Hurst- Must know Content

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select All That Apply 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated.

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? Choose One 1. Ibuprofen 2. Enalapril 3. Prednisone 4. Cyclophosphamide

1. Correct: The prescription of ibuprofen, a NSAID, would be questioned. Ibuprofen is a nonsteroidal ant-inflammatory medication. NSAIDs can cause acute interstitial nephritis and acute tubular nephritis. The client with nephrotic syndrome currently has damage to the micro blood vessels in the kidneys.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO3 24. What action should the nurse initiate? Choose One 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

1. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort.

The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? Select All That Apply1. Perform pin care daily.2. Rinse pins with water.3. Clean with chlorhexidine.4. Dry the area with clean gauze.5. Monitor pin site every 10 hours.

1., & 3. Correct: Pin care is prescribed 48 to 72 hours after insertion. The pin care is initiated once a day. Chlorhexidine is prescribed to clean the pin insertion site. 2. Incorrect: The pins are rinsed with sterile saline and not water. 4. Incorrect: The area around the pin site is dried with sterile gauze. The use of clean gauze is not appropriate. 5. Incorrect: The pin site is assessed. Every 10 hours is not often enough to monitor for infection.

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? Select All That Apply 1. Asterixis 2. Fetor 3. Grey Turner's sign 4. Hyperactive reflexes 5. Squiggly handwriting

1., 2., & 5. Correct: Signs and symptoms that a client diagnosed with cirrhosis is getting worse and headed for hepatic coma include asterixis, fetor, and handwriting changes. 3. Grey's turner is seen with pancreatitis.

Which signs/symptoms would lead the clinic nurse to suspect that a client may have bacterial meningitis? Select All That Apply 1. Nuchal rigidity 2. Photophobia 3. (+) Kernig 4. (-) Brudzinski 5. Fever 102.8 F (39.3 C) 6. Reports headache 9/10

1., 2., 3., 5., & 6. Correct. Signs and Symptoms of meningitis include nuchal rigidity, photophobia, a positive Kernig sign, chills and high fever, and severe headache.

What assessment finding by the nurse would support a client diagnosis of basilar skull fracture? Select All That Apply 1. (+) Halo test 2. Hyper-reflexia 3. Raccoon eyes 4. Battle's sign 5. Kernig sign

1., 3., & 4. Correct. Basilar skull fractures are the most serious fracture. You see bleeding where? Eyes, ears, nose, and throat. So, you will see cerebrospinal rhinorrhea with a (+) Halo test. If you have a bloody spot on the sheet, or wherever, when CSF is present, it will settle out and form a ring or halo around the blood spot. Raccoon eyes, is perioribital bruising which is seen with a basilar skull fracture. Battle's sign or bruising over the mastoid is also indicative of a skull fracture.

What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select All That Apply 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding

1., 3., 4., 5., & 6. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding. Note: UC affects more of the large intestine while chrons affect more of the ileum but can be found anywhere in the small or large intestine.

A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. The client also reports nausea and vomiting. Based on this data, what problem does the nurse suspect? Choose One 1. Glomerulonephritis 2. Renal lithiasis 3. Nephrotic syndrome 4. Acute kidney injury

2. Correct: These signs and symptoms are classic for renal lithiasis or kidney stones.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select All That Apply 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Choose One 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection.

A client returns to the room post appendectomy. In what position should the nurse place the client? Choose One 1. Sims 2. Prone 3. Semi-fowler's 4. Right lateral

3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line.

A child is admitted in a sickle cell crisis. What treatment should the nurse anticipate being most helpful in reducing the painful crisis? Choose One 1. Antibiotics 2. Oxygen 3. Hydration 4. Bedrest

3. Correct: Hydration is crucial with a sickle cell crisis. It helps minimize the vaso-occlusive process that is causing the pain as it pushes the sickled cells apart, allowing them to flow through the vessels more freely.

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? Select All That Apply 1. Change tubing and filter every 48 hours. 2. Monitor IV drip rate hourly. 3. Compare new bag with prescription prior to infusing. 4. Weigh weekly. 5. Cover TPN with dark bag. 6. Check urine for protein.

3., & 5. Correct: Remember safety and that TPN is a medication. You must make sure that what is in the bag is what was prescribed, so double check the bag against the prescription. Cover the IV bag with a dark bag to prevent chemical breakdown. 2. Incorrect: TPN must be placed on an IV pump. Relying on calculating to maintain a drip rate is dangerous. The client could get too much TPN too fast without having it on a pump at the prescribed rate per hour. This is a safety issue.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit: pH: 7.30 PaCO2: 55 Bicarb: 25 PaO2: 93 SaO2: 95% Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1 & 5 correct

A 7 month old is being evaluated in the emergency department for a possible head injury following a reported fall from the parent's bed. What would the nurse consider when evaluating the fontanels for evidence of increased intracranial pressure? Choose One 1. The anterior fontanel should be open at 7 months of age. 2. The anterior fontanel closes at 2 to 4 months of age. 3. The posterior fontanel should be open at 7 months of age. 4. The posterior fontanel closes at 4 to 6 months of age.

