Level 2 discussion board questions

A healthcare provider writes an order for aminophylline 1000mg in 250mL of D5W to be infused at 30mg per hour for the client with recurrent asthma attacks. The aminophylline is available in an ampule of 2000mg per 10mL. How many milliliters of aminophylline should the nurse add to the IV fluid to obtain the concentration ordered? (Record your answer as a whole number.) ______mL

5mL Using the formula method: D x Q H 1000mg x 10mL = 0.5mg x 10mL = 5mL 2000mg

Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply. A. Bran cereal B. Broccoli C. Tomato juice D. Navy beans E. Cheese

A,B,D: Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.

Which screening test is a neonatal nurse likely to use to detect developmental dysplasia of the hip (DDH)? A. Barlow's maneuver B. Pavlik's maneuver C. Gower's maneuver D. Allis's maneuver

A: The Barlow maneuver is performed by adducting the hip while pushing the thigh posterior. If the hip goes out of the socket, it is called "dislocatable" and is positive for DDH. A Pavlik harness is used to treat DDH. Gower's maneuver is used by children with muscular dystrophy to stand. An Allis's maneuver is used with children who can respond to positional instruction.

A nurse is educating a family whose child is newly diagnosed with scoliosis. The nurse explains that the goal of therapy is to: A. Limit or stop progression of the curvature. B. Prepare the child for surgery. C. Minimize the psychosocial complications of prolonged immobilization D. Develop a pain management protocol that will minimize complications of medications.

A: The goal of screening is to limit progression of the curve, obviating the need for more aggressive interventions. Not all children with scoliosis need surgery, nor do most require prolonged immobilization. Most do not require aggressive pain management.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? A. Sore throat B. Painful, excessive menstruation C. Constipation D. Increased urine output

A: The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

A nurse is assessing a client with suspected major depression. Which findings would support a diagnosis of major depression? Select all that apply. A. Loss of interest or pleasure nearly daily for at least 2 weeks. B. Presence of psychomotor agitation nearly daily for at least 2 weeks. C. Feelings of worthlessness nearly daily for at least 2 weeks. D. Having a depressed mood nearly daily for at least 2 weeks. E. Talking rapidly with pressured speech nearly daily for at least 2 weeks. F. Impaired concentration nearly daily for at least 2 weeks.

A, B, C, D, F: Loss of interest or pleasure, psychomotor agitation, feelings of worthlessness, depressed mood, and impaired concentration are symptoms that meed this diagnostic criteria for a major depressive disorder. Rapid, pressured speech is a diagnostic criterion for bipolar disorder and not major depressive disorder.

A client is hospitalized with a diagnosis of pneumonia. Which findings, based on the nurse's knowledge, are indicative of a deteriorating clinical state? Select all that apply. A. Increased respiratory rate B. Tachycardia C. Agitation D. Cyanosis E. Increased urinary output

A, B, C, D: Increased respiratory rate, tachycardia, and agitation are early signs of respiratory distress, and can be interpreted by the nurse as deteriorating clinical state. Cyanosis develops later in the progression of respiratory distress, but is still an indication of client deterioration. Increased urinary output is the opposite of what the nurse would expect in a client with respiratory distress whose condition is deteriorating.

A nurse is giving a change-of-shift report to another nurse. Which are essential components of a change-of-shift report? Select all that apply. A. Reporting the client diagnosis. B. Sharing new orders, medications, and treatments. C. Sharing personal opinions about treatment options. D. Discussing the effectiveness of analgesics. E. Sharing routine turning schedules for the client. F. Informing about client progress toward goals and areas for priority focus on the next shift.

A, B, D, F: During change-of-shift report, pertinent information related to events that occurred is conveyed to individuals responsible for providing continuity of care. This includes the client diagnosis, new orders, medications and treatments, and effectiveness of analgesics. Use SBAR (situation, background, assessment, and recommendation) to communicate information, especially information that requires follow-up action or is a priority in progressing the client toward meeting goals. Personal opinions not pertinent to providing client care should be omitted. The turning schedule can be reviewed in documentation and is not necessary in shift report.

A client with diverticular disease is receiving psyllium hydrophilic mucilloid. The drug has been effective when the client: A. Passes stool without cramping. B. Does not have diarrhea. C. Is no longer anxious. D. Does not expel gas.

A: Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid. Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety, or relieve gas formation.

The client newly diagnosed with heart failure has an ejection fraction of 20% Which criteria should the nurse use to evaluate the client's readiness for discharge to home? Select all that apply. A. There is a scale in the client's home. B. The client started ambulating 24 hours ago. C. The client is receiving furosemide IV 20mg bid D. A smoking cessation consult is scheduled for 2 days after discharge. E. A home-care nurse is scheduled to see the client 3 days after discharge.

