to the myocardium. The presence in the bloodstream of this protein is not found in individuals who are healthy. This protein is released immediately when there is injury to the heart muscle. The creatine kinase-MB and myoglobulin abnormal elevations are not seen until 2 hours after injury to the heart muscle.

Which blood test is used to diagnose renal failure? A. Glomerular filtration rate. B. Aspartate aminotransferase. C. Hemoglobin electrophoresis. D. Alanine aminotransferase.

A: Renal failure can be classified as acute or chronic; both blood and urine testing is used to evaluate the stage of the disease. Glomerular filtration rate is an important test to measure the progression of kidney disease and to provide an estimate of kidney function.

A nurse is caring for a client who displays signs of asthma. Which procedure may be ordered to confirm this diagnosis? A. Spirometry. B. Chest radiography. C. Computed tomography scan. D. Ventilation-perfusion scan.

A: Spirometry is a common lung function test that measures the volume and rate that air can be inhaled and exhaled. This test may be used to confirm a diagnosis of asthma.

A middle-aged client who was admitted for a multi-traumatic accident is suspected of developing "Systemic Inflammatory Response" (SIRS). Which set of vital signs would the nurse anticipate the client to display? A. RR- 24 breaths/min; HR- 120 beats/min; and temp of 100.8 F (38.2C) B. RR- 18 breaths/min; HR- 90 beats/min; and temp of 100 F (37.2 C) C. RR- 12 breaths/min; HR- 60 beats/min; and temp of 96.8 F (36 C) D. RR- 36 breaths/min; HR- 86 beats/min; and temp of 97.4 F (36.3C)

A: Systemic inflammatory response (SIRS) must be considered whenever a client who has suffered some sort of trauma and displays two or more of the following signs: respiratory rate greater than 20 breathes/min; PCO2 levels less than 32 mmHg; heart rate greater than 90 beats/min; and a temp either greater than 100.4 F (38C) or less than 96.8 F (36 C)

A mass casualty has been called at a level-one trauma center involving a motor vehicle collision. The triage nurse uses the color coding system to categorize the clients. Which color should the nurse assign a client who is bleeding profusely from the neck? A. Red B. Yellow C. Green D. Black

A: The goal of trauma triage is to quickly assess and categorize clients according to severity of injury. The nurse should triage the client as red, which indicates a life-threatening injury.

A nurse is providing care to a client who is being treated aggressively for septic shock with systemic inflammatory response syndrome (SIRS). Which organ is most susceptible to being damage and can result in a very high mortality rate if damaged? A. Lungs B. Heart C. Kidneys D. Intestines

A: The lungs are susceptible to damage due to the increasing formation of free oxygen radicals from the SIRS. These free radicals increase the risk of the development of acute respiratory distress syndrome (ARDS). The mortality rate is high in clients who developed ARDS when diagnosed with septic shock.

Which implementation should the nurse perform for a client with myasthenia gravis? A. Provide pulmonary toilet every two hours when the client is awake. B. Provide the client with extra snacks throughout the day. C. Allow the client time to leave the floor with family. D. Monitor pulse oximetry every 8 hours.

A: The nurse should perform close respiratory monitoring in clients with myasthenia gravis. In addition to providing frequent pulmonary testing, the nurse should provide pulmonary hygiene every two hours when the client is awake to keep airways clear of secretions.

The nurse is reviewing the bone marrow aspiration results of a client which revealed abnormal high amount of blast cells present. This client will most likely be diagnosed with which condition? A. Leukemia. B. Hemophilia. C. Hodgkin's Lymphoma. D. Autoimmune thrombocytopenic purpura.

A: The procedure bone marrow aspiration which reveals abnormal high levels of immature white blood cells referred to as "blast" cells is indicative of leukemia.

A client presents with persistent cough, fatigue, loss of appetite, and bloody sputum. The nurse should recognize that the client is exhibiting symptoms of which condition? Tuberculosis. Chronic obstructive pulmonary disease. Asthma. Cystic fibrosis.

A: Tuberculosis is an infectious disease caused by airborne bacteria. Signs and symptoms of tuberculosis include cough, fatigue, loss of appetite and bloody sputum.

The nurse is assessing a client who was out in the woods and developed a rash twenty-four hours later. The rashes are present on both lower legs and outer aspects of their hands and forearms. The appearance of these rashes are red with linear streaks of papules and vesicles which are draining clear light yellow fluid. What type of hypersensitivity/allergy reaction is this? A. Type IV: Delayed involving the release of sensitized T-cells with an antigen. B. Type I: Immediate in which the reaction of the IgE antibody on mast cells with an antigen. C. Type II: Cytotoxic in which the reaction of the IgG with the host's cell membranes and antigen. D. Type III: Immune Complex-mediated involving the formation of immune complex of antigen and antibody.

A: Type IV: Delayed hypersensitivity is the result of the reaction of sensitized T-cells with antigen and release of lymphokines, which activates macrophages and induces inflammation. Clinical examples of these types of reactions are seen with exposure to poison ivy or oak; graft rejection; positive TB skin tests and the disease sarcoidosis

A client with a chief complaint of severe, spasmodic pain in their (R) flank area that comes and goes accompanied with nausea and diaphoresis has additional assessment findings of hematuria and cloudiness appearance of their urine and a history of gout. The client denies any fevers or chills and is presently ad febrile.Based on these findings which condition would the nurse suspect? A. Urolithiasis. B. Urothelial cancer. C. Urinary incontinence. D. Urinary tract infection.

A: Urolithiasis (kidney stones) is suspected based on the client's presenting signs and symptoms of severe, spasmodic pain in the (R) flank area that is sporadic, accompanied with hematuria and turbidity and being adfebrile. Clients with history of diabetes or gout (hyperuricemia) have an increased risk for stone formation.

The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided? A. The client will verbalize lifestyle changes that are needed. B. The client will require additional teaching. C. The client will question the need to take hypertensive D. medications. The client will refuse to adhere to a cardiac diet.

A: Within the 24-hour period before discharge from the cardiac care step-down unit, the client should verbalize understanding of the disease, as well as the necessary lifestyle changes that may modify risk factors. It is important that the nurse be aware of expected outcomes and plan for the client's learning needs.

A nursing is conducting a health history on a slightly obese 58 year old post-menopausal female who came to the clinic with complaint of vague abdominal and gastrointestinal symptoms indicative of ovarian cancer. Which questions should the nurse include in her interview? A. What type of birth control have you used in the past? B. Have you ever been diagnosed with a sexual transmitted disease? C. At what age did you start your period and experience menopause? D. When you had your children, did you bottle-feed or breastfed your children? E. Have you ever been pregnant and what was your age at your first pregnancy?

A, C, D, E: It is important to teach women over 50 years old to think "ovarian" if they have vague abdominal and gastrointestinal symptoms of non-known source. Ovarian cancer causes more deaths from the reproductive system in women over 50 years because it is not detected until its late stages. Risk factors for ovarian cancer include: older than 40 years old; family history of ovarian or breast cancer, colorectal cancer; diabetes mellitus; nulliparity; older than 30 years old at first pregnancy; history of breast and/or colorectal cancer; infertility; BRCA 1 or 2 gene; early menarche or late menopause; endometriosis; obesity and high-fat diet. Women whose choice of birth control was tubal ligation or oral birth control and/or who had breastfed their children are at less of risk of developing ovarian cancer.

A nurse is teaching a client about the best way to manage their diagnosis of dumping syndrome. Which statements should the nurse include in her client teaching? Avoid dairy products and sweets. Limit food consumption to two meals a day. Diet should consist of high fat and protein content. Ensure to drink at least one glass of water with meals. Whole grains, fresh fruit and vegetables are encouraged.

A, C: The only way to manage dumping syndrome is through nutritional changes. Clients should be encouraged to eat several small meals throughout the day. Their diet should consists of relatively high fat and protein foods and be low in roughage and carbohydrates. They should avoid all milk products, sweets and sugars. Liquid should only be drunk in between meals to minimize the dumping of food contents in their stomach into the small intestine.

The client's lower extremity has an ulcer present. Which assesment findings would indicate to the nurse that the ulcer is the result of peripheral arterial disease? A. The ulcer is located on the great toe. B. The lower extremities pulses are bounding. C. The area where the ulcer is located is edematous. D. The ulcer site is painful and tender when manipulated. E. Dependent rubor is present in the extremity with the ulcer.

A, D & E: Arterial ulcers are located at the end of toes and/or between them. The great toe is often the site affected. Pain is present at the ulcer site. These ulcers are often deep in appearance, pale wound bed, with well-defined and even edges present. The extremity is often cold or cool to the touch, pulses are either decreased or absence. The extremity affected by the peripheral arterial disease and the extremity is pale when elevated and demonstrates dependent rubor when lowered.