1. Correct: The anterior fontanel closes between 12 to 18 months of age. The nurse could assess the anterior fontanel in this 7 month old with a normal finding being soft and flat. A bulging anterior fontanel would be indicative of increased intracranial pressure.

What action should the nurse take when caring for a client who has a subarachnoid screw? Choose One 1. Keep connections tight. 2. Use clean technique when caring for screw. 3. Clean daily with hydrogen peroxide. 4. Maintain a wet to dry dressing around site.

1. Correct. In order to prevent infection, all connections should be tight. We do not want leaking of the CSF.

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? Choose One 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? Choose One 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

1. Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained.

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? Select All That Apply 1. Smoking tobacco 2. Drinking alcohol 3. Eating a high fiber diet 4. Increasing fish consumption 5. Protect skin from sunlight by using tanning beds

1., & 2. Correct: Tobacco is the #1 cause of preventable cancer. Alcohol plus tobacco are co-carcinogenic. No tanning beds.. as bad as the sun with exposure to ultra-violet radiation.

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? Select All That Apply 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. PaO2 78 5. SaO2 82

1., &2. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis.

Which assessment findings would indicate to the nurse that a client may have a fracture? Select All That Apply 1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 5. Tenting of skin

1., 2., 3. & 4. Correct: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Select All That Apply 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully.

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE? Select All That Apply 1. Drink plenty of fluids on a daily basis. 2. Stop and move around every 4 hours when taking a long trip. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

1., 3., 4., & 5. Correct: In order to get this question correct, you must first consider some of the risk factors for developing a DVT and PE. Some causes include: dehydration, venous stasis from prolonged immobility or surgery, obesity, birth control pills, clotting disorders, and heart arrhythmias like A-Fib. Therefore preventive measures would include such things as hydration by increasing fluid intake, prevention of stasis by isometric and stretching exercises of the feet, knees, and hips every 2 to 4 hours, prevention of obesity, and walking around at least 4 to 6 times per day.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select All That Apply 1. Shortness of breath 2. Decreased heart rate 3. Wheezing in the affected area 4. Chest pain 5. Cough 6. Subcutaneous emphysema

1.,4.,5., & 6. Correct: With a hemothorax, we recall that blood has accumulated in the pleural space, and with a pneumothorax, we know that it is air that has accumulated in the pleural space. The presence of either of these causes the lung to collapse. The signs that the nurse expects to see includes shortness of breath, chest pain, and cough. We may also see subcutaneous emphysema as the air that escaped from the lung becomes trapped in the surrounding tissues.

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? Choose One 1. Administer high flow O2 per face mask. 2. Remove the occlusive dressing. 3. Notify the healthcare provider. 4. Initiate rapid IV resuscitation.

2. Correct: Based on these signs and symptoms, we recognize that the client has developed a tension pneumothorax due to the occlusive dressing not only preventing air from getting in, but not allowing the air to escape. Therefore, management of this emergency situation would be the nurse's priority. Removal of the occlusive dressing would allow the air to escape and should help reduce the pressure that is causing the mediastinal shift. Needle decompression may also be needed to relieve the tension pneumothorax. If available, a good option for covering an open or "sucking" chest wound would be a petroleum gauze dressing which would be taped down on only three sides. This creates a flutter valve mechanism that allows air to escape but prevents air from re-entering through the open wound.

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? Select All That Apply 1. The pain is located at the elbow area. 2. The prescribed opioid does not relieve the pain. 3. When forearm is elevated, the swelling in the forearm is reduced. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 5. When placing a cold compress on the forearm, the pain level is reduced.

2. & 4. Correct: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration.

What is the best position for the nurse to place a client for a thoracentesis of the right lung? Choose One 1. Lying supine with pillow removed and head of bed flat 2. Sitting on side of bed and leaning over the bedside table 3. Lying on the right side with the head of bed at 45 degrees 4. Lying supine with the left arm raised over the head

2. Correct: For maximum accessibility for the thoracentesis to be performed, the client should be positioned in a sitting position on the side of the bed, leaning over a bedside table, with arms propped on pillows and the feet supported. If the client is not able to sit up, the alternative position would be to lie on the unaffected side with the head of bed elevated 45 degrees.

A nurse is providing teaching to parents of a child diagnosed with Cystic Fibrosis. Which teaching points should the nurse include? Select All That Apply 1. Liver enzyme replacements must be administered to aid in digestion. 2. A well-balanced, high fat, and high calorie diet is important. 3. Water-miscible forms of fat soluble vitamins A, D, E, and K will be needed. 4. Pancreatic enzymes should be taken at least 1 hour after meals. 5. Respiratory and GI systems are often affected by thick, sticky secretions. 6. Both parents have the gene for this autosomal recessive disorder.