A, B, E: A scale is needed to monitor a change in fluid status and weight gain. The client should be ambulating 24 hours preceding discharge to determine functional capability. The client should have the home-care nurse visit or provide telephonic assistance within the first three days of discharge. Oral diuretic agents such as furosemide should be administered 24 hours prior to discharge to monitor effectiveness. Smoking cessation should be initiated prior to, not after, discharge.

What should the nurse include when teaching health maintenance strategies to the client with COPD? Select all that apply. A. Yearly influenza immunizations B. Immunization against pneumonia C. Limitation of physical activity D. Oral fluid restriction E. Adequate caloric intake

A, B, E: Clients with COPD are highly susceptible to respiratory infections such as influenza, so they should be immunized yearly. Clients with COPD are highly susceptible to respiratory infections such as pneumonia so they should be immunized as prescribed by their physician. Clients with COPD use a large amount of calories because of labored respiratory function; increased caloric intake is necessary to maintain a healthy weight. Clients with COPD should undergo a progressive rehabilitation program to increase their activity tolerance. Fluid restriction is not needed with COPD unless there is fluid retention from another etiology.

The nurse assesses the client with rheumatoid arthritis for which characteristic joint changes? Select all that apply. A. Swan-neck deformity B. Heberden's and Bouchard's nodes C. Tophi D. Charcot's joints E. Ulnar deviation

A, E: Swan-neck deformity occurs at the proximal interphalangeal (PIP) joints in rhematoid arthritis. Ulnar deviation occurs as the joint deteroriates and is a visible finding in clients with RA. Heberden's and Bouchard's nodes are commonly found in clients with osteoarthritis. Tophi (firm, moveable nodules) are associated with gout. Charcot's joint is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not specific to RA and is more likely to be seen as a complication in clients with diabetes.

A client is admitted to the hospital with a medical diagnosis of viral pneumonia. The nurse assesses for which of the following most frequent manifestations? Select all that apply. A. Presence of Ghon's tubercle on chest X-ray B. Nonproductive cough C. Normal or near normal white blood cell count D. High fever that is intermittent E. Profuse pleural diffusion on chest X-ray findings

B, C: Viral pneumonia is considered less serious for the client because symptoms are not as apparent compared with bacterial pneumonia. Viral pneumonia is associated with nonproductive cough and normal or near normal white blood cell count. Ghon's tubercles are seen on X-ray in clients with tuberculosis. Viral pneumonia is associated with low-grade fever. The client with viral pneumonia will display normal or minimal chest X-ray findings.

The clinic nurse is discussing risk factors for cancer with a male client, who asks which cancers have the highest incidence in men. In order of occurrence, the nurse should reply that the client has greatest risk for which cancers based on gender? A. Lung, prostate, and colorectal cancers B. Prostate, lung, and colorectal cancers C. Colorectal, lung, and prostate cancers D. Prostate, colorectal, and lung cancers

B: Prostate cancer has surpassed lung cancer in order of occurrence; colorectal cancer is the third-most common cancer.

The nurse is admitting the client with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. The client has been in atrial fibrillation for more than 2 days and has had no previous cardiac problems. Which initial interventions should the nurse anticipate? Select all that apply. A. Ablation of the AV node B. Immediate cardioversion C. Oxygen 2 liters per nasal cannula D. Heparin intravenous (IV) infusion E. Amiodarone IV infusion F. Diltiazem IV infusion

C, D, E, F: The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Amiodarone is used for pharmacological conversion of the atrial fibrillation rhythm. Diltiazem, a calcium channel antagonist (calcium channel blocker), is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist (calcium channel blocker) would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's HR. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been rulted out.

The nurse is assessing the client with an anterior-lateral MI. The nurse should add decreased cardiac output to the client's plan of care when which finding is noted? A. Pain radiates up left arm to neck B. Presence of an S4 heart sound C. Crackles auscultated in both lung bases E. Vesicular breath sounds over lung lobes

C. An anterior-lateral MI can produce left venticular dysfunction and low cardiac output. With decreased cardiac output, blood accumulates in the heart and backs up into the pulmonary system. The increased pulmonary pressure causes fluid to move into interstitial spaces and then into the alveoli. The fluid will be auscultated as crackles in the lungs. Pain radiation is associated with an MI and does not necessarily indicate that output has decreased. An S4 heart sound is produced when blood flows forcefully from the atrium to a resistant ventricle during late ventricular diastole. Vesicular breath sounds are normal over lesser bronchi, bronchioles, and lobes of the lung.

A client hospitalized with bipolar disorder is in a state of mania. The client, who was admitted on a formal voluntary status, demands immediate discharge from the facility. What should the nurse do? A. Notify the police of the client's intention. B. Inform the client's spouse of the request of the client. C. Offer the client a contract for safety. D. Notify the supervisor on the nursing unit.