Which nursing actions should be implemented to reduce the risk of the development of acute respiratory distress syndrome (ARDS)? A. Practicing scrupulous infection control guidelines. B. Implementing a restricted intake and documenting all output. C. Placing a cllient with active tuberculosis client in a negative pressure room. D. Adhering to aspiration precautions for clients with impaired swallowing and gag reflex. E. Raising the head of the bed to 30-45° for clients receiving enteral feedings.

A, D & E: Both aspiration and systemic infections increase a client's chances of developing acute respiratory distress syndrome (ARDS). To reduce the risk of a client aspirating while receiving enteral feedings, the nurse should raise the head of the bed 30 to 45 degrees. If the client has impaired swallow or reduced gag reflex, aspirations precautions should be put in place and followed. To help decrease the risk of a systemic infection, the nurse should adhere to scrupulous infection control guidelines.

A client has been admitted to the hospital with suspected TB. What drugs should the nurse plan to teach the client about before discharge? Select all that apply. A) Rifampin (Rifadin); contact lenses can become stained orange B) Isoniazid (INH); report yellowing of the skin or darkened urine C) Pyrazinamide (PZA); maintain a fluid restriction of 1200 mL/day D) Ethambutol (Myambutol); report any changes in vision E) Amoxicillin (Amoxil); take this drug with food or milk

A,B & D

Which interventions should a nurse use to minimize the development of decubitus ulcer formation with an immobile client? A. Keep the client's heels off the bed. B. Pat gently when drying client's wet skin. C. Reposition client at least every 3-4 hours. D. Provide client extra caloric nutrition of carbohydrates and fats. E. Use of wicking clothes where the client's two skin surfaces touch.

A,B & E: Interventions that can be used to help reduce the development of decubitus ulcers in an immobile client includes placing a pillow under the clients ankles to keep their heels off the surface of the bed; gently patting the clients skin when drying it rather than rubbing it; repositioning the client at least every two hours; the use of wicking clothes where two skin surfaces touch or perspiration collects and ensuring the client consumes a diet high in protein and calories and fluids to promote wound healing.

The nurse is preparing client teaching for a post-menopausal female who has a history of recurrent urinary tract infections. Which instructions should be included in the client teaching to minimize the risk of a urinary tract infection? A. Drink non-sweetened or lightly sweetened cranberry juice. B. Ensure to empty your bladder before and after intercourse. C. When cleaning your perineum area, wipe from front to back. D. Douche with vinegar or baking soda douches three times a week. E. Request a prescription of topical estrogen for your perineal area.

A,B,C,&E: Clients should be instructed to help reduced the occurrence of urinary infection to drink 2-3 liters of non-high fructose juices and liquids throughout the day (high glucose urine favorable to bacterial reproduction). Avoid tight fitting clothing and wear loose-fitting cotton underwear. If female, wipe and clean perineum area from front to back; avoid using irritating substances such as douches, scented lubricants for intercourse and bubble baths; empty bladder before and after intercourse. If menopausal ask for a prescription of topical estrogen for the perineal area because the medication will normalize the vaginal flora decreasing the risk of urinary tract infections.

The nurse is preparing a nutrition class to be given at the cardiac rehab clinic for a group clients diagnosed with hypertension, s/p myocardial infarction and/or heart failure. Which types of foods should be avoided and/or limited in these clients diets? A. Hot dogs. B. Swiss cheese. C. Pickled beets. D. Canned tomato juice. E. Frozen unsweetened fruit.

A,C,D: Clients diagnosed with hypertension, s/p myocardial infarction and/or heart failure should limit their salt intake. Foods such as deli meats contained high levels of salt. Processed meat such as hot dogs, bacon and ham contained high levels of salt. Any type of canned vegetables and juices such as tomato juice contained high levels of sodium. Anything pickled has high levels of sodium. Swiss cheese is naturally low in salt. Frozen or dried unsweetened fruit is low in salt.

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 10,000 cells per cubic millimeter (mm3) of blood. Which differential counts or percentages does the nurse report to the physician? A. Eosinophils 200/mm3 B. Monocytes 2000/mm3 C. Segmented neutrophils 5700/mm3 D. Lymphocytes 2100/mm3

B

Which parameter indicates to the nurse that the short-acting beta-adrenergic agonist the client took 5 minutes ago for an acute asthma attack is effective? A. Spo2 decrease from 85% to 78% B. Peak expiratory flow rate increase from 50% to 70% C. The obvious use of accessory muscles during inhalation and exhalation D. Active bubbling in the humidifier chamber of the oxygen delivery system

B

Which conditions should alert the nurse to avoid applying elastic stockings to a client's legs, and to contact the prescribing healthcare provider? A. The client's current use of warfarin. B. The presence of an open skin lesion. C. Extremities which are cool to the touch. D. Extremities which display edema bilaterally. E. Pedal pulses that are weak and difficult to palpate.

B, C, E: The use of elastic stockings is contraindicated if dermatitis or open lesion is present; recent skin graft; or the presence of decreased circulation in the lower extremities.

The health care provider prescribes celecoxib (Celebrex) for a client with osteoarthritis. What health teaching will the nurse provide for this client regarding this drug? Select all that apply. A. "Take the drug on an empty stomach before breakfast." B. "Stop taking the drug if unusual bleeding occurs and call your health care provider." C. "Report frequent episodes of indigestion to your health care provider." D. "Expect fluid accumulation in your legs and feet that usually gets worse during the day." E. "Call 911 immediately if chest pain occurs."

B, C, E: This drug is a nonsteroidal anti-inflammatory drug, which can cause bleeding, gastrointestinal (GI) problems, and fluid accumulation. Therefore, it should be taken after meals. Increased fluid retention can cause congestive heart failure.

A two year old client experiencing an anaphylactic reaction and respiratory distress with laryngeal spasms is being prepared for an endotracheal tube (ETT) placement. The healthcare provider has ordered 0.5mL of epinephrine 1:10,000 to be given STAT. The attempts to place an intravenous catheter were unsuccessful. What is another appropriate route to administer the epinephrine during this anaphylactic emergency? A. Orally. B. Interosseous. C. Intramuscularly. D. Subcutaneously. E. Endotracheal tube.

B, C,E: Ideally during an anaphylactic reaction intravenously administration of epinephrine would be the best route. In the event, an intravenous route is not available, epinephrine can be administered order of preference for faster absorption, tibial interosseous, followed by endotracheal tube after the dose has been diluted in 2.5mL of normal saline before being administered down the ETT. Intramuscularly would be your last option if no other access was available due to the slow absorption rate.

A client is admitted with a diagnosis of right-sided heart failure. Which conditions are known to contribute to the development of right-sided heart failure? A. Atrial septal defect. B. Left ventricular failure. C. Coronary artery disease D. Pulmonary hypertension. E. Right ventricular myocardial infarction.

B, D, E: Heart failure of the right side is usually caused by poorly managed left-sided heart failure due to the left ventricular failure, a myocardial infarction involving the right ventricular or pulmonary hypertension. Each of these conditions puts added workload on the right ventricle resulting in heart failure.

A nurse is reviewing a client's electronic medical record and noted that a client had a skin scratch test for suspected allergies. Results of the test revealed the following: the presence of a "wheal" for ragweed, grass, strawberries and pineapple; and no presence of a "wheal" for oak, pine, peanut or banana. Based on the results the skin scratch testing, select which statements are true. A. It is safe for the client to consume a peanut butter and bananas. B. The client had a negative result for the allergens oak, pine, peanut or banana. C. The results indicate the client does not have allergies to oak, pine, peanut or banana. D. The client had a positive result for the allergens ragweed, grass, strawberries and pineapple. E. The client should avoid eating and/or exposure to strawberries, pineapple, ragweed and grass.

B, D,& E: If a client does not have a reaction to a skin scratch test to a suspected allergen, you cannot say they are not allergic to that suspected allergen. In order to determine if a client is not allergic to a suspected allergen, an intradermal test would have to be done. If the client does not have a reactive response to a suspected allergen with an intradermal test, then it can be declared they appear not to possess an allergy to that particular allergen.

The nurse is reviewing client education with a parent and their teenager. Which interventions should help minimize the occurrence of sickle cell crisis? A. Receive a yearly pneumonia vaccination. B. Always wear socks and gloves when outside on cold days. C. Engage in vigorous aerobic exercise at least 3-4 times a week. D. You should drink at least 3-4 liters of non-caffeinated liquid a day. E. Avoid cigarettes and/or tobacco products and second hand smoke.

B, D,E: In order to help minimize the occurrence of a sickle cell crisis, the client should be instructed to: drink 3-4 liters of non-caffeinated liquid/day; avoid alcoholic beverages; avoid cigarettes and/or tobacco to include second-hand smoke; receive an annual flu shot; a pneumonia shot every 5 years or according or the CDC guidelines; avoid being too hot or cold; wear socks and gloves outside on cold days; avoid high altitudes; avoid strenuous exercise; and engage in mild, low impact exercise 3xs/week when not in a crisis.