2., 3., 5., & 6 Correct: Nutrition is a major part of the care for clients with Cystic Fibrosis (CF). These clients are often underweight due to digestive problems. Fats are easier to digest than proteins or carbohydrates and provide more calories than other foods do. Increased pancreatic enzyme replacements will be needed as more foods that are higher in fat are consumed. Since these clients do not absorb fat well, the water-miscible forms of the fat soluble vitamins are needed. CF affects the exocrine glands. The mucous secretions are thick and sticky which often leads to problems and blockage in the respiratory and GI systems. Because it is a genetic disease with autosomal recessive transmission, this means that both parents must have the gene. The parents would need to know this when considering future pregnancies. 4. Incorrect: Pancreatic enzymes must be taken within 30 minutes of eating. Keep in mind that the beads should not be crushed or chewed.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select All That Apply 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

2., 4., & 5. Correct: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided. 3. Incorrect: Salt, as a seasoning, should be avoided because this would increase the fluid retention problem. However, a good alternative to salt for seasoning foods is to use lemon, lemon juice, and pepper. These are lower in sodium than salt.

A nurse is preparing to obtain vital signs on a 2 year old. What should the nurse consider when preparing to perform this task? Choose One 1. The blood pressure should be obtained first to get an accurate reading. 2. Count the RR and HR for 30 seconds to avoid prolonged disturbance. 3. If the child becomes upset, record the behavior with the measurements. 4. The axillary route is the most reliable route for checking the temperature.

3. Correct: Infants, toddlers, and young children often become anxious or upset during procedures, such as vital sign measurement, and we know that this activity could affect the vital sign results. Nurses or other healthcare providers would need this information to consider when evaluating the results.

The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? Choose One 1. "The crutches are adjusted according to my height." 2. "I will support my weight on the hand grips when not walking." 3. "I plan to place my affected leg on the step first when ascending stairs." 4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."

3. Correct: This statement is incorrect and further client teaching is needed. When going up stairs, the client should lead with the unaffected leg. The unaffected leg will provide the support required to then move the affected leg to the step.

The nurse is teaching a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful? Choose One 1. "I need to decrease protein in my diet since my kidneys no longer work." 2. "Heating the dialysate in the microwave for 30 seconds will prevent abdominal cramping." 3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy." 4. "The automated peritoneal dialysis (APD) cycler is used every few hours during the day."

3. Correct: The number 1 complication of peritoneal dialysis is infection. So, the client does need to monitor the drainage, which should be clear or straw-colored. If it is cloudy, that indicates infection and the primary healthcare provider should be notified.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit: pH: 7.35 PaCO2: 30 Bicarb: 19 Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3., & 7. Correct. These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred.

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? Select All That Apply 1. Position left-side lying, supine. 2. Place on clear liquid diet after peristalsis returns. 3. Monitor tracheostomy for pulsations with heart beat. 4. Provide mouth care every 2 hours. 5. Maintain a humidified environment.

3.,4., & 5. Correct: If a client's trach is pulsating with the heartbeat, you need to notify the primary healthcare provider immediately, as this could lead to rupture of the innominate artery. Frequent mouth care will decrease the bacterial count in the mouth. We are trying to prevent pneumonia. When breathing in and out through a trach, the client will not be able to warm, filter, and humidify the air. The air is really dry, so it irritates the trach. That is why when the client first gets the trach it has a lot of secretions. A humidified environment will help.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 mL per hour The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour.

The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action? Choose One 1. Clamp the chest tube closest to the chest wall. 2. Increase the water level in the water seal chamber. 3. Have the client take a deep breath and do valsalva maneuver. 4. Notify the healthcare provider.

4. Correct: Continuous bubbling in the water seal chamber indicates that there is an air leak in the system. The healthcare provider should be notified. The healthcare provider may prescribe for the tube to be clamped at intervals along the tube for only a few seconds to determine the location of the air leak, but clamping of the tube should never be done without a prescription.

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit: pH: 7.44 PaCO2: 51 Bicarb: 31 Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 7. Correct. The pH is on the alkalosis side of normal (7.35-7.45). Anything above 7.0 is on the alkalotic side of normal. Look at the CO2. The CO2 is high, which indicates acidosis, so this does not match the alkalotic pH, does it? No. Look at the Bicarb. The bicarb is high, indicating alkalosis, so there is your match. The bicarb is higher than 26, so there is a lot of base in the body. So, this is metabolic alkalosis. Has compensation begun? Yes. The PaCO2 is high. The lungs are attempting to compensate by holding on to carbon dioxide, an acid, to make the pH normal. Since the pH is normal, full compensation has occurred.

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? Exhibit: Awake, alert, and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F (38.3 degrees C), BP 96/64, HR 102, RR 26. 1. Cirrhosis 2. Pancreatitis 3. Peptic ulcer 4. Ulcerative colitis

Pancreatitis: 2. Correct: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever.

A client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Causes of respiratory acidosis include any causes of decreased respiratory drive, such as drugs (narcotics) or central nervous system disorders. With a massive cerebral vascular accident (CVA or stroke), the respiratory center in the brain is impaired and affects oxygenation. Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest.

