*HURST REVIEW Qbank/Customize Quiz - Adult Health

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? 1. Monitor blood sugar around 2am. 2. Decrease bedtime snacking. 3. Decrease intermediate acting insulin. 4. Increase intermediate acting insulin.

1. Correct: Morning hyperglycemia may be the result of dawn's phenomenon or the Somogyi effect. The client must take their blood sugar between two and three o'clock in the morning for several days to determine the cause of morning hyperglycemia. If the client has decreased blood sugar between two and three o'clock in the morning, suspect Somogyi effect. 2. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of morning hyperglycemia in order to treat the condition appropriately. 3. Incorrect: This is an intervention; assessment should come first. The nurse must determine the cause of hyperglycemia in order to treat the condition appropriately. An appropriate intervention for a client with Somogyi effect would be to decrease the evening dose of intermediate acting insulin, however, the nurse must first determine that the client is in fact experiencing the Somogyi effect. 4. Incorrect: This is an intervention; assessment should come first. Increasing the intermediate acting insulin would not be appropriate action for a client experiencing Somogyi effect.

A client who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid

1., 3., 4., 5. Correct: The following foods can cause a false-positive reading: red meats, liver, turnips, broccoli, cauliflower, melons, salmon, sardines, and horseradish. Medications altering the test include aspirin, ibuprofen, ascorbic acid, indomethacin, colchicines, corticosteroids, cancer chemotherapeutic agents, and anticoagulants. Ingestion of vitamin rich foods can cause a false negative result. 2. Incorrect: A tomato is not on the food list for false-positive reading and do not have to be avoided.

A RN is observing an unlicensed nursing personnel (UAP) feed a client who is on aspiration precautions. Which action by the UAP would require the nurse to intervene? 1. Elevating the head of the bed to a 90 degree angle 2. Instructing the client to lean the head back slightly when swallowing. 3. Adding a thickening agent to liquids. 4. Feeding the client small amounts of food per bite.

2. Correct: This is an incorrect action, and needs intervention by the nurse. The chin should be flexed to prevent the risk of aspiration. A chin down or chin tuck maneuver is widely used in dysphagia treatment to prevent aspiration. 1. Incorrect: This is a correct action. The head of the bed should be elevated which aids in esophageal peristalsis and swallowing is aided by gravity. 3. Incorrect: This is a correct action. Thickened liquids are easier to swallow without aspirating. Drinking liquids thickened will help to prevent choking and stops fluid from entering the lungs. 4. Incorrect: This is a correct action by the UAP, so the nurse does not need to intervene. Smaller amounts of food can be chewed more thoroughly and swallowed with less risk for aspiration.

What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply 1. Smokeless tobacco increases risk for lung cancer. 2. Inspect mouth frequently for lesions. 3. White patches in mouth should be reported to healthcare provider. 4. Risk for stomach cancer can be decreased by not swallowing smokeless tobacco juice. 5. Report decreased saliva to primary healthcare provider. 6. Smoking cessation.

2., 3., & 6. Correct: The mouth should be inspected frequently for painless lesions that do not heal. This may be a sign of oral cancer and should be reported to the primary health care provider. White patches (leukoplakia) is a sign of potential oral cancer as well. Nicotine is addictive and is found in smokeless tobacco. Clients using smokeless tobacco can benefit from smoking cessation information/classes. 1. Incorrect: Use of smokeless tobacco increases the risk developing of esophageal cancer, cancers of the mouth, throat, cheek, gums, lips, tongue, pancreatic cancer, stomach cancer, kidney cancer. 4. Incorrect: This is an incorrect statement. Some amount of tobacco juice will be swallowed and can lead to esophagus and stomach cancer. 5. Incorrect: Decreased saliva is not associated with oral cancer.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. CORRECT: Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. INCORRECT: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary. 2. INCORRECT: Most facilities have policies to change an IV site at specific intervals, usually every three days. Changing the site daily exposes the client to an increased chance of infection from the invasive procedure. Steroids do not irritate veins and do not require frequent site changes. 4. INCORRECT: There is no rationale for contact precautions since the client's disease process is not contagious. The main concern is to protect the client from other individuals.