A client had a right total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Stand on your right leg and pivot to the chair." B. "Do not bend your hips more than 90 degrees." C. "Cross your legs to be most comfortable." D. "Avoid twisting your body when moving." E. "Use a long-handled shoe horn to put on your shoes."

B,D, & E: After total hip arthroplasty, clients should not bend or flex more than 90 degrees or adduct their legs (such as crossing them). A long-handled shoe horn prevents having to bend forward.

The nurse observes clouding of the lens when performing an eye examination on a client. The client reports blurry vision, sensitivity to light, and seeing "halos" around lights. Which tool should the nurse anticipate will be used to aid in a diagnosis? A. Tono-pen. B. Ophthalmoscope. C. Refractor. D. Snellen chart.

B: A cataract is a clouding of the lens of the eye which is often accompanied by blurred vision, seeing double, and sensitivity to light. This condition may be diagnosed by examining to eye with an ophthalmoscope.

The nurse is monitoring a client who has just returned from a liver biopsy. Which sign should alert the nurse that a serious complication has occurred as a result of this procedure? A. Confusion. B. Decreased blood pressure. C. Nausea and vomiting. D. Hematoma at the incision site.

B: A liver biopsy is performed by inserting a needle into an area of the liver to remove a small sample of tissue. Because the liver is highly vascular, a small amount of bleeding is expected; however, a drop in blood pressure may indicate that a significant amount of bleeding has occurred.

The nurse is planning care for a client who was just diagnosed with acute pericarditis. Which screening test should the nurse educate the client about? A. Creatinine clearance. B. 12-lead electrocardiogram. C. Dobutamine stress test. D. Blood transfusion.

B: Acute pericarditis is an inflammatory process involving the pericardium and epicardial surfaces of the heart. The nurse should provide client education about the 12-lead electrocardiogram, which will assess for any dysrhythmias.

The nurse assesses a client with suspected acute pericarditis. Which assessment finding is most consistent with this condition? A. Slow deep breathing. B. Stabbing chest pain. C. Bradycardia. D. Pain relieved by supine position.

B: Acute pericarditis is caused by inflammation involving the pericardium and epicardium. Stabbing pain in the chest is a common clinical symptom of this condition.

The client having an intravenous injection of radiocontrast material (dye) for an angiogram starts to have skin wheals at the injection site and difficulty breathing. What is the nurse's best first action? A. Administer oxygen by mask or nasal cannula. B. Stop the infusion of the contrast material. C. Prepare an injection of epinephrine. D. Notify the Rapid Response Team.

B: All actions listed are important. Stopping the infusion of the radiocontrast material while maintaining IV access is critical in limiting the reaction.

A nurse is reviewing a client's medical history in their electronic medical record (EMR). Which of the following factors is attributed to an increase risk in the development of premature severe atherosclerosis? A. Familial history of the disease. B. Poorly managed diabetes mellitus. C. BMI of 36%, sedentary job; and lack of exercise. D. Smoking history of 20+ years; (1.5) packs per day.

B: An adult client of any age who has poorly managed diabetes mellitus (DM) resulting in unstable fluctuations in their glucose levels are at an increase in the development of premature severe atherosclerosis. This occurs from the effect of hyperglycemia causing microvascular damage that occurs with the severity of the DM condition. The condition of DM also increases LDL-C and triglycerides in the client's plasma.

The triage nurse is assessing a client with a six week history of a persistent cough producing rusty colored mucus, 10 pounds (4.54kg) weight loss, decreased appetite and night sweats. Based on the client's history which nursing action should the nurse do next? A. Request a prescription for chest x-ray and lab work. B. Place a mask on the client and place the client in a private room. C. Assess the client's vital signs to include a pulse oximetry reading. D. Auscultate the lung fields as the client takes deep and slow breaths.

B: Based on the client's presenting history and complaints, the nurse needs to place a mask on the client and place the client in a private room, until tuberculosis (TB) can be ruled out. Clinical manifestations of TB are a persistent cough, weight loss, anorexia, night sweats, fevers or chills, dyspnea or hemoptysis.

The nurse is assigned a client who was admitted for a basilar fracture. Which finding is indicative of a complication that should be reported to the healthcare provider immediately? A. The client's report of some neck stiffness. B. The presence of new onset of post nasal drip. C. Client's request for acetaminophen for a headache. D. Slight increase of temperature to 100.1° F (37.8° C).

B: Basilar fracture is a fracture that occurs at the base of the skull, usually along the paranasal sinus. If the client demonstrates any type of leakage of fluid from the ears or the nose it needs to be further evaluated for cerebral spinal fluid. The presence of post nasal drip needs to be investigated and reported immediately because it could be signs of of cerebral spinal fluid leaking from the nasal cavity and dripping down the back of the client's throat.

The nurse is assessing a client that is experiencing indigestion and vague abdominal pain that radiates to the right shoulder, increase passing of gas, burping and nausea whenever they eat greasy fried food. The client has clay-colored stool, urine that appears dark colored and foamy. Based on the clients presenting signs and symptoms which condition is this client most likely to be diagnosed? Pancreatitis. Cholecystitis. Appendicitis. Gastroenteritis.

B: Cholecystitis is inflammation of the gallbladder which occurs when gallstones (cholelithiasis) obstruct the gallbladder's cystic duct. The obstructed duct causes the entrapment of the bile which in turn causes inflammation of the gallbladder. The entrapped bile then causes the client's stool to be clay-colored due to lack of bile and their urine becomes dark and foamy as the kidneys attempt to excrete the excess circulating bilirubin out through the urine. The gastric symptoms of flatulence, dyspepsia, eructation and abdominal pain that radiates to the (R) shoulder occur whenever fatty or large volume of food is ingested.

The nurse case manager is preparing a discharge plan for a client who has had a total hip arthroplasty. What is the most important device the client should have at home as part of the post-op care of the hip prosthesis? A. Crutches. B. A raised toilet seat. C. An assistive ambulatory walker. D. Grab bars throughout the home.

B: Clients who have a total hip arthroplasty (hip replacement) need to ensure that they do not flex their hips beyond 90° in order not to put strained on the hip prosthesis and cause it to dislodge out of place. Using a raised toilet seat will prevent the client flexing more than 90° (hyper flexing) when they sit down to use the toilet.

What action should the nurse take to reduce the risk of infection for a client with acute pancreatitis? A. Administer prophylactic antibiotics. B. Monitor WBC count. C. Obtain blood cultures when the client is afebrile. D. Check body temperature every 8 hours.

B: Clients with acute pancreatitis are at an increased risk for bacterial infection. The nurse should closely monitor the WBC count and intervene as necessary.

The nurse is caring for a client with chronic hepatic failure who has developed refractory ascites who has not responded to traditional diuretics. Which action should the nurse take to manage the accumulation of ascites? A. Limit sodium intake to 2,000 mg per day. B. Administer mannitol. C. Prepare the client for a peritoneovenous shunt. D. Limit fluid intake to 500 ml per day.

B: Impaired liver function for six months or longer is a characteristic sign of chronic liver failure. According to a NIH study, if a client has not responded to traditional antidiuretics such as lasix or spirolactone, mannitol has shown to help the improving the response of diuretics in producing urinary output and lowering of sodium levels in refractory ascites. Therefore, in order to manage the client's ascites, the nurse should administer mannitol.

Which action should the nurse take to reduce the risk of infection in a client with an enterocutaneous fistula? A. Stop enteral feedings. B. Optimize gravity drainage of fistula. C. Check temperature orally every 2 hours. D. Administer antibiotics as needed.

B: In order to prevent infection, the nurse should optimize gravity drainage of each fistula individually. This promotes wound healing through increased rate of tissue granulation.

An adult client reports a five-day history of nausea and vomiting. The client has been taking antacids for symptom relief. Which condition is the client likely to develop? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

B: Metabolic alkalosis is a type of acid-base imbalance in which the pH of the tissues becomes elevated. This condition may result from the loss of acid from the gastrointestinal system through vomiting, nasogastric suctioning, and overuse of antacids.

The nurse is assessing a client who is 12 hours post spinal cord injury at C-6. The client is flushed in appearance with hot and dry skin. The client's heart rate has dropped to 58 beats per minute and blood pressure dropped to 86/52 mmHg. The client's signs and symptoms are indicative of which complication? A. Spinal Shock B. Neurogenic Shock C. Cardiogenic Shock D. Hemorrhagic Shock

B: Neurogenic shock is a type of distributive shock, resulting in the loss of vasomotor tone and system innervation causing the client to experience peripheral vasodilation and venous pooling, characterized by hypotension and bradycardia. Initially the skin temperature may be warm due to the peripheral dilation. This is seen with spinal cord injuries at or above T6.