A 7 month old infant is brought to the emergency department with a sudden onset of inconsolable crying and currant jelly-like stools. The infant is drawing up the knees toward the abdomen and grimacing. What diagnosis should the nurse anticipate? Choose One 1. Intussusception 2. Hirschsprung's Disease 3. Pyloric Stenosis 4. Meconium Ileus

1. Correct: Intussusception is a condition in which a piece of the bowel telescopes in on itself, forming an obstruction. This causes a sudden onset of cramping and abdominal pain. The client tends to be inconsolable and draws the knees upward in response to the pain. The stool may appear normal at first and then currant jelly-like stools may be noticed as blood and mucus become mixed with the stool. 2. Incorrect: Hirschsprung's disease, known as aganglionic megacolon is a congenital anomaly in which there is an absence of nerves in a portion of the bowel, typically the sigmoid colon. This results in mechanical obstruction. Here, you would see constipation and abdominal distention. If stools are passed, they are often ribbon-like that have a foul smell.

The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. What action should the nurse take first? Choose One 1. Put on gloves. 2. Pick up implant with tongs. 3. Place implant in lead lined container. 4. Call radiation department to take the implant out of the room.

1. Correct: The first thing the nurse should do is to put on gloves.

The nurse is performing a neurological assessment on an adult client suspected of having a traumatic brain injury (TBI). Which signs/symptoms would indicate to the nurse that the client's ICP is increasing. Select All That Apply 1. Projectile vomiting 2. Narrowing pulse pressure 3. Delay in verbal response 4. DTR: left 2+/4+, right 2+/4+ 5. (-) Babinski 6. Glasgow Coma Scale Score 13

1., & 3. Correct: Projectile vomiting can occur because the vomiting center in the brain is being stimulated. Anytime you have a head thing and the client begins to vomit, you have to assume that the ICP is going up! With increasing ICP the client's speech may change - it may become slow or slurred. There is a delay in verbal suggestion. In other words, they may be slow to respond to commands. 2. Incorrect: With increasing ICP the client will develop systolic hypertension with a widening pulse pressure. A narrowed pulse pressure is seen with cardiac tamponade.

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention actions should the nurse include? Select All That Apply 1. Annual mammogram starting at age 40. 2. Maintain normal body weight. 3. Cancer support group. 4. Colonoscopy beginning at age 50. 5. Limit or eliminate alcohol intake.

1., & 4. Correct: Secondary prevention includes screenings to pick up on cancer early. Screening is very important because then we have a greater chance for cure or control. Annual mamogram starting at age 40 with two views of each breast is recommended if the client has no family history of breast cancer. Colonoscopy at age 50, then every 10 years after that if there has been no problem is also recommended.

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating.

1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer. 5. incorrect: sitting up after a meal is counterproductive, since this will increase the food through the digestive tract. Client encouraged to lie down on the left side following meals to slow the processing of food.

The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? Select All That Apply 1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 5. Use the palms of hands when moving the cast for first 6 hours.

1., 2., 3., & 4. Correct: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding. 5. Incorrect: To prevent indentations in the plaster cast, the cast should be moved with the palms of hands for first 24 to 72 hours.

The nurse is performing a neurological assesment on a client who reports frequent headaches. What question(s) should the nurse ask during this assessment? Select All That Apply 1. "When did the headaches begin?" 2. "What symptoms accompany the headaches?" 3. "Does anything relieve the headaches?" 4. "Does anything make the headaches worse?" 5. "Are you experiencing depression?"

1., 2., 3., & 4. Correct. These are all questions that are part of a focused neurological assessment. You want to inquire about the client's current condition, onset of symptoms, description of symptoms, and associated factors.

What sign/symptom would indicate to the nurse that a client has had an inhalation injury? Select All That Apply 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing.

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? Select All That Apply 1. Weigh daily 2. Measure abdominal girth 3. Provide skin care 4. Position in semifowlers 5. Intake and output

1., 2., 3., & 5. Correct: The client with nephrotic syndrome is producing less urine. Due to the decrease in urinary output the client is retaining fluid. The client should be weighed daily, and the girth would be measured to evaluate fluid retention. Edematous skin is prone to skin breakdown, so adequate skin care is necessary. Intake and output is required whenever there is a fluid volume problem.

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? Select All That Apply 1. Malaise 2. Blood pressure - 16O/92 3. 24 hour urinary output - 960 mL 4. Costovertebral angle tenderness 5. Urine specific gravity of 1.040

1., 2., 4., & 5. Correct: A client with glomerulonephritis is retaining toxins. The result is the client has a overall sense of being ill with possible fatigue and decrease interest in activities. A client with glomerulonephritis is producing less and less urine. Due to the retention of fluid, the client's blood pressure is elevated. Costovertebral angle tenderness (CVAT) is elicited by percussing the flank area of the back over both the kidneys. If pain is present, the client would be assessed for a kidney infection. The normal range of urine specific gravity ranges from 1.010 to 1.030. An elevated urine specific gravity of 1.040 is reflective of highly concentrated urine. The client is not diuresing appropriately. The client's specific gravity of 1.040 supports glomerulonephritis.