C: The manic client has poor judgement and is impulsive and at risk for injury. The nurse should attend to the safety needs of this client before taking other actions. It is possible that the client will not be able to contract for safety. (At this point the first part of the contract would be for the client to remain in the hospital.) If the client could not do this, the nurse's next action is to explain the terms of the client's admission status. Because the client is being treated on a formal voluntary basis, the nurse cannot comply with the client's demand to be discharged. It is not appropriate to involve the police. While informing the spouse might be an appropriate later action, at this time the nurse should focus attention on the client. It is appropriate for the nurse to report the client's request to the nursing supervisor, but the first response to the client's request should be made to the client. Meeting the client's safety needs is of higher priority than informing the supervisor.

Which nursing diagnosis should a nurse give highest priority when caring for a client with major depressive disorder? A. Powerlessness B. Potential for spiritual distress C. Potential for injury D. Disturbed sleep patterns

C: The potential for suicidal behavior is the highest priority for clients diagnosed with major depressive disorder. The presence of powerlessness, spiritual distress, and disturbed sleep patterns are concerning but do not take priority over the potential for suicide.

A nurse is planning care for four clients. Prioritize the order in which the nurse should plan to see/attend to the clients. A. A 13-year-old client waiting to be admitted from the emergency department after receiving stitches for facial lacerations from a dog bite. B. A 9-year-old whose mother is present to receive teaching about wound care for her child's left leg skin graft in anticipation of discharge tomorrow. C. A 5-year-old client with an infected leg wound who is scheduled for a dressing change now. D. A 2-year-old client who's temperature has risen to 103.8F.

D, C, A, B: The 2-year-old client with an elevated temperature should be assessed first. This is the most life-threatening situation. The next action should be to change the leg dressing for the 5-year-old client. Delaying the dressing change increases the risk of sepsis. Next, the child can then be admitted from the emergency department. The child should still be monitored while in the emergency room, and it is appropriate to delay admission to the unit if other interventions are priority. The last action by the nurse should be to teach the 9-year-old child's mother on wound care. This client is being discharge tomorrow, which means that the wound care teaching, while important, can be delayed.

The nurse is developing a plan of care for the client admitted with a cough, fever, dyspnea, and a diagnosis of pneumonia. Which is the best intervention to include in the client's plan of care to prevent atelectasis? A. Suction oral secretions every 2 to 4 hours. B. Provide continuous use of oxygen at 2 L via nasal cannula. C. Teach and reinforce coughing every four hours. D. Encourage hourly use of an incentive spirometer.

D: Incentive spirometry, also known as sustained maximal inspiration, is a type of bronchial hygiene used in pneumonia to prevent or reverse alveolar collapse (atelectasis). There is no indication that the client is unable to expectorate secretions. Oxygen is used to treat hypoxia rather than to prevent atelectasis. Clients should be encouraged to cough effectively at least every two hours while awake to promote airway clearance and expand the lungs.

The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse's priority intervention? A. Palpate pedal pulses B. Measure vital signs C. Assess for uticaria D. Check the insertion site

D. Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases the risk for clot disruption and bleeding from the femoral artery. Sneezing would not affect the pedal pulses. Although the BP could decrease if the client were bleeding, this is not the priority. Sneezing can be an early sign of an allergic reaction to the contrast but is a minor sign compared to the potential loss of blood.

The nurse teaches a mother how to attach a spacer to the metered-dose inhaler for a young child. How should the nurse explain the purpose of the spacer? A. Makes the device look less intimidating to a small child. B. Makes it unnecessary to shake the inhaler before administering the drug. C. Concentrates the medication in the upper respiratory tract. D. Reduces the risk for oral yeast by depositing medication more deeply into the airways.

D: Steroids given via metered-dose inhaler on oral mucosa increase the risk for yeast infection. A spacer avoids the mucous membranes and works directly on the airways. The purpose of the spacer is not related to the appearance of the inhaler. Use of a spacer on a metered-dose inhaler does not change the need to shake the medication before administration. It is desirable for the medication to penetrate into the lower respiratory tract to be most effective.

The nurse who is explaining the pathophysiology of COPD to a client includes the fact that alveolar destruction results in which manifestations? Select all that apply. A. Decreased surface area for gas exchange B. Increased dead space air C. Development of pulmonary emboli D. Chronic dilation of bronchioles E. Airway collapse related to loss of elasticity

A, E: The loss of elasticity in the airway of a client with COPD can be airway attributed to repeated infections and inflammation, which leads to airway collapse. Airway collapse can cause alveolar destruction because of either over- or under-inflation of alveolar sacs. The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area available for gas exchange. Destruction of alveoli is not related to increased dead space air, pulmonary emboli, or chronic dilation of bronchioles. With COPD, there is progressive narrowing of bronchioles.