A client has been admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis. The primary healthcare provider writes prescriptions based on the lab values. The nurse would monitor the effectiveness of medications by observing for what specific neurologic changes in the client? Exhibit: Lab Results: Sodium: 129 meq/dl Potassium: 3.0 meq/dl Albumin: 2.0 gm/dl Ammonia: 80 mcg/dl Bilirubin: 2.0 gm/dl BUN: 32 mg/dl Creatinine: 2.0 mg/dl BP: 100/60 Pulse: 110 Resp: 28 Medication: Furosemide (Lasix) 60 mg IV every 12 hours Lactulose 30 mg by mouth every 4 hours K-Dur 40 meq by mouth twice daily Albumin 25% 100 mL IV twice daily 1. Increased urination and improved memory. 2. Increased blood pressure and lower pulse. 3. Frequent diarrhea with orientation x three. 4. Clear speech and +2 pitting edema to BLE.

3. Correct: Neurologic deterioration in clients with cirrhosis is secondary to increased ammonia levels in the body and brain, resulting in development of encephalopathy. Frequent diarrhea, secondary to the use of lactulose, helps rid the body of ammonia, allowing the client's orientation to improve to normal. 1. Incorrect: Although increased urination is expected because of the furosemide, this medication would not impact the client's memory. Additionally, there is no indication whether the improvement reflects changes in long-term or short-term memory. 2. Incorrect: As the client slowly improves, vital signs should begin to stabilize, with the blood pressure increasing and the pulse decreasing toward the normal range of 60-100. However, neither of these changes would relate to specific changes in the neurologic status. 4. Incorrect: Though the client's speech is now clear, this does not indicate improvements in either orientation or alertness. The client's speech could be clear even with disorientation. The +2 edema in BLE is decreasing but does not indicate neurologic improvement.

Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Bodybuilder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome

4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.

What would be the best way for the nurse to evaluate the effectiveness of fluid resuscitation during the emergent phase of burn management? 1. Weight increases by 2 pounds in 24 hours 2. Urinary output is greater than fluid intake 3. Blood pressure is 90/60 mmHg 4. Urine output greater than 35 mL/hour

4. Correct: Urine output of 30 to 50 mL/hour indicates adequate fluid replacement. 1. Incorrect: May indicate fluid retention. 2. Incorrect: Does not indicate fluid balance. 3. Incorrect: Blood pressure alone does not indicate adequate fluid balance.

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space

1. Correct: A chest tube placed in the upper chest is to remove air from the pleural space. Remember air rises and fluid settles down low. 2. Incorrect: Chest tubes are placed in the pleural space to get rid of air, blood, fluid, or exudate so that the lung can re-expand. The purpose is not to create an access for irrigating the chest cavity. 3. Incorrect: The chest tube is inserted into the pleural space because the lung has collapsed due to air, blood, fluid, or exudate. The chest tube does not go into the lung so secretions can not be removed from the bronchioles and alveoli by way of the chest tube. 4. Incorrect: You have to know the purpose of the upper chest tube. Fluid drains down, so the lower one is for fluid.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway first. Check for patency of the ET tube. If this is patent, then the other options would be next. 2. Incorrect: This is the next best answer, but hypoxia and airway comes first. 3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or obstructions. 4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client first.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room

1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. Elevate the head of the bed to promote comfort and decrease intracranial pressure. The client is at an increased risk for seizures, and the nurse should implement seizure precautions which include padding the side rails. A sponge bath is an independent nursing intervention appropriate for a fever greater than 101°F (38.3°C). Darkening the room is also a comfort measure as this client will have photophobia. 4. Incorrect: Droplet precautions should be initiated for the first 24 hours of antimicrobial therapy.