The nurse is planning care for a client admitted with a diagnosis of acute renal injury. What interventions should the nurse include in this plan? Select All That Apply 1. Provide meticulous skin care. 2. Reposition every 2 hours. 3. Maintain a high carbohydrate, high protein diet. 4. Provide foods low in phosphate. 5. Monitor intake and output. 6. Give IV medications in smallest volume allowed.

1., 2., 4., 5., & 6. Correct: The leading cause of death from acute renal injury is infection, so meticulous skin care and aseptic technique are critical. Repositioning every 2 hours will help to prevent pressure ulcers. Clients in acute renal injury have high phosphorus levels and low calcium levels (remember that inverse relationship?). So they need foods low in phosphorus. Monitor intake and output. The client cannot handle excess fluid at this time. This is also why all IV meds should be administered in the smallest possible volume allowed.

What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury? Select All That Apply 1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 2. The dialysate is infused through the catheter into the stomach. 3. Once infused, dialysate remains for prescribed dwell tiime. 4. Withdraws dialysate using a large piston syringe. 5. Assists client to stand if all the drainage is not removed.

1., 3. Correct: These actions are correct. The dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. The dwell time is the length of time that the dialysate stays in the peritoneal cavity. This allows for toxins to be drawn out of the blood and into the peritoneal cavity for removal.

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? Select All That Apply 1. Pain 2. Foot drop 3. Muscle spasm 4. Bone displacement 5. Itching under the straps

1., 3., & 4. Correct: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement. 2. Incorrect: Foot drop is the weakness or paralysis of the muscles that lift the front part of the foot. Causes of foot drop may include; nerve injury, muscle or nerve disorders, brain and spinal cord disorders, and immobility.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select All That Apply 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

1., 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up!

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? Select All That Apply 1. Squeeze tennis ball with right hand every 2-4 hours while awake. 2. No blood pressure readings in right arm for one year. 3. Wear gloves when gardening. 4. Wear your watch on the left wrist. 5. Brush your hair with your left hand until pain free.

1., 3., & 4. Correct: Squeezing a tennis ball will help promote new circulation. Protect the hand and arm at all times. A tiny cut could turn into a major infection, so wearing gloves while gardening is a good idea. Since the mastectomy was on the right breast, the client can wear a watch on the left wrist. Do not wear anything constricting on the right wrist, or arm.

A parent voices concern because the 6 year child has not been eating as much in the last 3 months. What response from the nurse would be appropriate? Choose One 1. "You need to make the child eat more frequent meals to avoid becoming anorexic." 2. "This is not unusual in this age child because the growth rate has slowed down." 3. "Try providing high calorie foods that the child likes to increase the calories to 3500 per day." 4. "You are just being overly cautious. There is no need to worry about how much the child eats."

2. Correct: Think about normal growth and development here. Remember that the growth rate slows down in the school age child between 6 and 12 years of age. Therefore, they may not seem as hungry as they are during periods of growth spurts.

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? Choose One 1. Immediately escort spouse to ED to check radiation levels. 2. Begin discharge teaching to the client and spouse. 3. Have spouse wash hands thoroughly and apply sterile gloves. 4. Explain that spouse must remain outside the room until urinal is emptied.

2. CORRECT. Internal radiation, also called brachytherapy, is placed inside the body as close to the cancer as possible. Internal radiation therapy can be permanent or temporary as well as sealed or unsealed, which refers to the amount of radiation risk posed by the client. Implanted seeds used to treat prostate cancer are a type of sealed radiation, indicating the body fluids are not radioactive. Emptying the urinal poses no risk to the spouse.

In what position should the nurse place a client post lumbar puncture? Choose One 1. Reverse trendelenburg 2. Prone 3. Side-lying 4. Supine HOB elevated 45 degrees

2. Correct. Post lumbar puncture, the client should lie flat or preferably prone for 4-8 hours so that a seal will form at the puncture site.

A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority? Choose One 1. Administer hydralazine 20 mg IV. 2. Elevate head of bed 45 degrees. 3. Remove impaction with topical anesthetic. 4. Close air vents in the room.

2. Correct. These signs/symptoms should lead the nurse to realize that the client is experiencing autonomic dysreflexia. The priority is to lower the blood pressure by raising the head of the bed to a semi-fowler's position.

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? Choose One 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

2. Correct. These symptoms are indicative of hypokalemia and metabolic alkalosis. What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic. Low potassium levels cause an increase in the reabsorption of bicarb by the kidneys. That is why you sometimes see metabolic alkalosis with Cushing's disease and prolonged steroid use. What electrolyte imbalance do we see with metabolic alkalosis? It's hypokalemia. So, if you have a client who is hypokalemic then they may have muscle weakness, hypotension and life threatening arrhythmias. And we know when the potassium is messed up, we should always think about the heart first. Connect the client to the cardiac monitor.