A client's stools are light gray in color. The nurse should assess the client further for which of the following? Select all that apply. A. Intolerance to fatty foods. B. Fever C. Jaundice. D. Respiratory distress E. Pain at McBurney's point. F. Peptic ulcer disease.

A,B,C: Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. A bile duct obstruction can cause pale-colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis

At 0745 hours, the nurse is informed by the health care provider that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse's priority? A. Place the client on NPO (nothing per mouth) status. B. Teach the client about the cardiac catheterization. C. Start an intravenous (IV) infusion of 0.9% NaCl. D. Witness the client's signature on the consent form.

A. A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam, during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure. Because of the time element, NPO status should be initiated first, and then teaching should occur. To avoid administering too much fluid to the cardiac client, the saline infusion is usually only started just prior to the client leaving the unit for the procedure. A consent form should be signed after the cardiologist has spoken with the client.

TPN is prescribed for a client with Crohn's disease. Which of the following indicate the TPN solution is having an intended outcome? A. There is increased cell nutrition. B. The client does not have metabolic acidosis. C. The client is hydrated. D. The client is in a negative nitrogen balance.

A. The goal of TPN is to meet the client's nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.

The client is admitted with an ACS (acute coronary syndrome). Which should be the nurse's priority assessment? A. Pain B. Blood pressure C. Heart rate D. Respiratory rate

A. The nurse's priority assessment in ACS is the client's pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP is a response stemming from the lack of perfusion but is not the priority assessment. HR is a response stemming from the lack of perfusion but is not the priority assessment. Respiratory rate is a response stemming from the lack of perfusion but is not the priority assessment.

A nurse is assessing an elderly client in Buck's traction to temporally immobilize a fracture of the proximal femur prior to surgery. Which finding requires the nurse to intervene immediately? A. Reddened area on the sacrum. B. Voiding concentrated urine, 50mL/hour. C. Capillary refill 3 seconds, dorsiflexion and sensation intact, pedal pulses palpable. D. Lower leg secure in traction boot and ropes and pulleys and 5 pound weight hanging freely.

A: A reddened sacrum is the first sign of a pressure ulcer that is caused by pressure or friction and sheer. Sheer results from the weight of the skin traction pulling the client to the front of the bed and then the client sliding back up in bed. Immediate interventions are required before it develops into a stage II ulcer. The 50mL/hour output is adequate, thought the nurse should evaluate the client's amount of intake. Option C findings are normal. Buck's traction is skeletal traction. Traction (usually 5 to 8 pounds) is applied either to a boot in which the client's lower extremity is secured or to traction tapes applied to the client's extremity.

A state's nurse practice act does not allow a registered nurse (RN) to suture wounds. The practitioner offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. The nurse should: A. Refuse to suture the wounds B. Follow the practitioner's instructions C. Report the situation to the state board of nursing D. Agree to suture wounds in the practitioner's presence

A: A state's nurse practice act is the ultimate source relative to a nurse's professional practice; a nurse may not function outside of the legal definition of nursing practice. Performing suturing, with or without supervision, conflicts with the state's nurse practice act, and the nurse would be functioning outside the legal scope of nursing practice. The state board of nursing does not have jurisdiction concerning this procedure.

The nurse would question an order for ipratropium bromide ordered for a client with asthma if the client had which concurrent medical history? A. Glaucoma B. Cushing's syndrome C. Warfarin therapy D. Fluid retention

A: Anticholinergics such as ipratropium are contraindicated in clients with angle-closure glaucoma because they can inhibit flow of aqueous humor and raise intraocular pressure. The other medical conditions would not cause the nurse to question an order for ipratropium.

The parents of a child with asthma are learning about performing postural drainage exercises. The nurse should teach them to perform which action before performing the exercises? A. Administer the child's bronchodilator B. Change the child's clothes C. Administer the child's antibiotic D. Suction the child's throat

A: Bronchodilators open the airways and afford easier removal of secretions. Changing the child's clothes prior to the postural drainage exercises is unnecessary. Administering the child's antibiotic before the postural drainage is not necessary. Suctioning of the child's throat could be done after the procedure, if necessary.

The client with interstitial pulmonary disease is experiencing dyspnea and fatigue. Which recommendation by the nurse will be most helpful to this client? A. Use energy conservation measures B. Use oxygen therapy while at home C. Remain in an upright position D. Use controlled coughing for airway clearance

A: Energy conservation includes the use of rest periods and breathing techniques and is the only option that focuses on both symptoms of interstital pulmonary diseases in this client with dyspnea and fatigue. Using oxygen focuses only on the symptom of dyspnea; there is no information about the client's oxygen saturation to indicate that oxygen is needed. Although sitting upright will help expand the lungs, energy conservation will be more helpful to prevent dyspnea and fatigue. There is no indication that this client has ineffective airway clearance.