A client rescued from a house fire is being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? 1. Estimation of total surface burn area 2. Characteristics of cough and sputum 3. Calculation of client weight and age 4. Extent of edema to arms

2. CORRECT: A client rescued from a burning house is presumed to have inhaled superheated air during that process. Though calculating fluid replacement is vital to the client's survival, the ABCs dictate the highest priority is airway. Noting any cough or sputum can help determine whether prophylactic intubation may be necessary. 1. INCORRECT: The total amount of body surface burned is crucial information needed to determine fluid replacement using the Parkland Formula. However, though IV fluids are necessary, calculating the burn percentage is not the highest priority. 3. INCORRECT: The client's age is not an immediate priority, although a complete health history will be essential to the final outcome. The client's weight will be used to calculate fluid replacement; however, there is a higher initial priority. 4. INCORRECT:. A burn causes cellular damage that leads to edema. Depending on the location and extent of that edema, circulation could be greatly impaired. However, when monitoring a burned client, the ABCs place circulation third on the priority list.

Which arterial blood gas value would the nurse expect to see when monitoring a client in a hyperosmolar hyperglycemic state (HHS). 1. pH 7.32 2. PaCO2 47 3. HCO3 22 4. PaO2 78

3. Incorrect: Normal HCO3 is 22-26. You would expect to see a normal bicarb level in this client. For a client in DKA, the expected HCO3 would be less than 22. 1. Incorrect: In HHS, the client will not be in acidosis. That is the primary difference between HHS and DKA. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. 2. Incorrect: Normal PaCO2 is 35-45. This is a high CO2 level that would be seen with DKA, not HHS. 4. Incorrect: Normal PaO2 is 80-100. An expected finding in HHS will be normal or increased PaO2, not decreased.

What information should the nurse include when providing community teaching on burn prevention strategies? Select all that apply 1. Have chimney professionally inspected every 5 years. 2. Microwave a baby bottle rather than heating on the stove. 3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

3., 4., 5., & 6. 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. Space heaters need space at least three feet (0.91 meters) away from anything that can burn. 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. 1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. 2. Incorrect. Never microwave a baby bottle. The formula inside the bottle can become scalding hot in the center.

The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? Select all that apply 1. Use small joints and muscles. 2. Turn door knobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.

4. & 5. Correct: Pushing off with the palms of the hands is using a larger joint and muscles. Using the fingers will cause more joint injury. Use long handled devices such as a hairbrush with an extended handle to decrease stress on joints (in this case the wrist). 1. Incorrect: Larger joints and muscles can take more stress and weight than smaller ones. Using small joints again and again puts more stress on them and may lead to deformity. Try to spread the strain and weight over several joints. This helps you use each part of your body to its best advantage. 2. Incorrect: Do not turn a door knob clockwise. Turn it counterclockwise to avoid twisting the arm and promoting ulnar deviation. 3. Incorrect: Sit in a chair that has a high, straight back. This will provide more support for the back.

Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.

4. Correct: A regular routine and physical activity help client's with Alzheimer's disease maintain abilities for a longer period of time. Physical activities promote strength, agility and balance. The client's walking should be supervised for client safety issues. 1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's Disease. The client can become agitated and/or more disoriented with an increase in environmental stimuli. 2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory impairment. Board games require complex cognitive actions. 3. Incorrect: Restraints should be avoided because they increase agitation. The client may become agitated by the restriction of he restraints. Also the client may perceive the restraints as a threat.

What should the nurse emphasize when teaching clients how to decrease the risk of chronic obstructive pulmonary disease? Select all that apply 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Avoid prolonged exposure to occupational dusts and chemicals. 5. Get a yearly influenza and pneumococcal vaccination.

3., & 4. Correct: The most important environmental risk factor for COPD is cigarette smoking. Second hand smoking also contributes to COPD. Risk factors for COPD include prolonged and intense exposure to occupational dust and chemicals as well as indoor and outdoor air pollution. 1. Incorrect: Exposure to individuals with respiratory infections does not increase risk of chronic obstructive pulmonary disease. Respiratory infections may cause an acute exacerbation in a client with existing COPD. 2. Incorrect: Increasing intake of vitamin C does not decrease risk of obstructive pulmonary disease. 5. Incorrect: Clients should get the influenza vaccine annually in autumn. The pneumococcal vaccine should be administered every 5 years, rather than yearly.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.