In clients with renal failure, which medication should the nurse anticipate the client may need to take with meals? A. Pepto-Bismol. B. Calcium carbonate. C. Lactose supplement. D. Simvastatin.

B: Nutrition planning for clients with renal failure includes a reduction in foods containing potassium, phosphorous, and sodium. Calcium carbonate is often given with meals in clients with renal disease to act as a phosphorous binder.

Which should the nurse identify as a contributing factor to the development of pressure ulcers? A. High protein diet. B. Paralysis. C. Independent ADLs. D. Upper respiratory infection.

B: Paralysis results in decreased micromovements and decreased sensation. Clients with paralysis are at greater risk for developing pressure ulcers.

Which statement made by the client who is newly diagnosed with polycystic kidney disease (PKD) indicates to the nurse that additional teaching for self-management is needed? A. "I will need to increase my daily water intake." B. "I will restrict my sodium to less than 2 g daily." C. "Now I will need to take a blood pressure drug daily." D. "If I become sexually active or plan to have a family, I will seek genetic counseling."

B: Patients with PKD waste sodium rather than retaining it. They need an increased sodium and water intake. Aggressive control of hypertension is needed to preserve kidney function. Genetic counseling is advised before having children because PKD is inherited.

Which side effect of pilocarpine ophthalmic should the nurse anticipate when caring for a client with glaucoma? A. Xerostomia. B. Retinal detachment. C. Dry eyes. D. Fever.

B: Pilocarpine ophthalmic is often prescribed to treat glaucoma, as it decreases intraocular pressure by allowing excess fluid to drain from the eye. Retinal detachment may occur when using pilocarpine ophthalmic.

While teaching a client with chronic obstructive pulmonary disease about nutritional needs, which type of food should the nurse recommend? A. Cruciferous vegetables. B. Poultry. C. Citrus fruits. D. Pasta.

B: Shortness of breath and increased work of breathing can make maintenance of a healthy body weight difficult in clients with COPD. Lean, high protein foods, such as poultry, should be included in the diet of patients with COPD to decrease the likelihood of protein energy malnutrition.

Which statement by the nurse is important in determining the plan of care for a victim of a stab wound? A. "Stab victims should be placed in supine position." B. "Length of the impaling object is an important consideration." C. "Stab wounds are considered high-velocity injuries." D. "Stab victims should be given blood products immediately".

B: Stab wounds are classified as penetrating trauma caused by the impalement of a foreign object. The nurse should consider the length of the impaling object in relationship to the vital organs in the path and area of the impalement.

When providing client education about the Zika virus, what should the nurse explain is the primary mode of transmission? A. Consuming contaminated food. B. Receiving a bite from an infected mosquito. C. Shaking hands with an infected person. D. Breathing in contaminated air.

B: The Zika virus is a type of flavivirus. It is transmitted through blood and body fluids, often through the bite of an infected mosquito.

The nurse is examining a client for possible anemia. The client complains of fatigue, reduced exercise intolerance, and is pallor in color and has fissures noted at their corners of the mouth. The client's signs and symptoms are indicative of which type of anemia? A. Aplastic anemia. B. Iron deficiency anemia. C. Folic acid deficiency anemia. D. Vitamin B12 deficiency anemia.

B: The classic sign of iron deficiency anemia is fissures at the corners of the mouth. Along with the pallor, fatigue and reduced exercise intolerance as seen in all anemias.

An arterial blood gas (ABG) analysis is drawn for a client. The results show pH of 7.30; PaCO2 of 68 mm Hg and an HCO3 of 24 mEq/L. What should the nurse interpret this blood gas as? A.Compensated metabolic alkalosis B. Uncompensated respiratory acidosis C. Compensated metabolic acidosis. D. Uncompensated respiratory alkalosis.

B: The nurse should interpret the arterial blood gas (ABG) result as uncompensated respiratory acidosis due to the fact the pH is acidotic and the CO2 is hypercapnic and the sodium bicarbonate is within normal limits. This ABG result is reflective of acute respiratory distress.

A client is admitted with several bruises and has been diagnosed with ascites and a deficiency in clotting. Which intervention helps promote clotting? A. Verify that heparin has been ordered. B. Administer a vitamin K injection. C. Offer the client high protein foods to eat. D. Provide the client a soft bristle toothbrush.

B: Vitamin K is necessary for the liver to produce the protein prothrombin which is one of the factors for the clotting process. Deficiency of vitamin K can result in bruising and bleeding.

A client is admitted with several bruises and has been diagnosed with ascites and a deficiency in clotting. Which intervention helps promote clotting? A. Verify that heparin has been ordered. B. Administer a vitamin K injection. C. Offer the client high protein foods to eat. D. Provide the client a soft bristle toothbrush.

B: Vitamin K is necessary for the liver to produce the protein prothrombin which is one of the factors for the clotting process. Deficiency of vitamin K can result in bruising and bleeding.

The nurse is caring for a client who has just been placed on lisinopril for treatment of hypertension. The nurse should educate the client about what common side effect of this medication? A. Frequent urination. B. Dizziness. C. Dry skin. D. Increased hunger.

B: When administering medications, it is important that the nurse understand side effects that may be either drug- or drug class-specific. Dizziness is a common side effect of the class of antihypertensives known as ACE inhibitors.

The nurse is caring for a client who has just been placed on lisinopril for treatment of hypertension. The nurse should educate the client about what common side effect of this medication? A. Frequent urination. B. Dizziness. C. Dry skin. D. Increased hunger.

B: When administering medications, it is important that the nurse understand side effects that may be either drug- or drug class-specific. Dizziness is a common side effect of the class of antihypertensives known as ACE inhibitors.

Which assessment should the nurse perform on a client with suspected renal failure? A. Diet log. B. Orthostatic blood pressure. C. List of supplements. D. Surgical history.

B: When assessing a client with suspected renal failure, the nurse should evaluate the client's blood pressure for changes indicative of fluid volume excess or depletion. The nurse should check the client's orthostatic blood pressure.

A client is admitted to the telemetry unit after a right-sided cardiac catheterization. What is the nurse's priority when caring for this client? A. Assess the intensity and quality of the client's pain. B. Position the client in a sitting position to improve breathing. C. Check the client's arterial insertion site. D. Apply oxygen at 2 L/min via nasal cannula.

C

A client is prescribed enalapril (Vasotec) for control of hypertension. What health teaching will the nurse provide before the client begins therapy? A. "You may develop a higher pulse rate." B. "You may notice some swelling in your feet." C. "You may develop a nagging cough." D. "Your diet should include foods high in sodium."

C

For which assessment finding in a client who has severe hyperthyroidism does the nurse notify the Rapid Response Team? A. An increase in premature ventricular heart contractions from 4 per minute to 5 per minute B. An increase in or widening of pulse pressure from 40 mm Hg to 46 mm Hg C. An increase in temperature from 99.5° F (37.5° C) to 101.3° F (38.5° C) D. An increase of 20 mL of urine output per hour

C

The client is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the client's skin on the palms of the hands and the soles of the feet. Which additional assessment data support the nurse's suspicion of possible graft-versus-host disease (GVHD)? A. The client's temperature is slightly below normal. B. Today's platelet count is 5,000/mm3 and the WBCs are low. C. The client has had 6 to 10 watery stools daily for 3 days. D. The client's urine output is less than 800 mL in 24 hours.

C

The nurse closely monitors the client with acute pancreatitis for which complication? A. Duodenal ulcer B. Infection C. Pneumonia D. Heart failure

C

Which health problems are considered results of microvascular complications from long-term or poorly controlled diabetes mellitus? A. Obesity and hyperglycemia B. Systolic hypertension and heart failure C. Retinal hemorrhage and male erectile dysfunction D. Diabetic ketoacidosis and hyperglycemic-hyperosmolar state

C

The nurse is reviewing the electronic health record of a 70 year old client. Which vaccinations should be current for this client? A. Cholera B. Smallpox C. Influenza D. Meningitis E. Pneumococcal

C &E: Vaccination recommendations from the CDC for individuals over the age of 65 include influenza yearly and pneumococcal every 5 years to help prevent these illnesses.

The nurse assessing a client who has been diagnosed with osteoarthritis (OA). Which elements in the client's history are consistent with risk factors for the development of OA? A. BMI of 23. B. Vegetarian diet. C. History of smoking. D. Construction worker. E. Previous joint surgery.

C,D,E: Obesity (BMI 30+); joint trauma whether it is from recreational or occupations which causes recurrent stress to joints; past surgeries on joints and history of smoking can be contributing risk factors to the development of OA.

When caring for a client in renal failure, which symptoms should the nurse interpret as an indication of hyperkalemia during the oliguric phase? A.General fatigue and irritation. B. Increased appetite and restlessness. C. Muscle weakness and paresthesia. D.Confusion and itching.