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? Choose One 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? Choose One 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important.

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for further teaching? Choose One 1. "I will take deep breaths using my incentive spirometer every 2 hours." 2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 3. "I will talk to my healthcare provider before taking the narcotic pain medicine that I currently have at home." 4. "I will notify my healthcare provider if I develop any change in my respirations or secretions."

2. Correct: Immobilizing, and therefore restricting the chest wall movement, with binders and straps is not recommended as it leads to shallow breathing, atelectasis, and pneumonia. The client should be taught to use the hands to support the injured area.

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: This client has a high fever. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. Here, the ABGs reflect respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal.

A teen male was diagnosed with infectious mononucleosis. What would be of most concern for the nurse when performing a history on this client? Choose One 1. Rides a bicycle three times a week 2. Plays on the varsity football team 3. Member of the swim team 4. Dances with the performing arts group

2. Correct: With infectious mononucleosis, the liver and spleen are often enlarged. Therefore, participation in contact sports should be limited to prevent injury. We worry about splenic rupture with contact sports such as football.

Assessment of a trauma client in the emergency department reveals paradoxical chest wall movement, respiratory distress, cyanosis, and tachycardia. The family is asking why the client needs positive end-expiratory pressure (PEEP). What should the nurse inform them regarding the rationale for this treatment? Select All That Apply 1. Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath. 2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 4. Allows for positive pressure to be applied continuously during inspiration and expiration. 5. It is less invasive and does not require the client to be on the ventilator.

2., & 3. Correct: I hope that you were able to recognize that the signs and symptoms are characteristic of a flail chest. This occurs with multiple rib fractures. The client will have pain, be anxious, and short of breath. The classic sign of a flail chest is the paradoxical (see-saw) chest movement in which the affected part of the chest sucks inwardly on inspiration and puffs out on expiration (opposite of what the normal side is doing). Dyspnea, cyanosis, and tachycardia are also generally seen. So, what is done about this unstable chest? PEEP may be used because it helps to improve gas exchange and decreases the work of breathing. As it exerts pressure in the lungs, it also facilitates the expansion and realignment of the ribs so that they can start growing back together.

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? Select All That Apply 1. Nausea and Vomiting 2. Skin shedding 3. Erythema with pain 4. Pancytopenia 5. Exhaustion

2., 3, 4 and 5. CORRECT. External beam radiation uses high energy proton rays to deliver radiation from outside the body. This therapy prevents cell reproduction and destroys cancer cells. Expected side effects can be topical or physiological, depending on the area radiated. Skin radiated by the beam becomes reddened (erythema), dry and peeling. Shedding skin and even blistering may occur because of multiple treatments. As radiation enters tissues, damage affects even healthy tissue like bone marrow. The client may eventually develop pancytopenia: a lack of all blood components, including red cells, white cells and platelets. As the body struggles with cancer and the effects of radiation, the client may experience severe or overwhelming fatigue which needs reported to the primary healthcare provider.

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select All That Apply 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications.

2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin. 1. Spleen removes not liver 4. Exocrine function of the pancreas

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select All That Apply 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select All That Apply 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained. 1. Incorrect: Magnesium administration does not impair liver function, so although the alcoholic client may have altered liver function, this is not an assessment that the nurse would be most concerned about related to magnesium administration. In fact, hypomagnesemia is a common problem in alcoholics which may require increasing foods high in magnesium or magnesium supplementation by PO or IV routes. 3. Incorrect: Magnesium levels are not influenced by calcium levels, so this is not an assessment that would be a priority for the nurse at this time.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? Choose One 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO

3. Correct: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider.

The nurse has initiated discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that further teaching is needed? Choose One 1. "I will have protein in my urine for several months." 2. "My urinary output will increase in 1 to 3 weeks." 3. "I should keep a record of the headaches I experience over 3 months." 4. "I should notify my primary healthcare provider if my urinary output decreases."

3. Correct: The client should report headaches sooner than 3 months to their primary healthcare provider. The headaches are related to the fluid retention due to the decreased filtration of the glomerulus. The retention of fluid will result in hypertension. This client will require additional discharge instructions.

The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? Choose One 1. "The compression sock on the stump will increase your balance when crutch walking." 2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump." 3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." 4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."

3. Correct: Wrapping the stump with an ace bandage will assist in configuring the stump into a cone shape. The cone shape is smaller and rounded on the bottom. The cone shaped stump will result in the stump fitting easier into the prosthesis.

The nurse is educating a group of college students about early signs and symptoms of cancer. When explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? Choose One 1. Nausea 2. Nipple drainage 3. Nagging cough 4. Nose bleeds

3. CORRECT. The mnemonic "C-A-U-T-I-O-N" represents an easy way to recall the seven early warning signs and symptoms of potential cancer. Each letter indicates a specific body alteration that should be reported to the primary healthcare provider. 'N' stands for a nagging cough or hoarseness.