1. Correct: In this particular situation, a private room is best due to the elevated temperature. This could mean the client has an infection and is contagious. All of the often clients do not need to be exposed to this client with fever of unknown cause. 2. Incorrect: Does not need to be exposed to infection. Biliary colic is pain due to a gallstone blocking the bile duct. The client may need surgery and definitely should not be exposed to infection. 3. Incorrect: Post op client already at risk for infection. This is not the most appropriate client to room with the new admit. 4. Incorrect: Does not need to be exposed to infection. The client is already at risk for infection due to the skeletal traction. Complications of skeletal traction include risk for bone infection due to a screw being placed in a bone.

A client arrives at the Emergency Department after receiving 3rd degree burns to the upper chest, neck, and face area. What would be the priority nursing intervention? 1. Prepare for endotracheal intubation. 2. Monitor hourly urinary output. 3. Treatment of the open burn wounds. 4. Assessment and management of pain.

1. Correct: The evaluation and maintenance of the airway should always be the first priority with upper body burns. Edema may develop due to the increased capillary permeability that occurs with burn injuries. Since the burn is so close to the airway, the priority would be rapid assessment and management of the airway. The healthcare provider may need to perform tracheal intubation prophylactically to prevent airway occlusion in this client. If the airway becomes too edematous before intubation can be performed, the client will need an emergency tracheostomy. 2. Incorrect: Monitoring urinary output in burn clients is important due to the possibility of FVD occurring secondary to fluid loss from the burn area and 3rd spacing of fluids. This could result in shock, and decreased renal perfusion. Although this is a very important intervention, it is not priority over the airway. 3. Incorrect: Burn injuries can be disturbing to look at due to the extensive skin injury, but the priority of care would not be the treatment of the wound. The priority must be the airway. 4. Incorrect: Clients with burns may experience severe pain, and will very likely be requesting pain relief. However, the priority of this client must be focused on the airway, not pain. Always consider what can kill the client or cause the most harm.

The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? 1. Assisting with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measuring urinary output every hour. 4. Turning off room lights.

1. Correct: The nurse should interrupt the UAP assisting with TCDB because this may increase intracranial pressure (ICP). TCDB increases intrathoracic pressure which then increases ICP. 2. Incorrect: Maintain client with head trauma in the head up position. This position promotes drainage from the head and decreases vascular congestion. 3. Incorrect: This is an acceptable action and one the UAP can do. 4. Incorrect: You want to decrease stimulation and turning off room lights will provide restful environment in an effort to decrease ICP.

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.

1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that room up. 2. Incorrect: This will not improve circulation and can lead to infection. 3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good sensation so there is risk of another burn to the graft with this. 4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will not help, particularly if the environment remains cool.

A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regarding? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia

1., 2., & 3. Correct: Spironolactone blocks androgen and progesterone receptors and may inhibit the action of these hormones. Side effects can include gynecomastia, decreased sexual desire, impotence, menstrual irregularities, and gastrointestinal distress. 4. Incorrect: Hyponatremia, rather than hypernatremia, may be seen. 5. Incorrect: Hyperkalemia, rather than hypokalemia, may be seen.

What discharge education should a nurse provide to a client post hip replacement with a metal joint? Select all that apply 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1., 2., 3., & 5. Correct: Weight bearing limits on the involved extremity varies according to the healthcare providers preference but are commonly prescribed. The client needs to avoid flexion. This includes sitting in low chairs and getting into a bathtub; elevated toilet seats and raised seats are necessary. Sexual intercourse should be carried out with the client in a dependent position (flat on the back) for 3-6 months to avoid excessive adduction and flexion of the new hip. To avoid flexion when dressing, adaptive devices and utensils may be used to help with bathing, dressing and personal hygiene. 4. Incorrect: Showers are preferable as getting into a tub would cause flexion of the new hip. This could cause the hip to dislocate.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbent position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output. 3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and lessen pulmonary edema.

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1., 2., 4., 5., & 6. Correct: These are all modifiable risk factors that can be managed through lifestyle changes or medical treatment. 3. Incorrect: Hispanics, African Americans, Native Americans, and Asian Americans have a higher incidence of strokes than whites. You cannot change your race or ethnicity so this is a non-modifiable risk factor for stroke.