A nursing assistant (UAP) asks for advice about talking with a client recently diagnosed with dissociative identity disorder (DID). When the UAP asks, "Should I talk about her childhood abuse?" What is the best response? A. "If she brings up the abuse, listen to her and be supportive." B. "You will need to really push her to get it all out." C. "Ask her to discuss this only with her therapist." D. "Remind her that sometimes adults exaggerate their childhood experiences."

A: Listening and being supportive if the client mentions the abuse is correct. Trust is the basis of a therapeutic relationship, and the client should proceed at a self-determined rate, particularly if the subject is painful. Self-pacing avoids flooding the client with severe anxiety. This self-disclosure should be accepted nonjudgmentally by all persons with whom the client has contact. Pushing the client to get it all out would result in flooding the client with anxiety, which is not recommended. Additionally, the nurse should recognize that a nursing assistant is not properly prepared for this sort of intervention. Asking the client to discuss it only with her therapist could interfere with trust and the client's readiness to disclose. Reminding the client that sometimes adults exaggerate their childhood experiences is non-accepting and demeaning to the client.

Immediately after having surgery to create an ileostomy, which goal has the highest priority? A. Providing relief from constipation. B. Assisting the client with self-care activities. C. Maintaining fluid and electrolyte balance. D. Minimizing odor formation.

C: A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

Which nursing action should be implemented on the second postoperative day for a client who received a right total hip replacement (THR) with a cemented prosthesis? A. Assisting the client to the bathroom, which has an elevated toilet seat, using a walker and partial weight bearing of the right leg. B. Removing the Hodgkin's splint, which maintained leg alignment during the night, and positioning pillows to adduct the client's right leg. C. Reinfusing the returns from a Stryker wound autotransfusion drainage system, which has collected 400mL in the past 24 hours. D. Assisting the client to get out of bed on the left side so the client can stand to use the urinal.

A: On the second postoperative day following THR, the client should have weight-bearing restrictions but should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits. The client's legs should be abducted, not adducted. Drainage from a wound drain reinfusion system would not be used 6 hours postoperatively because the drainage would primarily be fluid and debris and not blood. Not every client may have a would drainage system following THR. The best side for the client to get out of bed is the affected side. This allows the client to shift position with the good leg and the trapeze to the edge of the bed, lower the affected leg over the edge of the bed, and, with the assistance of the nurse, turn to a sitting position without exceeding the 90-degree hip flexion.

What explanation should the nurse give to a client and family regarding the development of COPD in a young adult? A. Hereditary deficiency of alpha-1-antitrypsin B. Onset of smoking during childhood C. Heavy secondary smoke exposure during childhood D. Use of smokeless tobacco during childhood

A: Onset of the physiological changes compatible with COPD is most often associated with a hereditary deficiency of alpha-1-antitrypsin, an enzyme that protects lung tissue against loss of elasticity. The other explanations are not typically associated with early onset of the physiological alterations of COPD.

The nurse teaches a client that which factor might increase risk of developing an exacerbation of systemic lupus erythematosus (SLE)? A. Pregnancy B. Hypotension C. Fever D. GI upset

A: Pregnancy can be associated with an exacerbation because of increased estrogen levels. Hypotension, fever, and GI upset do not exacerbate SLE.

The nurse writing a care plan determines that which nursing diagnosis is a priority early in the care of a client with scleroderma? A. Impaired Skin Integrity B. Disturbed Body Image C. Activity Intolerance D. Hopelessness

A: Skin manifestations are a common finding in clients with scleroderma and therefore require preventative and supportive nursing care as the priority. As the disease progresses, dermatologic effects may lead to disturbances in body image. With disease progression, there may be an impact on respiratory and musculoskeletal function, leading to activity intolerance. Hopelessness can develop with worsening symptoms later in the disease process.

Having requested it as part of a comprehensive treatment program, the client is to receive disulfiram. Which statement should the nurse include when teaching the client about this drug? A. "Inhaling fumes from pains and wood stains may cause a disulfiram reaction." B. "Eating inadequately cooked seafood may lead to disulfiram resistance." C. "Talking disulfiram will reduce your physical craving for alcohol." D. "If you consume alcohol while taking disulfiram, rapid intoxication will occur."