C: Acute renal failure is caused by a deterioration in kidney function that results in the accumulation of waste and decreased urinary output. Renal dysfunction is a common cause of hyperkalemia (decreased potassium). The nurse should interpret muscle weakness and paresthesia as signs of hyperkalemia.

When teaching a client how to manage an allergy to tree pollen, which food should the nurse tell the client to avoid? A. Bread B. Rice C. Apples D. Wheat

C: Apples and other tree fruits can cause allergic cross-reactivity in persons with pollen allergies.

When teaching a client how to manage a latex allergy, what food should the nurse tell the client to avoid? A. Chicken. B. Rice. C. Bananas. D. Oats.

C: Banana, avocado, chestnut, and kiwi have the highest association of cross reactivity to latex in clients with latex allergy.

The client passes a urinary stone that laboratory analysis indicates is composed of calcium oxalate. Based on this analysis, which instruction does the nurse specifically include for dietary prevention of the problem? A. "Increase your intake of meat, fish, and cranberry juice." B. "Avoid citrus fruits and citrus juices such as oranges." C. "Avoid dark green leafy vegetables such as spinach." D. "Decrease your intake of dairy products, especially milk."

C: Calcium oxalate stones form more easily in the presence of oxalate. Sources of oxalate include spinach, black tea, and rhubarb. Avoiding these sources of oxalate may reduce the number of stones formed. Citrus intake is not restricted in this type of stone and is often suggested to be increased. Dietary intake of calcium does not appear to affect calcium-based stone formation, although the client should avoid calcium mineral supplements. Moderation of meat reduces stone formation in general.

A nurse is reviewing a client's medical administration record that was diagnosed with acquired immune deficiency syndrome (AIDS). The nurse knows that clients diagnosed with AIDS are typically placed on what type of regime of medications? A. Antibiotic therapies. B. Antifungal products. C. Antiretroviral agents. D. Anticholinergic meds.

C: Clients diagnosed with HIV and AIDS are placed on antiretroviral therapy. These medications do not kill the virus, but inhibits viral replication. The medication regime consists of multiple combinations of antiretroviral meds, often referred to as "cocktails" and known as an approach called "highly active antiretroviral therapy" (HAART).

The nurse is caring for a client who just been brought into the emergency department after a myocardial infarction. Which action is the priority for this client? A. Administer pain medications. B. Begin educating the client about what to expect in the cath lab. C. Administer 2-4L oxygen by nasal cannula. D. Obtain an electrocardiogram.

C: Clients experiencing myocardial infarction often experience pain and discomfort. To relieve ischemic pain, the nurse can provide additional oxygen via nasal cannula, which will promote delivery of oxygen to the heart.

Which action should the nurse take when caring for a client with a spinal injury who suddenly begins showing signs of autonomic dysreflexia? A. Turn the client every 4-6 hours. B. Monitor blood pressure every 2-3 hours. C. Elevate the head of the bed. D. Encourage the client to ambulate.

C: Clients with spinal injuries are at risk for developing autonomic dysreflexia (AD) due to lack of parasympathetic or sympathetic nervous system activity. When the client exhibits symptoms of AD, the nurse should elevate the head of the bed or place the client in a seated position to promote a decrease in blood pressure and look for signs of possible cause such as an overextended bladder or impacted rectum that is eliciting the AD response.

The nurse is assessing a 42-year-old male who has a diagnosis of diabetes mellitus since the age of 28 years old, a history of lower back injuries related to work and admits to smoking 1-1.5 packs of cigarettes a day and drinking 2- 3 alcoholic beverages per day. Based on the client's medical history, which condition is he at risk of developing? A. Prostate cancer. B. Testicular cancer. C. Erectile dysfunction. D. Benign prostatic hyperplasia.

C: Diabetes mellitus is the main cause of organic erectile dysfunction (ED). Other causes of ED can be due to inflammation of the prostate, urethra or seminal vesicles; s/p prostatectomy; pelvic fractures; and lumbosacral injuries. Additionally, vascular disease; use of antihypertensive medications; chronic neurologic conditions; smoking and alcohol consumption; and poor overall health are also contributing factors to erectile dysfunction.

The critical care nurse is completing a physical assessment on a client admitted with diabetic ketoacidosis. Which assessment finding should the nurse anticipate? A. Cool, clammy skin. B. Hypertension. C. Kussmaul respirations. D. No change in LOC.

C: Diabetic ketoacidosis (DKA) is a potentially life-threatening condition associated with hyperglycemic crisis, ketosis, acidosis, hypovolemic shock due to dehydration, and electrolyte imbalance. Due to low pH levels, the nurse should anticipate Kussmaul breathing, a condition marked by deep, rapid respirations.

A client who complains that about 30 minutes after eating they start to sweat and become light-headed and dizzy, and feel like their heart is racing. They stated that lying down appears to provide some comfort. Based on these symptoms which condition are they mostly experiencing? Ulcerative colitis. Food poisoning. Dumping syndrome. Chronic cholecystitis.

C: Dumping syndrome occurs when there is rapid emptying of the food in the stomach into the small intestine. The signs and symptoms usually present thirty after eating as the client experiencing vertigo, tachycardia, syncope, diaphoresis, palpitations and a desire to lie down.

The nurse is conducting a physical assessment on a client who has a history of unexplained weight loss, an enlarged thyroid, exophthalmos, elevated BP and rapid pulse. The client also complains of the inability to concentrate, memory loss and overreacting in stressful situations. Based on the physical assessment findings, which condition should the nurse suspect? A. Crohn's disease. B. Hypothyroidism. C. Graves' disease. D. Diabetes mellitus.

C: Graves' disease also known as hyperthyroidism is a condition in which there is increased activity of the thyroid gland, with overproduction of the thyroid hormones T4 and T3, resulting in an exaggeration of metabolic processes.

The nurse is providing care for a client with hydrocephalus. Which would alert the nurse that the client's intracranial pressure has increased? A.Narrowing pulse pressure. B.Regular breathing pattern. C.Worsening headache. D. Tachycardia.

C: Hydrocephalus is caused by an accumulation of cerebrospinal fluid in the brain. A worsening headache should alert the nurse to increased intracranial pressu

An unstable client with hyperglycemic hyperosmolar syndrome (HHS) has been assigned to the nurse. Which action should the nurse take initially? A. Insert a urinary catheter. B. Prepare to administer isotonic IV fluids. C. Evaluate the client's airway. D. Place two large bore IVs.

C: Hyperglycemic hyperosmolar syndrome (HHS) is caused by insulin deficiency and resistance, which then results in severe hyperglycemia. Clients experience diuresis that can cause dehydration. Assessing the client's airway is the nurse's first priority.

A nurse is assigned a client who was being treated for early sepsis with IV antibiotics and IV fluids. During the client's assessment the nurse notes that the client's blood pressure which was 86/52mmHg is now 118/78mmHg; their skin which was cool is now appears pink and warm to touch and their heart rate has increased from 75-89 beats per minute. How should the nurse interpret these assessment findings? Select the most appropriate statement. A. The client appears to be responding well to the antibiotic therapy. B. The status of the client is improving as evident by the skin changes. C. The condition of the client may be getting worse rather than improving. D. The circulation is improving as evidenced of the increased blood pressure and skin.

C: In early sepsis the clients will exhibit mild hypotension; slight decrease in urine output and increase respirations which result in decrease cardiac output. Their skin on their extremities may appear slightly pale and cool to touch. If the sepsis does not respond to interventions, the client will shift into severe sepsis and the body will attempt to compensate by increasing the heart rate which will increase the stroke volume in turn increased the cardiac output, return the blood pressure and central venous pressure back to normal. The increased cardiac output and vasodilation will make the appearance of the skin to become pink and warm to touch. Unfortunately, this compensation is actually a sign of the client's condition worsening and is only temporary, in which the client's cardiac output will drastically reduce and the client then progresses into septic shock.

When teaching a client with otitis externa about ways to avoid recurring infections, which information should the nurse include? A. Clean cerumen from ear canals. B. Apply ointment to ears daily. C. Keep ear canals dry. D. Take oral antibiotics once daily.

C: Otitis externa is inflammation of the outer ear and ear canal that is frequently associated with water activities, such as swimming. Clients should be educated to keep the ear canals dry to help prevent recurrent infections such as using ear plugs when swimming if going to submerge head under water or avoid submerging head under water altogether.

Which medication is used to treat otitis externa? A. Witch hazel poultice. B. Oral NSAIDs. C. Antibiotic drops. D. Oral antifungals.

C: Otitis externa, commonly known as swimmer's ear, is an inflammation of the outer ear and ear canal that is frequently associated with water activities such as swimming. It is treated with antibiotic ear drops.

The nurse is caring for a client who is at risk for developing pneumonia. Which action should the nurse take to decrease the risk of infection? A. Encourage the client to stay in bed and rest. B. Maintain an option suction system when suctioning the client. C. Teach the client how to cough and deep breathe. D. Implement protective isolation precautions.