What foods should the nurse teach a client who has been diagnosed with iron deficiency anemia to increase in the diet? Select all that apply 1. Chickpeas 2. Milk 3. Oysters 4. Raisins 5. Spinach 6. Tuna

1., 3., 4., 5., & 6. Correct: All of these are high in iron. 2. Incorrect: Milk is not high in iron and slows the absorption of iron.

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Pursed-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

1., 4. & 5. Correct: These three findings would indicate that further treatment is needed. 3+ pedal edema, and pursed-lip breathing is seen when client is still short of breath. Pale conjunctiva, nail beds, buccal mucosa are signs of impaired gas exchange. 2. Incorrect: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. 3. Incorrect: Weight loss indicates that fluid is being removed. 6. Incorrect: A urine output of 50 mL/hour indicates that renal perfusion is adequate.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.

Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

2. Correct: Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease. 1. Incorrect: This is primary prevention which is aimed at reducing the incidence of mental or physical disorders within the population. 3. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness. 4. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness.

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.

2. Correct: The arm should be situated so there is no compression on the graft site. Applying pressure to the graft may cause the graft to move which may result in damage to the graft site. 1. Incorrect: The temperature should be monitored at least every 8 hours or less. An elevated temperature may indicate an infection under the graft or at another area. If the temperature is elevated, the source of the infection should be addressed. 3. Incorrect: The first dressing change is planned 2 to 5 days after surgery. The dressing is not changed in the first 24 hours to prevent any disturbance to the skin graft. 4. Incorrect: The burn is located on the forearm. Passive range of motion exercises are implemented to improve joint function. The client is not having difficulties with the wrist, elbow, or shoulder joints. The movement to the arm should be done cautiously to prevent any damage to the graft.

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having chest pain and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client actions have nothing to do with oxygen administration and would cause more distress to the client with chest pain.

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Exhibit: Lab Values: Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55% 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

2. Correct: We already know that the question is about what life threatening complication? A pulmonary embolism. And these lab values say that the client is what? Dehydrated! So the only thing that is going to fix that is....... Increasing fluids. 1. Incorrect: This will not prevent pulmonary embolism. The problem is dehydration. Do something to fix the problem. Foods high in iron will not fix the problem. 3. Incorrect: This will not prevent pulmonary embolism. How will obtaining a urine sample for culture fix dehydration? It won't. This client needs to increase fluid intake. 4. Incorrect: We do want to monitor intake and output to see how the client is doing, however, this will not fix the problem. Hydrating the client will help the problem.

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? Exhibit: Vitals: BP 90/40; HR 125; RR 30 and labored; + jugular venous distention (JVD) with subcutaneous emphysema noted to right shoulder area. Select all that apply 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

2., 3. & 4. Correct: Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large bore IV line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via non rebreather mask because of the client's respiratory distress. 1. Incorrect: There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. Incorrect: This trauma client will be secured to a backboard, most likely with a cervical collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? Select all that apply 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL's, should be completed early in the day when the client has the most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals. 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise combined with periods of rest throughout the day. Weight lifting would be too strenuous and would quickly tire this client, possibly leading to a myasthenia crisis. 5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed in relation to meals, so consistent but smaller meals would be more beneficial for the client.

The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include? Select all that apply 1. Use sunscreen with a sun protection factor (SPF) of at least 30. 2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. 4. Stay in the shade between 9 AM and 4 PM. 5. Tanning beds are safer than outdoor tanning.

2., 3., & 4. Correct: People of all ages should avoid tanning. If you like the look of tanned skin, choose a self-tanning product that contains the active ingredient DHA. This active ingredient has been approved by the U.S. Food and Drug Administration and is safe to use. Most are fast-acting and will give skin a darker appearance in a matter of a few hours. This "tan" will last about a week. Put on sunscreen every day, even on days when it is cloudy. UV rays from the sun can reach you on cloudy and hazy days, as well as bright and sunny days. UV rays also reflect off surfaces like water, cement, sand, and snow. The hours between 10 a.m. and 4 p.m. Daylight Saving Time (9 a.m. to 3 p.m. standard time) are the most hazardous for UV exposure outdoors in the continental United States. UV rays from sunlight are the greatest during the late spring and early summer in North America. 1. Incorrect: Use sunscreen with a SPF of 15 or higher, and both UVA and UVB (broad spectrum) protection. 5. Incorrect: Tanning beds are dangerous. Avoiding the sun but replacing it with a tanning bed does not reduce the risks that are associated with UV damage to the skin.