A: Stating that inhaling fumes from paints and wood stains may cause a disulfiram reaction is correct. The adverse reaction of disulfiram will occur if the person taking this drug ingest, inhales, or absorbs alcohol, even in very small doses (such as inhaling vapors from paints or woodstains, or oral ingestion in products such as mouthwash). These reactions include throbbing headache, tachycardia, diaphoresis, and respiratory distress. Death can occur. This drugs is not used often, but the nurse should know about its uses and dangers. While eating improperly cooked seafood might lead to gastric distress and/or liver problems, uncooked seafood does not precipitate a disulfiram reaction. Disulfiram does not reduce the craving for alcohol, but opioid antagonists, such as naltrexone do. Disulfiram works on the classic principle of conditioned avoidance. If the individual drinks alcohol while taking disulfiram, intensely unpleasant and dangerous physical reactions can occur. The effect of disulfiram when combined with alcohol is not intoxication. Instead, the individual experiences intensely unpleasant and dangerous physical reactions.

The spouse of a client who is experiencing a fugue state asks the nurse if the spouse will be able to remember what happened during the time of the fugue. What is the nurse's best response? A. "Your spouse will probably have no memory for events during the fugue." B. "Your spouse will be able to tell you - if you can gently encourage talking." C. "It is not possible to predict whether your spouse will remember the fugue state." D. "Avoid mentioning it, or your spouse may start alternating old and new identities."

A: Stating that the client will probably have no memory of events during the fugue is correct. The client who has experienced a fugue is generally unable to remember events occurring during the fugue state, despite encouragement. During fugue states, clients are generally reclusive and quiet, so their behavior rarely attracts attention. Amnesia for the events occurring during the fugue state can be predicted. The client does not have the ability to alternate personal identity with the partial identity assumed during the fugue state.

The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply. A. Increase isometric arm exercises to build endurance. B. Wear a facemask when outdoors in cold weather. C. Take nitroglycerin before a stressful event even if pain free. D. Perform most exertional activities in the morning. E. Take a daily laxative to avoid straining with bowel movements. F. Discontinue use of all tobacco products if you use these.

B, C, F: Blood vessels constrict in response to cold and increase the workload of the heart. Nitroglycerin produces vasodilation and improves blood flow to the coronary arteries and should be taken before exertional or stressful activities. Nicotine stimulates catecholamine release, producing vasoconstriction and an increased HR. Isometric exercise of the arms can cause exertional angina. Exertional activity increases the HR, thus reducing the time the heart is in diastole, which is the time when blood flow to the coronary arteries is the greatest. A period of rest should occur between activities, and activities should be spaced. Straining at stool increases sympathetic stimulation and cardiac workload, and it should be avoided. However, a daily laxative should not be taken; it may result in diarrhea.

The nurse is teaching the client newly diagnosed with asthma. Which instructions should the nurse include to reduce allergic triggers? Select all that apply. A. Wash bedclothes and linens in cold water. B. Use dust covers on mattresses and pillows. C. Keep house fresh with a scented deodorizer. D. Vacuum carpets daily in the bedrooms. E. Clean the albuterol MDI daily under hot running water.

B, D: The nurse should instruct the client to use dust covers on mattresses and pillows to reduce exposure to dust mites. Vacuuming the carpets in the bedrooms daily helps to remove dust mites and dust particles. Bedclothes should be washed in hot water or cooler water with detergent and bleach to reduce allergen levels. Scented sprays should be avoided because they may trigger an asthmatic attack. Albuterol is a beta-2 adrenergic agonist. Only the plastic sleeve, and not the canister, should be placed under warm (not hot) running water.

The nurse has taught an anxious client a relaxation technique. The nurse would evaluate the effect of the instruction on which client goal? Select all that apply. A. "The client will confront the source of the anxiety." B. "The client will experience anxiety without feeling overwhelmed." C. "The client will keep a journal of times anxiety is experienced." D. "The client will suppress anxious feelings." E. "The client will work through problems without being devastated."

B, E: Two options are correct. The goal of teaching calming techniques such as relaxation therapy assists the client to learn to experience anxiety without feeling threatened and overwhelmed, and to work through problems without being devastated. Relaxation therapy does not assist a client to confront sources of anxiety, but rather to reduce the level of intensity of the anxiety. keeping a journal is a self-monitoring technique but is not used to measure the outcome of relaxation. The goal is not to suppress anxious feelings but to make them more manageable.

A nurse assesses a client 4 hours after a left total knee replacement. The client has a knee immobilizer in place with medial and lateral ice packs that have warmed. The surgical extremity's neurovascular status is intact and vital signs stable. A Stryker wound drain, an autoinfusion drainage system, has 350mL drainage collected. The client reports pain at a level 3, which is tolerable, and denies nausea. The client has not voided since before surgery. Which interventions should the nurse plan to implement at this time? Select all that apply. A. Notify the client's physician. B. Reinfuse the salvaged blood loss. C. Remove the immobiizer and place a pillow behind the client's knee to create a 90-degree knee flexion. D. Stand the client at the bedside to facilitate bladder emptying. E. Place the affected extremity in a continuous motion device (CPM) to begin early motion. F. Replace the ice packs in the knee immobilizer