C: Pneumonia occurs due to an infection in the lungs as the result of consolidation of pulmonary secretions in the lobes of the lungs. In order to reduce the risk of pneumonia infection, the nurse should teach the client how to cough and deep breathe to aid in the removal of these secretions from the lungs.

The nurse is working with a client who was born with an inherited disorder in which the nephrons of their kidneys are affected and usually do not become symptomatic until they reach their 30's when their nephron and kidney function become less effective. These clients usually experience hypertension as a result of this condition. This client is most likely diagnosed with which condition? A. Cystitis. B. Urolithiasis. C. Polycystic disease. D. Urothelial cancer.

C: Polycystic kidney disease is an inherited disorder in which the nephrons of the kidneys are affected with fluid-filled cysts. At birth, there are only a few cysts located in the nephrons. Once a person reaches their 30's the small cysts usually become larger as they fill up with fluid and then create a compromise on the nephron and kidney function.

An adult client presents with increased thirst, increased hunger, and excessive urine production. The nurse records the client's height and weight at 5 feet 2 inches and 280 pounds. Which diagnosis should the nurse suspect? A. Cushing's syndrome. B. Hyperaldosteronism. C. Diabetes mellitus. D. Diabetes insipidus.

C: Polyuria, polydipsia, and polyphagia are common symptoms of diabetes. Obesity places the patient at greater risk for the development of type 2 diabetes mellitus.

Which treatment should the nurse plan to implement for a client diagnosed with septicemia? A. PO antibiotics and IV fluid resuscitation. B. IV antibiotics and IV fluids at a keep open rate. C. IV antibiotics and IV fluid resuscitation. D. PO antibiotics and IV fluids at a keep open rate.

C: Sepsis is a life-threatening condition caused by an underlying systemic infection. This condition may be treated aggressively with IV antibiotics and IV fluid resuscitation.

The nurse is assisting a client with a long arm casted limb changing their clothes and notices there are some non-bleeding skin abrasions located on the (L) iliac crest area and (L) knee distally from a skateboard accident. What type of precautions should the nurse follow when assisting this client with dressing? A. Sterile precautions. B. Contact precautions. C. Standard precautions. D. Biohazard precautions.

C: Standard precautions should be used when providing care to a client who has any areas of exposed non-intact skin.

What is the most reliable method a nurse should use to document the status of fluid retention in a client diagnosed with heart failure? A. Assess their skin turgor. B. Auscultate their lung sounds. C. Weigh them daily in the morning. D. Evaluate them for the presence of edema.

C: The best way to determine the fluid status of a client diagnosed with heart failure is measuring the client's weight early in the morning every day. Weight gain or loss is the most reliable way to assess the fluid status of these clients.

A client with a left tibial fracture has a short leg cast. While assessing the client, the nurse notes that the left foot is edematous, with taught, pale, cool skin. The pedal pulse is present but weaker than the pulse in the right foot. Capillary fill in the left foot is slower than in the right foot. The client is requesting pain medication within one hour of the last dose and reports that the right foot is feeling numb. Which intervention would improve the client's condition? A. Administration of a muscle relaxant intramuscularly. B. Elevation of the left leg above the level of the heart. C. Fasciotomy procedure performed by a surgeon. D. Application of cool compresses over the cast.

C: The client is exhibiting clinical signs and symptoms of acute compartment syndrome. The only way to relieve the pain caused by this condition is a fasciotomy. This phenomenon occurs when there is increased pressure in one or more compartment areas of the body surrounded by fascia. The lower leg and forearm are the most common sites this occurs. Increasing pain which is not relieved by pain medication, tautness of skin, edema, decrease pulses and capillary refill, accompanied by paleness accompanied by the history of the tibial fracture are indicative of acute compartment syndrome.

A nurse is assigned the care of a client who is presently experiencing hypovolemic shock. The client's MAP has decreased by 20 mmHg from its baseline, tissue ischemia and anoxia of non-vital organs is occurring, pulses are weak, urine output is absent and the client's skin is cool and moist. The client appears to be confused and extremely anxious. Which stage of hypovolemic shock do these clinical signs and symptoms indicate? A. Initial Stage B. Refractory stage C. Progressive stage D. Non-Progressive Stage

C: The client is exhibiting the clinical signs and symptoms of the progressive stage of hypovolemic shock which if allowed to progress will lead into the refractory stage and eventually death. The clinical signs and symptoms of hypovolemic progresses in four stages, if the condition causing the shock and/or interventions is not done and/or successful. If the interventions and the cause of the shock are corrected within 1-2 hours after onset, then the effects are temporary and irreversible.

The community health nurse is assessing an older client and notices that the client walks with short, hesitant steps. The client walks with a slow, shuffling motion and with very little arm movement. At rest, the client has tremors. The nurse also notes that the client speaks in a very soft, low-pitched voice and has difficulty finding the right words. Which condition most likely explains the client's behaviors? A. Fibromyalgia. B. Polyneuropathy. C. Parkinson's disease. D. Wernicke-Korsakoff Syndrome.

C: The client is presenting clinical signs of Parkinson's disease. Parkinson's disease is a debilitating neurologic disorder involving the basal ganglia and substantia nigra. Clients with this condition experience depletion of dopamine which causes difficulty with initiation and coordination of voluntary movement. The disease is characterized by muscle rigidity, akinesia, postural instability, tremors, dysarthria, and a mask like facial appearance.

The community health nurse is assessing an older client and notices that the client walks with short, hesitant steps. The client walks with a slow, shuffling motion and with very little arm movement. At rest, the client has tremors. The nurse also notes that the client speaks in a very soft, low-pitched voice and has difficulty finding the right words. Which condition most likely explains the client's behaviors? A.Fibromyalgia. B. Polyneuropathy. C. Parkinson's disease. D. Wernicke-Korsakoff Syndrome.

C: The client is presenting clinical signs of Parkinson's disease. Parkinson's disease is a debilitating neurologic disorder involving the basal ganglia and substantia nigra. Clients with this condition experience depletion of dopamine which causes difficulty with initiation and coordination of voluntary movement. The disease is characterized by muscle rigidity, akinesia, postural instability, tremors, dysarthria, and a mask like facial appearance.

A client is having a surgical procedure to relieve their lower back pain caused by a herniated disk. Which surgical procedure if repeated several times may necessitate the client to have a spinal fusion? A. Allografts. B. Diskectomy. C. Laminectomy. D. Laser thermodiskectomy.

C: The lamina of the spine is the posterior curvature wall of the vertebrae, enclosing the spinal cord. A laminectomy is removal of part of the laminae and facer joints of the vertebrae to allow the surgeon access to the disc space. If the laminectomy procedure is repeated several times it may cause the spine to become unstable, so a spinal fusion may have to perform.

A female client has had a scleral buckling with the use of silicone oil for repair of partial retinal detachment of her right eye. The client is transferred to the surgical floor. The client is lying on her left side with her head in the midline position during the nurse's assessment. A protective shield is covering the client's right eye. Which is the most important nursing intervention the nurse should implement post-operatively? A. Offer pain medication continuously around the clock. B. Keep both of the eyes covered with protective eye shields. C. Ensure the client remains on her left side with her head midline. D. Administer topical corticosteroids and immunosuppressants.

C: The most important nursing intervention for a client following retinal detachment repair in which gas or silicone oil placed in the eye to promote retinal attachment is to maintain the client's head in the same position the surgeon has placed it. The gas or oil bubble is used to float up against the retina to hold the retina in place until it heals in place.

A client who is twelve hours status-post graft for arterial revascularization is complaining of limb pain. Select the appropriate nursing action. A. Administer pain medication as prescribed. B. Immediately notify the surgeon of the finding. C. Ask the client to describe the pain being experienced. D. Elevate the extremity and assess the surgical dressing.

C: The nurse needs to determine the source of the pain by getting a more descriptive explanation of the pain the client is experiencing. The first sign of a possible post-op complication of arterial revascularization of a graft is occlusion and ischemia. A complaint of severe continuous and aching pain may be the first symptom that an occlusion is occurring. Clients may experience a throbbing pain which is considered normal as the increase blood flow returns to the distal limb. The nurse also needs to assess the operative limb. If the limb becomes cool, cold, pale, ashen or cyanotic and the distal pulse from the operative site becomes decreased or absent and/or the client describes a severe continuous and aching pain; the surgeon needs to be notified immediately.

An unlicensed assistant personnel (UAP) is providing a bed bath to a client who is 48 hours post radical neck dissection due to oral cancer. Upon turning the client to the side, the UAP notices the client's neck dressing start to ooze bright red blood. The UAP immediately applies pressure to the neck dressing and calls the nurse. What should the nurse do first? A.Raise the head of the client's bed to 45° and flex the client's knees. B. Switch out their gloved hand for the UAP's non -gloved hand. C. Instruct the UAP to gently take their hand off the client's dressing. D. Maintain direct pressure on dressing and transport client to the operating room.