The nurse is teaching a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that teaching has been successful? Select all that apply 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."

2., 3., & 5. Correct: Popcorn without salt is a healthy snack choice for clients on a low sodium, low saturated fat, and low cholesterol diet. Homemade tomato sauce can be made without adding salt. The American Heart Association no longer makes recommendations on how many egg yolks to eat or not to eat. A good, general guideline is to eat no more than 1 egg yolk a day, up to 5 total a week. There is no restriction on egg whites (including those used in baking and cooking). 1. Incorrect: Consume whole vegetables and fruits rather than fruit juices. Fruit juices have added sugars and lack fiber. 4. Incorrect: Use skim or 1% milk rather than 2% or whole milk.

What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? Select all that apply 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2., 3., 4., & 5. Correct: The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

A nurse is participating in a cancer risk screening program. Which signs/symptoms would indicate to the nurse that a client needs further investigation? Select all that apply 1. Unexplained weight gain of 10 pounds 2. Leukoplakia 3. Prolonged hoarseness 4. Hematuria 5. Persistent abdominal bloating

2., 3., 4., & 5. Correct: White patches inside the mouth or white spots on the tongue may be leukoplakia, which is a precancerous area that is caused by frequent irritation. It is often caused by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at high risk for leukoplakia. If untreated, it can become mouth cancer. A cough that does not go away and prolonged hoarseness may be a sign of cancer. Hematuria may be a sign of bladder or kidney cancer and needs further investigation. Although women may experience bloating with changes in the menstrual cycle, constant bloating should be investigated to rule out ovarian cancer. 1. Incorrect: Unexplained loss of weight or loss of appetite may indicate some types of cancer. Weight gain is not typically associated with cancer.

The nurse is preparing to administer a dose of potassium iodide 300 mg by mouth to a client diagnosed with hyperthyroidism. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to hold the potassium iodide dose and notify the primary healthcare provider? Exhibit: Client Information: Medical diagnosis: Hyperthyroidism Current vital signs: BP 142/88, HR 102, R 20 Medical history: Hypertension Physical examination: Alert/oriented. PERRLA. Skin warm/dry. Lungs sounds clear bilaterally. Normal S1/S2 without murmurs, clicks, rubs. Lab test results: Glucose- 98 mg/dl (5.4 mmol/L), Sodium- 139 mEq/L (139 mmol/L), Potassium- 5.5 mEq/L (5.5 mmol/L), Creatinine - 0.9 mg/dL (79.5 µmol/L), Creatinine Clearance 110 mL/min Current medications: Losartan 50 mg one by mouth daily, Methimazole 10 mg by mouth daily Drug Reference: Medication: Potassium iodide Classification: Antithyroid agent Indications: Adjunct with other antithyroid drugs in preparation for thyroidectomy. Treatment in thyrotoxic crisis. Radiation protectant following radiation emergencies or administration of radioactive iodine. Contraindications/Precautions: Hypersensitivity; hyperkalemia; pulmonary edema; impaired renal function. Use cautiously in tuberculosis; bronchitis; cardiovascular disease. Adverse reactions/Side effects: Confusion, weakness, GI BLEEDING, diarrhea, nausea, vomiting, hyperkalemia, tingling, joint pain. Interactions: Use with lithium may cause increased hypothyroidism. Increases the antithyroid effects of methimazole and propylthiouracil. Increased hyperkalemia may result from combined use with potassium-sparing diuretics, Ace inhibitors, angiotensin II receptor antagonists or potassium supplements. Route/Dose: 300-500 mg three times a day by mouth Select all that apply 1. Creatinine - 0.9 mg/dL (79.5 µmol/L) 2. Potassium- 5.5 mEq/L (5.5 mmol/L) 3. Glucose- 98 mg/dl (5.4 mmol/L) 4. Taking losartan 50 mg one by mouth daily. 5. Currently taking methimazole 10 mg by mouth daily. 6. Creatinine Clearance 110 mL/min