B, F: An autotransfusion drainage system should be used in the immediate postoperative period if extensive bleeding is anticipated. Collected drainage can be reinfused up to 6 hours postoperatively. Ice packs, used to reduce swelling and control bleeding, are replaced every 2 hours. If they have warmed, they need to be replaced. If the vital signs are stable, it is unnecessary to notify the physician. This amount of blood is expected and does not indicate excessive bleeding. Flexing the knee to 90 degrees staunches excessive bleeding. The client's bladder should be scanned using a bedside bladder ultrasound to determine the amount of urine in the bladder. Research indicates bladder scanning reduces the need for catheterization and is cost effective. Four hours after surgery may be too soon to stand the client at the bedside. The nurse assists the client to get out of bed in the evening or the day after surgery. The client's leg would not begin cycling in the CPM machine until the amount of drainage decreases.

To prevent dislocation of the hip prosthesis following total hip replacement, a nurse should plan to: (Select all that apply) A. Place pillows or a wedge pillow between the client's legs to keep them adducted. B. Use a fracture bedpan and instruct the client to flex the unaffected hip and use the trapeze to lift the pelvis while the nurse places the pan. C. Prevent hip flexion by not elevating the head of the bed more than 90 degrees. D. Place a pillow between the client's knees when initially assisting the client out of bed. E. Elevate both of the client's legs when sitting in the wheelchair to decrease swelling.

B,D: The client's hip should never be flexed more than 90 degrees. A regular bedpan is too large, so a fracture pan should be used. The client should be reminded not to flex the affected hip when using the bedpan. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation. A pillow should be used to maintain abduction (not adduction). The head of the bed should not be elevated more than 60 degrees. This allows the client no more than 30 degrees of hip flexion if lifting the leg. The hip should never be flexed more than 90 degrees. Elevating the affected leg when sitting increases the risk of flexing the client's hip beyond 90 degrees.

The home health nurse would be most concerned that a client is experiencing digoxin toxicity after noting which manifestations during a routine visit? Select all that apply. A. Palpitations, elevated blood pressure, and shortness of breath B. Anorexia, nausea, and reports of yellow vision C. Chest pain, fatigue, and decreased blood pressure D. Taste alterations, dry mouth, and constipation E. Visual disturbances, vomiting, and diarrhea

B,E: Anorexia, nausea, and yellow vision, visual disturbances, vomiting, and diarrhea are signs of digoxin toxicity. The other options are not signs of digoxin toxicity.

The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a LVN to provide client care? Select all that apply. A. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). B. A client who underwent inguinal hernia repair surgery 3 hours ago. C. A client with an intestinal obstruction who needs a Salem sump tube inserted. D. A client with diverticulitis who needs teaching about take-home medications. E. A client who is experiencing an exacerbation of his ulcerative colitis.

B,E: The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of ulcerative colitis are appropriate clients to assign to a licensed vocational nurse (LVN) as the care they require falls within the scope of practice for a licensed vocation nurse. It is not within the scope of practice for the LVN to administer TPN, insert naogastric (NG) tubes, or provide client teaching related to medications.

The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity? A. Pulse rate increased by 15 beats per minute during activity B. BP 130/86mmHg before activity; 108/66mmHg during activity C. Increased dyspnea and diaphroesis relieved when sitting in a chair D. A mean arterial pressure (MAP) of 80 following activity

B. A drop in BP of 20mmHg from the baseline indicates that the client's heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. An increased HR during activity indicates the heart is able to adapt. The relief of dyspnea and diaphroesis with rest indicates the heart is able to adapt. A MAP of 80 is normal.

The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homocysteine levels includes eating foods rich in which nutrient? A. Monosaturated fats B. B complex vitamins C. Vitamin C D. Calcium

B. Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats are included in a healthy diet but have not been found to affect the homocysteine levels. Vitamin C is included in a healthy diet and enhances immune system functions but has not been found to affect the homocysteine levels. Calcium is important for bone health but has not been found to affect the homocysteine levels.

A client has an order to begin an IV nitroglycerin drip. What consideration should the nurse make in preparing to administer this medication? A. Cover the solution with a plastic bag. B. Maintain the solution in a glass bottle. C. Replace the solution every 2 hours due to instability. D. Prepare the solution under a laminar flow hood.

B. Intravenous nitroglycerin (NTG) must be prepared only in glass bottles, and infused via the manufacturer-provide tubing. There is no indication that the solution needs to be covered by a plastic bag. NTG is stable in a glass bottle for 24 hours. The preparation of NTG solution does not require laminar flow ventilation.