C: The oozing blood indicates a leak of the carotid artery rather than a rupture. A client who is status post radical neck dissection should be monitor for the development of carotid artery leakage or rupture. A ruptured artery will appear as large amounts of bright red blood spurting quickly. A carotid artery with a leak will appear as oozing of bright red blood. If a carotid leakage is suspected, do not touch the area because additional pressure could cause immediate rupture; instead call the Rapid Response Team. The UAP should stop applying pressure. Direct pressure is only applied to a ruptured carotid artery.

A nurse who is caring for a client diagnosed with Graves disease suspects the client has progressed in to a thyrotoxicosis crisis. Which assessment finding would support this suspicion? A. Bradycardia. B. Hypertension. C. Profuse sweating. D. Hypothermia.

C: Thyrotoxicosis crisis can be a complication of Grave's disease and is considered a life-threatening emergency. The nurse should monitor the client for elevated temperature, excessive perspiration, vomiting and diarrhea, delirium, severe weakness, seizure activity, arrhythmias, hypotension and coma which are complications of this condition.

Which goal should the nurse include in the care plan for a client with myasthenia gravis within the first 24 hours of treatment? A. PaO2 equal to 70. B. PaCO2 equal to 60. C. O2 saturation greater than 95%. D. RR of 22 breaths/min.

C: Within 2-24 hours after the initiation of treatment, a client with myasthenia gravis should have an oxygen saturation level greater than 95%.

The healthcare provider has prescribed a treatment for a chronic wound that utilizes a technique which uses a special sponge that is placed in the wound bed and is sealed for 48 hours with a continuous low-level negative pressure. Based on the description of this prescription the nurse needs to prepare the client for which procedure? A. Electrical stimulation. B. Topical growth factors. C. Vacuum-assisted closure. D. Hyperbaric oxygen chamber.

C: Wound vacuum-assisted closure is a procedure that uses a special sponge that is placed in the wound bed that is sealed for 48 hours and uses continuous low-level negative pressure to remove any drainage in the wound bed to promote wound healing.

A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A. Repositioning the client every 2 hours B. Providing oral care with chlorhexidine rinse C. Checking tube placement at the client's incisor D. Turning off ventilator alarms while working in the room

D

The nurse is providing teaching for a client scheduled for a paracentesis. Which statement by the client indicates the teaching has been successful? A. "I must not use the bathroom prior to the procedure." B. "I will lie on my stomach while the procedure is performed." C. "I will not be allowed to eat or drink anything the night before surgery." D. "The physician will likely remove 2 to 3 liters of fluid from my abdomen."

D

With which client is it most important for the nurse to use latex-free gloves? A. 38-year-old woman taking oral contraceptives B. 68-year-old man with total hip replacement C. 38-year-old man allergic to shellfish and nuts D. 28-year-old woman with spina bifida

D

A client has just been diagnosed with nephrogenic diabetes insipidus. Which assessment finding should the nurse interpret as a sign of electrolyte imbalance? A. Nocturia. B. Poor skin turgor. C. Increased thirst. D. Leg cramps.

D: A chronic kidney disorder can result in nephrogenic diabetes insipidus which affects the kidney's ability to respond properly to the anti-diuretic hormone (ADH). This causes high urine output, increased thirst and electrolyte imbalances resulting in the client experiencing nausea, lethargy, muscle cramps and confusion. The nurse should interpret leg cramps are a sign of an electrolyte imbalance.

A client with increased intracranial pressure has not had a bowel movement in three days. Which should the nurse anticipate will be administered to the client? A. Vegetables. B. Milk of magnesia. C. Prune juice. D. Docusate sodium.

D: Activity restrictions due to hospitalization and narcotic analgesic use may predispose the client with intracranial pressure (ICP) to constipation. To avoid increases in ICP due to straining, docusate sodium or other stool softeners may be administered.

The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan? A. Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment. B. The client will be weaned from the ventilator within 24-48 hours after initiation of treatment. C. Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment. D. The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.

D: Acute respiratory failure generally results from a primary lung dysfunction. When treating a client with acute respiratory failure, the client should have adequate gas exchange within 2 to 4 hours of initiating treatment. A PaO2 greater than 80 mmHg indicates adequate ventilation.

The nurse is preparing a client for an esophagogastroduodenoscopy (EGD) following an episode of acute gastrointestinal bleeding. The client asks why the EGD is being performed. Which reason should the nurse give? A. To rule out malignancy. B. To remove intestinal obstructions. C. To cauterize the site. D. To locate the source of bleeding.

D: An esophagogastroduodenoscopy (EGD) involves passing an endoscope through the mouth, esophagus, and stomach. It is performed while the client is sedated to assess and determine the exact source of bleeding in the upper gastrointestinal tract.

The nurse is reviewing the laboratory results for a client with rheumatoid arthritis. Which test result is a marker for the degree of inflammation present in autoimmune disorders? A. Troponin I. B. Myoglobin. C. Homocysteine. D. C-reactive protein.

D: C-reactive protein is the marker for inflammation. This protein helps to diagnose and treat the severity of the disorders such as lupus, rheumatoid arthritis and inflammatory bowel disease along with the presenting signs and symptoms.

Which assessment finding indicates that a client is in progressive (stage III) of shock? A. Eupnea. B. Active bowl sounds. C. Normal sinus rhythm. D. Cold, clammy skin.

D: Cellular edema occurs during the progressive stage (stage III) of shock. The clinical presentations of this include cold and clammy skin, anuria, absent bowel sounds, and lethargy progressing to coma.

Which assessment finding indicates that a client is in progressive (stage III) of shock? A. Eupnea. B. Active bowl sounds. C. Normal sinus rhythm. D. Cold, clammy skin.

D: Cellular edema occurs during the progressive stage (stage III) of shock. The clinical presentations of this include cold and clammy skin, anuria, absent bowel sounds, and lethargy progressing to coma.

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? A. Assess the client's oxygen saturation level. B. Ask the laboratory to retest the potassium level. C. Give potassium as an IV infusion. D. Check the client's serum creatinine.

D: Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.

The nurse is assessing the function of a client's blood glucose meter. Which is the best evidence that the meter is accurately measuring blood glucose? A. A sample tested on the client's meter are within 20 points of the result on a similar meter. B. The nurse's blood glucose is within normal limits on the client's meter. C. An average of the client's blood glucose values are consistent with the A1c value. D. A sample of control solution yields results within the range for the client's meter.

D: Control solution is used to verify a blood glucose meter's performance. Other options are not used as quality checks (comparing two meters, using a nurse's sample, or averaging to match A1c).

What should the nurse identify as a common side effect of ferrous sulfate? A. Diarrhea. B. Headache. C. Vision changes. D. Dark stools.

D: Ferrous sulfate is a type of iron. Dark stools are a side effect of taking oral iron.

A client is admitted for a thyroid scan to rule out Graves Disease. The nurse has delegated care of this client to an unlicensed assistive personnel (UAP). Which is the most important data that the UAP should report to the nurse immediately? A. Apical pulse of 110 beats per minute. B. Blood glucose reading of 150mg/dl. C. Presence of tremors and blurred vision. D. Temperature change from 99.1 to 100.1°F (37.3-37.8°C).

D: For the client with Graves disease (hyperthyroidism), an increase in temperature may indicate worsening of the condition and the onset of a thyroid storm. An increase of 1° F should be reported immediately.

A client is diagnosed with severe sepsis and admitted to the hospital. The nurse should anticipate which type of anti-infective medication to be initiated within one hour of the admission to treat which type of causative organism associated with sepsis? A. Parasitic. B. Retroviral virus. C. Anaerobic fungus. D. Gram-negative bacteria.

D: Gram-negative bacteria are the most common organism known to cause septic shock. If a sepsis diagnosis is suspected, then a broad spectrum antibiotic to treat against gram-negative bacteria is initiated within one hour of diagnosis, even before the causative organism is identified.

A client with Graves' disease has been prescribed methimazole. Which explanation by the nurse correctly describes how this medication works? A. It increases absorption of thyroid hormone. B. It increases availability of thyroid hormone. C. It helps the body use thyroid hormone more effectively. D. It interferes with production of thyroid hormone.

D: Graves' disease is an autoimmune condition that is the characterized by elevated thyroid hormone (hyperthyroidism). Methimazole is used to treat overactive thyroid by interfering with the production of thyroid hormone.

A family member is visiting a client in the critical care unit. During the visit, the client has a cardiac arrest. As resuscitation efforts begin, what action should the nurse take with the visitor? A.Contact the chaplain to take the family member to the chapel. B.Have another nurse escort the family member to the waiting room. C. Keep the family member updated, as they wait outside the room. D. Upon the family member's request, allow the person to remain in the room.