2., 4., & 5. Correct: The medication is potassium iodide, which can lead to hyperkalemia when administered, so it is contraindicated if the client already has hyperkalemia. This client's potassium level is 5.5 mEq/L (5.5 mmol/L), which would support the nurse holding the medication and contacting the primary healthcare provider. Additionally, the drug guides states that potassium iodide increases the antithyroid effect of methimazole and propylthiouracil. Increased hyperkalemia may result from combined use with potassium-sparing diuretics, Ace inhibitors, angiotensin II receptor antagonists or potassium supplements. This client is currently on both losartan, an ARB, and methimazole. 1. Incorrect: This is a normal creatinine level. Normal range is 0.8 - 1.4 mg/dL (70-124 µmol/L) in males and 0.56-1.0 mg/dL (50-88 µmol/L) in females. 3. Incorrect: Potassium iodide does not affect glucose and this is a normal glucose level. 6. Incorrect: The normal creatinine clearance is 75-125 mL/min. Therefore, 110 mL/min is within normal limits and would not require withholding the potassium iodide.

A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take? Exhibit: Select all that apply 1. Have client ambulate back to bed. 2. Initiate 100% oxygen per non rebreather mask. 3. Obtain client's blood pressure. 4. Prepare for cardioversion. 5. Auscultate lung sounds. 6. Administer nitroglycerin 1 tab SL.

3. & 5. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds. 1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall. 2. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100%. Start with the least amount of oxygen that could relieve symptoms. 4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs. 6. Incorrect: Nitroglycerin would be given if the client is experiencing chest pain or is suspected of having an MI. Get the client back in bed and provide the client with oxygen at 2 L/NC first.

A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."

3. CORRECT. All the reported problems have the potential to be serious and must be investigated; however, one problem has already occurred and could permanently impair the client's mobility. The inability to extend fingers, particularly in a casted extremity, is a contracture resulting from prolonged ischemia of muscle tissues. Swelling inside the cast causes muscles to shorten and scar, leading to deformities or contractures called Volkmann contractures. Mild cases may be treated with splinting and exercise but severe cases need surgical intervention and possible even transplanted tissues with no guarantee of restored dexterity or mobility. 1. INCORRECT. Obviously a 'really tight' sensation of the arm is of great concern, since swelling could be an early indication of compartment syndrome. However, the nurse should seek further clarification from the client regarding the "tightness" and its exact location. Another problem is of even greater concern. 2. INCORRECT. Many odors could emanate from casting material, from skin breakdown to the odor of drying cast material. The client may even have put something down inside the cast so the smell should definitely be investigated. However, the nurse has greater priority at the moment. 4. INCORRECT. There are many reasons pain medication may not relieve discomfort, including too low a dose or patient noncompliance with medication regime. On-going pain should certainly be investigated as a potential sign of greater problems but this is not the nurse's priority at this time.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries

3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. 2. Incorrect: Cheese and crackers are high in sodium. This client is at risk for CAD, so sodium should be limited. 4. Incorrect: This client does not need high potassium, which fried sweet potatoes have. The high potassium dietary approaches to stop hypertension (DASH) diet is only for healthy clients with hypertension.

A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation

4. CORRECT. The physical therapy department is best qualified to assist a client in adjusting to the use of crutches prior to discharge. Because the client wants to use older crutches, it is even more important for a physical therapist to determine whether it is safe for the client to do so. Physical therapy can evaluate the condition of the old crutches, the client's ability to manage that equipment and to walk safely with those crutches. 1. INCORRECT. It is permissible for a client to use previously owned medical equipment. However, the stability of that equipment and the client's ability to use the equipment safely must be evaluated by physical therapy. Cancelling physical therapy would also violate the physician's orders and place the client at risk for injury upon discharge. 2. INCORRECT. While the nurse may be able to adjust the old crutches to the client's height, crutch safety and walking should be evaluated by physical therapy to be certain the previous equipment is appropriate. 3. INCORRECT. Insurance does not designate whether assistive medical devices can be reused by clients or if a new device must be purchased. It is cost effective to reuse durable medical equipment if it is appropriately suited to the client's current needs.