The nurse is teaching a group of female clients how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? Choose One 1. "You can ask your healthcare provider to do this with your yearly physical." 2. "If you have no family history of cancer, you won't need to worry about this." 3. "Self-breast exams may detect changes early enough for successful treatment." 4. "You have the right to refuse anything related to health because of client rights."

3. CORRECT. The nurse responds to this client's incorrect statement by presenting an accurate fact in a non-judgmental and open manner, allowing for further discussion about breast cancer facts. The nurse has a responsibility to provide the client important data about the topic of self-breast exams.

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? Choose One 1. Insertion of a chest tube in the 7th intercostal space 2. Immediate removal of client from the ventilator 3. Needle decompression in the right 2nd intercostal space 4. Emergency thoracentesis of the left lung

3. Correct: Did you recognize the signs of a tension pneumothorax? This client may have developed this because of a high PEEP level and/or compromised lung status combined with mechanical ventilation. Regardless of the cause, this is an emergency situation and the initial treatment involves the insertion of a large bore needle into the 2nd intercostal space, midclavicular line of the affected side. In this case, you should recognize that the absence of breath sounds on the right side indicate that the problem is on the right side. Needle decompression is done to release the pressure that is building up in the pleural space and causing the organs and vessels to be compressed. The mediastinal shift occurs toward the opposite (left) side. The client will most likely have a chest tube inserted on the right side, but the initial life saving measure for this would be the needle decompression

A child, admitted to the emergency department is noted to be drooling and has dysphagia. No cough is noted, and the child appears worse than the sound indicates. The parent states the child seemed "fine" when put to bed. History reveals that the child has not received some of the recommended immunizations. What should the nurse anticipate as part of the care for this child? Choose One 1. Placement in the lateral, supine position. 2. Prompt initiation of respiratory syncytial virus immune globulin. 3. Transfer to OR for placement of ET tube. 4. Oral dose of dexamethasone.

3. Correct: Did you recognize these symptoms as being characteristic of epiglottitis? Yes! It is considered a medical emergency in which there can be rapid progression to severe respiratory distress due to airway occlusion. An endotracheal tube (ET) may be needed, but it is best for the child to be in the OR where anesthesia can be administered, and an emergency trach can be performed if the airway is too occluded for the passage of the ET tube.

The nurse is caring for a surgical client who developed a pulmonary embolus (PE). Which diagnostic test would be the most sensitive for providing a definitive diagnosis for a PE? Choose One 1. D-dimer 2. Pulmonary function test 3. Pulmonary angiography 4. Chest X-ray

3. Correct: Pulmonary angiography is the most sensitive and specific test for a PE. However, since it is very expensive and invasive, the computerized tomography angiogram (CTA) is the most frequently used test to diagnose a PE.

What is the most important action for the nurse to take prior to a client having a liver biopsy? 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.

3. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up.

Which interventions would the nurse implement for a client with a right total hip arthroplasty performed 6 hours ago? Select All That Apply 1. Remove the abductor pillow. 2. Place a pillow under both knees. 3. Position the feet with the toes pointed upward. 4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses. 5. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.

3. & 4. Correct: These are correct interventions. The feet should be placed in a neutral rotation position with the toes pointed to the ceiling. This positioning of the feet prevents the hips from rotating inwardly or outwardly. If the hips are not positioned appropriately, there is a postoperative risk for dislocation of the hip. The postoperative neurovascular assessment of the right leg includes evaluating the client's popliteal, dorsalis pedis, and posterior tibial pulses. The nurse should evaluate the peripheral pulses distal to the hip. The primary healthcare provider should be notified of any alterations in the peripheral pulses.

A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? Select All That Apply 1. Continuous bubbling is occurring in the suction control chamber. 2. Intermittent bubbling is noted in the water seal chamber. 3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 4. Slight fluctuations of water level in water seal chamber with respirations. 5. 190 mL of drainage noted in drainage collection chamber at 8 PM.

3. & 5. Correct: Do you see the problem with the bedside table? Yes! It's too high! The chest tube system should always be kept below the level of the chest to prevent backflow of drainage or air into the pleural space. You want to promote gravity drainage. The next problem that we see is excessive drainage. The chest tube was inserted at 5 PM and the client was admitted to the unit 2 hours later. The amount of drainage at upon arrival at 7 PM was 80 mL. At 8 PM, there was 190 mL of drainage. This is 110 ml of drainage in one hour. Drainage of 100 mL or greater any hour after the first hour is considered excessive. The healthcare provider would need to be notified of this amount of drainage.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select All That Apply 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor

3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.

Which intervention would the nurse include when planning care for a client who has increased intracranial pressure (IICP)? Select All That Apply 1. Place client supine. 2. Hyperextend head to maintain airway. 3. Maintain body temperature below 100.4 F (38 C). 4. Cluster nursing care. 5. Monitor vital signs for Cushing's Triad. 6. Limit suctioning.