D: If a family member desires to remain in the room during the resuscitation, the standard of care is to allow them, as long as they don't interfere in the resuscitative efforts. It is good practice to have a member of the healthcare team to be next to them to offer support and explanations during the resuscitation efforts.

The nurse is providing care for a client diagnosed with acute infective endocarditis. Which symptom should the nurse expect to find on assessment in the late infective stage? A. Bradycardia. B. Increased appetite. C. Extremity pain. D. Petechiae.

D: Infective endocarditis (IE) often involves an infection of a heart valve. The client's skin is often pale, and late assessment findings include anemia, petechiae, and clubbing of fingers.

The nurse is educating a student nurse about collaborative care methods used with clients with increased intracranial pressure (IICP). Which method is appropriate treatment for clients with IICP? A. "Anti-hypertensives are considered first line therapy in client's with ICP." B. "Intravenous calcium antagonists increase perfusion." C."Glycerin has been clinically proven to increase ICP and should not be used." D."Clients given mannitol should be monitored for electrolyte imbalances."

D: Mannitol lowers intracranial pressure by reducing fluid in the client's brain cells. After administering mannitol, the nurse should closely monitor the patient to be sure excessive dehydration does not occur.

A client from a nursing home is admitted with diagnoses of diabetes mellitus, chronic pancreatitis and alcoholism. The healthcare provider has prescribed the client pancrelipase (Creon, Pancrease). How should the nurse document the effectiveness of this prescribed medication? A. The absence or presence of delirium tremors. B. The character and quality of abdominal pain. C. Glucometer readings before and after each meal. D. The number, frequency and consistency of stools per day.

D: Pancrelipase is a pancreatic enzyme to aid in the digestion of carbohydrates, protein and fat due to pancreatic insufficiency from the chronic pancreatitis. To evaluate the effectiveness, the nurse should record the number, frequency and consistency of the client's daily stools. If the medication is being effective the stools should become less frequent and have less steatorrhea.

A client from a nursing home is admitted with diagnoses of diabetes mellitus, chronic pancreatitis and alcoholism. The healthcare provider has prescribed the client pancrelipase (Creon, Pancrease). How should the nurse document the effectiveness of this prescribed medication? The absence or presence of delirium tremors. The character and quality of abdominal pain. Glucometer readings before and after each meal. The number, frequency and consistency of stools per day.

D: Pancrelipase is a pancreatic enzyme to aid in the digestion of carbohydrates, protein and fat due to pancreatic insufficiency from the chronic pancreatitis. To evaluate the effectiveness, the nurse should record the number, frequency and consistency of the client's daily stools. If the medication is being effective the stools should become less frequent and have less steatorrhea.

The nurse is caring for a client with a pressure ulcer that is 6 cm in diameter and extends to the underlying muscle and tendon. How should the nurse classify this ulcer? Stage 1. Stage 2. Stage 3. Stage 4.

D: Stage 4 pressure ulcers involve extensive tissue damage that extends into the underlying muscle tissue, tendons, or bone.

A client diagnosed with kidney stones is experiencing a urine output decrease of less than 0.5ml/kg per hour; increase BUN and creatinine levels; decrease glomerular filtration rate; flank pain and wheezes and crackles in their lungs, along with 2+ pitting edema in their extremities. Which complication is the client most likely developing? A. Cystitis. B. Urolithiasis. C. Pyelonephritis. D. Acute kidney injury.

D: The client has already been diagnosed with urolithiasis which are the diagnosed kidney stones. The client is presenting signs and symptoms of acute kidney injury as a result of the kidney stones causing obstruction(s). Decrease in urine output less than 0.5m/kg per hour; abnormal or sharp increase of BUN and creatinine levels; decrease in their GFR and signs and symptoms of fluid overload as evidence of pulmonary edema and peripheral edema and flank pain.

A 28-year-old client is exhibiting signs and symptoms of confusion, severe muscle weakness, tachycardia and hypotension and episodic of vomiting and constipation. The client has asthma and has been prescribed prednisone (Rayos, Winpred) and albuterol inhaler for the past year. Their vital signs are T- 97.8° F (36.6° C); P- 90; B/P 86/48 with lab values of sodium 130mmol/L; potassium 5.9mmol/L and calcium 10.3mg/dL. Which condition is the client most likely experiencing? A. What have you eaten in the last 24 hours? B. How often do you have to use your albuterol inhaler? C. Are you currently taken any SSRI's or MAOIs medication? D. When was the last time you took the prednisone medication?

D: The client is exhibiting signs and symptoms of acute adrenal insufficiency or commonly known as Addison crisis, based on the clients presentation of signs and symptoms. The use of glucocorticoid drugs (prednisone) can cause secondary adrenal insufficiency if they are stopped abruptly. These drugs must be tapered off, to allow for the pituitary production of ACTH and activation of the adrenal cells to produce cortisol.

An adult client is admitted to the emergency department presenting with symptoms of temperature-103.4°F (39.7°C); severe headache; decreasing level of consciousness and the presence of tremors. The client's has several mosquito bites present. Which condition does the nurse suspect the client will be diagnosed? A. Zika virus. B. Ebola fever. C. Dengue fever. D. West Nile virus.

D: The client's presenting symptoms of a high fever, severe headache, decreasing level of consciousness, and the presence of tremors are indicative of the West Nile virus which can be transmitted by mosquito bites.

A client wanders into the emergency department confused and somnolent. The client is bleeding profusely from the first three digit sites which have been severed from the hand from a lawn mower accident. The nurse immediately applies pressure to the severed sites. Which nursing action should the nurse do next? A. Start an IV with two large bore needles and place supine on the gurney. B. Placed the client on a gurney with their feet elevated and their head flat and apply oxygen. C. Apply a tourniquet and ice to the site and have client sit upright with arm above heart level. D. Placed the client in a fowler's position with their arm elevated above their head and apply oxygen.

D: The nurse needs to continue applying pressure to the severed sites. Place the client on a gurney with their feet elevated and their head flat or no more than 30°angle, apply oxygen. Then proceed to have two large bore IV catheters put in place. It is not in the scope of practice for a nurse to apply a tourniquet.

Which assessment finding should the nurse anticipate in a client experiencing an acute asthma exacerbation? A. Decreased nasal secretions. B. Frequent productive cough. C. Answering questions in full sentences. D. Prolonged phase of forced expiration.

D: The nurse should expect to observe a prolonged phase of force expiration, frequent unproductive cough, increased nasal secretions, and breathlessness in the client experiencing acute asthma exacerbation.

The presence of heat, erythema, edema, and pain at the wound site is an indication of what process? A.Malignancy. B. Allergy. C. Infection. D. Inflammation.

D: These are known as the "cardinal signs" of inflammation.

A client has been diagnosed with chlamydia. The nurse should anticipate that the client will need which medications? A. Cephalexin and Augmentin. B. Cefepime and azithromycin. C. Cefazolin and Augmentin. D. Ceftriaxone and azithromycin.

D: Treatments for sexually transmitted infections, such as chlamydia, are based upon guidelines provided by the Centers for Disease Control and Prevention (CDC). Ceftriaxone and azithromycin are used to treat uncomplicated chlamydia.

Vasopressin

Given along with norepinephrine. • Infuse at low doses (e.g., 0.03 U/min) using an IV pump. • Do not titrate infusion. • Use cautiously in patients with coronary artery disease.

Levodopa (Dopar, Larodopa)

Levodopa is an isomer of dihydroxyphenylalanine and is the metabolic precursor of dopamine. It is converted to dopamine in the basal ganglia. It is used to treat Parkinson's disease and to control the symptoms of parkinsonism. Levodopa should be used with caution in patients who have a history of myocardial infarction or ventricular arrhythmias. In addition, gastrointestinal hemorrhage, psychiatric disorders, and bronchospasm have been reported as adverse effects of this drug. Dosage: Adults only: (Oral) 500 mg to 1 gm/day in divided doses.

Sympathomimetic agents stimulate adrenergic receptors, thereby simulating the effects of sympathetic nerve stimulation. Included in this category are naturally occurring catecholamines (epinephrine, dopamine, and norepinephrine) and synthetic catecholamines (dobutamine and isoproterenol). The cardiovascular effects of these medications, which vary according to their selectivity for specific receptor sites, are often dose-dependent as well. Table 13-18 describes the cardiovascular effects of sympathomimetic agents at various dosages.

Table 13-18

What is the general rule for fluid resuscitation during hypovolemic shock?

The underlying principles of managing patients with hypovolemic shock focus on stopping the loss of fluid and restoring the circulating volume. Fluid resuscitation in hypovolemic shock initially is calculated using a 3 : 1 rule (3 mL of isotonic crystalloid for every 1 mL of estimated blood loss)