A client with a history of angina has returned to the unit following a cardiac catheterization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. CORRECT: The greatest risk following a cardiac catherization is the potential for hemorrhage, most often from the insertion site. Therefore, the affected extremity must remain straight and immobilized for 4-6 hours after the procedure. 1. INCORRECT: The frequency of vital signs is determined by facility protocol, but generally vital signs are obtained every ten minutes for the first half hour, then every fifteen minutes for another half hour. While vital signs provide valuable information to compare to baseline, another action is more important. 2. INCORRECT: It is vital to assess pedal pulses in order to verify circulation following a catherization. The frequency is based on facility protocol. However, this action is not the highest priority. 3. INCORRECT: Because the client is on bed rest, it is crucial for the client to be able to summon staff when needed. Despite the importance of this action, there is an even more important action.

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears.

A client is awake in the recovery room following a cardiac catheterization performed through the left radial artery. During the assessment, the nurse notes severe swelling of the left upper arm with a diminished left radial pulse, indicating an internal arterial hemorrhage. The cardiologist states the client will require immediate surgery to repair the leaking artery. The nurse understands what fact about the current consent form? 1. Can be assumed since it's an emergent situation. 2. Should be signed by client who is currently awake. 3. Is not needed since client consented to catheterization. 4. Must be approved by family or a spouse.

4. Correct: An additional procedure requires a new consent form which describes specifically what the cardiologist plans to do. Even though the client is awake, residual sedation from the catheterization makes it necessary for a family member or spouse to sign the consent form. 1. Incorrect: Emergent situations are those in which the client's life or limb is threatened. That type of consent is called "implied" consent; however, despite the seriousness of the situation, implied consent is not valid in this case. 2. Incorrect: Though awake following the catheterization, the client is considered impaired because of the sedation used during the catheterization. Even if the client understands what is occurring, a signature by the client is not considered legal at this time. 3. Incorrect: Once the surgery and potential risks are explained to the client, a consent form is completed specifically describing the procedure to be performed by the cardiologist. That form does not cover any additional procedures, even if directly connected to the original surgery.

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."

4. Correct: Following cataract removal, a new lens is sutured in place, which slightly alters the corneal curve. Newer surgical approaches involve the use of a "suture-less glue" but that method is less common. Although the client's vision will eventually improve and stabilize, minor blurring may exist during the 6 to 12 week healing period. After that time, any remaining visual issues can be corrected with glasses. 1. Incorrect: Only the operative eye is protected by an eye patch during the healing process. The primary healthcare provider will remove that covering at the first post-operative checkup. Covering both eyes would pose a greater safety risk and decrease the client's self care abilities. 2. Incorrect: Pain following cataract surgery is the sign of a serious complication and should be reported to the surgeon immediately. Clients may experience a small amount of serous drainage or scratchy sensation, but should not have pain. 3. Incorrect: Implantation of a new lens causes a mild astigmatism that will be permanent. The client may still need to use corrective lenses, even if just for reading.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

4. Correct: People with Alzheimer's disease (AD) get more confused over time. They also may not see, smell, touch, hear and/or taste things they once did. By creating a contrast in color between the floors and walls makes it easier for the person with AD to see. 1. Incorrect: Be careful with small pets. The person with AD may not see the pet and trip over it. This is a safety issue. A fall could cause a major injury to the client. 2. Incorrect: The water heater should be set below 120 degrees Fahrenheit (48.8 degrees Celsius) to prevent burns. 3. Incorrect: Limit the size and number of mirrors in the home. Mirror images may confuse the person with AD. They may not recognize self and may see the person as a stranger.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? Exhibit: ABGs: pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23 Select all that apply 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

4., & 5. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in uncompensated respiratory alkalosis. 1. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 2. Incorrect: The blood gases confirm respiratory alkalosis. The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. For this client to be in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The Bicarb is normal, so the problem is not metabolic. 6. Incorrect: Compensation has not begun because the bicarb is normal. To compensate the bicarb would need to decrease to bring the pH down to normal. 7. Incorrect: Fully compensated would occur if the pH is normal with abnormal CO2 and bicarb.