3., 5., & 6. Correct. The goal of treatment is to relieve the IICP by reducing cerebral edema, reducing the amount of cerebrospinal fluid, or reducing the blood volume in the brain, We also have to maintain cerebral perfusion.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Choose One 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die.

A client is admitted with a diagnosis of bacterial meningitis. Which action should the nurse initiate first? Choose One 1. Darken room. 2. Provide sponge bath for fever of 102 F (38.8 C). 3. Pad side rails. 4. Place on Droplet precautions

4. Correct. Bacterial meningitis is transmitted through the respiratory system. According to the Center of Disease Control (CDC), clients with bacterial meningitis should be placed on "Droplet Precautions".

A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? Choose One 1. Respirations - 24. 2. Oxygen saturation - 94%. 3. Arterial blood gas - pH 7.34. 4. No infiltrates noted on chest x-ray.

4. Correct: A fat embolism is caused by droplets of bone marrow fat that is released into the venous system. The droplets may lodge in the lungs. An x-ray of the lungs with the bone marrow fat will have a "snowstorm" appearance. A chest x-ray that does not identify any filtrates and does not have a "snowstorm" appearance is indicative the fat embolus is decreasing in size or completely resolved.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? Choose One 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss.

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? Choose One 1. Opioids 2. Antidiabetic 3. Corticosteroids 4. Aminoglycoside

4. Correct: Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin. Clients with kidney damage should not be prescribed aminoglycoside antibiotics.

A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? Choose One 1. Physically reduce the fracture. 2. Externally rotate the left leg. 3. Position the bed into a high Fowler's position. 4. Cover the fractured site with a sterile dressing.

4. Correct: An open fracture is when the bone has broken the skin and underlying soft tissue, and the bone is protruding from the wound. The nurse should cover the fracture site with a sterile dressing to prevent contamination of deeper tissues. 1. Incorrect: The leg was splinted as a temporary emergency intervention. Upon arrival in the emergency room, the fracture should not be reduced by the nurse. Once the skin has been broken at the fracture site, the wound is a portal of entry for contaminants. A surgical procedure is performed to clean the wound and the bone.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? Choose One 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low.

A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 ounce (360 mL) soft drink? Choose One 1. Take the soft drink away from the client. 2. Document the client is noncompliant. 3. Notify dietary to no longer send beverages with food trays. 4. Reinforce the importance of the fluid restriction with the client.

4. Correct: Educate the client on appropriate choices and lifestyle changes that are necessary to manage the client's condition.

A 5 year old girl is upset and saying she is to blame for her brother getting hit by a car on his bike because she was mad at him earlier and wanted to hit him. What does the nurse recognize this type thinking to be in a child? Choose One 1. Abstract 2. Egocentric 3. Animism 4. Magical

4. Correct: Magical thinking is common in young children and is the belief that the world around them can be influenced or impacted by their own thoughts, desires, or wishes. Therefore, when something happens that is related to their thoughts, the child may perceive that it occurred because of those thoughts. This child may have connected the thoughts of being upset with the brother and the desire to hit him with the aspect of the car hitting him later. Other times, this magical thinking may be linked to a desire to make positive things happen by their thoughts. The interesting part about magical thinking is that young children may believe that they can make things or events in life be anything or anyway they want them to be.

The nurse provided a community safety presentation for parents and included car seat safety. Which would demonstrate to the nurse that the parents correctly understood the teaching for a 2 month old weighing 10 pounds (4.55 kg)? Choose One 1. The car seat is placed upright in the rear facing position in the front passenger seat. 2. Padding is placed under the young infant's head in the semi-reclined car seat in a rear facing position. 3. The car seat is secured in the side of the rear seat in a reclined, front-facing position. 4. The car seat is placed semi-reclined in the middle of the back seat in a rear-facing position.

4. Correct: The guideline for infants < 20 pounds (9kg) is to place them in the middle of the back seat in a rear-facing, semi-reclined car seat. This provides the best protection for their heavy head and weak neck.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? Choose One 1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

4. Correct: This ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO2 and normal HCO3.

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? Choose One 1. "Octreotide is an antibiotic given to decrease the risk of developing an infection." 2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence." 3. "Octreotide helps eliminate ammonia from the body." 4. "This medication lowers the pressure in the liver, so bleeding stops."

4. Correct: Octreotide is a synthetic hormone that selectively inhibits the release of vasodilating hormones in the internal organs. By doing this it decreases blood flow to the liver. When you decrease blood flow to the liver, the pressure in the liver lowers. Less volume, less pressure. So, bleeding should stop.

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? Select All That Apply 1. Nursing assignments should be rotated weekly. 2. The nurse should care for no more than 3 clients with a radiation implant per shift. 3. Limit visitors to 60 minutes per day. 4. Wear film badge throughout assigned shift. 5. Educate visitors to stay at least 6 feet from the client.

4., & 5. Correct. Wear a film badge at all times so that you know how much radiation you are getting. Visitors should stay at least 6 feet from the source to decrease exposure to radiation. The closer you get the more radiation exposure.