A client with angina pectoris received nitroglycerin tablets sublingually for chest pain. The client reports a severe headache shortly after the medication is administered. What interpretation should the nurse make based on the client's statement? A. This is a common but unhealthy response to the medication. B. This common response will diminish as tolerance to the medication develops. C. This is a response caused by cerebral hypoxia induced by the medication. D. This is adverse reaction should be reported to the physician immediately.

B. The incidence of headache decreases over time as the client develops tolerance to the medication. Headache is a common side effect (not adverse reaction) related to the vasodilation properties of nitroglycerin. Headache is not an indication of cerebral hypoxia induced by nitroglycerin; the medication has vasodilation properties. The client should be encouraged to continue to use nitroglycerin as needed; acetaminophen or aspirin can be taken for the headache, according to the preference of the physician.

The nurse is caring for a client with posttraumatic stress disorder (PTSD). Which statement by the client would indicate the most improvement? A. "I am responsible for what happened to me." B. "I enjoy being back at work with my friends." C. "I like to stay awake all night." D. "I can't relax. I stay alert all the time."

B: "I enjoy being back at work with my friends" is correct. People with PTSD often avoid interaction and develop an isolated lifestyle that prevents them from working and socializing with others. Clients are likely to feel victimized by the traumatic event ("I am responsible for what happens to me.") The other options reflect symptoms of PTSD, indicating the client is not yet showing improvement.

A client is undergoing percutaneous transluminal coronary angioplasty (PTCA), and requires an antiplatelet agent. What drug should the nurse anticipate administering to this client immediately following the procedure? A. Heparin B. Abciximab C. Clopidogrel D. Aspirin

B: Abciximab (ReoPro) is often given IV following this type of procedure, to help prevent possible reocclusion of the coronary artery that has been treated. It can be administered in conjunction with weight-based heparin therapy, but heparin alone is an anticoagulant agent. Clopidogrel is an example of an antiplatelet agent that is given orally, and not utilized in this particular acute-care setting; however, these clients are often with be transitioned to this medication and continue to take it post-discharge. Aspirin is an example of antiplatelet agent that is given orally, and is not utilized in this particular acute-care setting. However, aspirin can be given later as follow up to the procedure, to prevent possible complications related to vessel occlusion.

The home health nurse is visiting the client whose chronic bronchitis has recently worsened due to not following previous instructions. Which instruction should the nurse reinforce? A. Increase amount of bedrest B. Increase fluid intake to 3 liters C. Decrease carbohydrate intake D. Decrease use of home oxygen

B: Adequate fluids may help liquefy secretions for easier expectoration. Imposing bedrest on the client with shortness of breath may worsen the situation. Physical activity interspersed with adequate rest can improve respiratory function. A diet high in calories can compensate for this client's hypermetabolic state, dyspnea, and poor appetite. Reducing home oxygen use in this situation would most likely exacerbate the client's symptoms.

A client newly diagnosed with asthma has infrequent acute episodes. The nurse should teach the client that which medication is most effective for providing quick relief in acute episodes? A. Corticosteroid via metered-dose inhaler as needed B. Beta-agonist via metered dose inhaler C. Anti-inflammatory via metered-dose inhaler D. Daily use of a bronchodilator inhaler

B: Clients with mild and infrequent asthma symptoms are treated with a short-acting beta-agonist inhaler for quick relief in acute episodes. Corticosteroids as oral or inhaled medication are used for clients with more severe and frequent episodes of asthma. Clients with mild and infrequent asthma symptoms are treated with regular daily administration of an anti-inflammatory inhaler. Bronchodilators as oral or inhaled medication are used for clients with more severe and frequent episodes of asthma.

The nurse documents which expected finding after auscultating the lungs of a child with bacterial pneumonia? A. Wheezes B. Crackles C. Apnea D. Retractions

B: Excess fluid in the alveoli is a manifestation of bacterial pneumonia. The sound produced by fluid in the airways is crackles. Wheezes are often typical of pneumonia caused by RSV, or conditions where the air passages are narrowed, such as asthma. Apnea is a pause in respirations, which is under the control of the central nervous system. Retractions are asymmetrical chest wall movements that are seen in any client having respiratory difficulty.

A client, with a lower leg amputation, is experiencing edema, so an unlicensed assistant personnel (UAP) elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing the client's leg has been elevated? A. Thank the UAP for being so observant and intervening appropriately. B. Remove the pillows, raise the foot of the bed, and inform the UAP that the limb should not be elevated on pillows because it could cause a flexion contracture. C. Inform the UAP that this was the correct action at this time in the client's recovery, but once the client's incision heals the leg should not be elevated. D. Report the incident to the surgeon and tell the UAP to complete a variance report because the client's leg should not have been elevated.

B: Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture. All other options are incorrect. It is unnecessary for the nurse to report the incident to the surgeon and to complete a variance report unless the client was in the position for an extended period of time.

When conducting a health history of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: A. Anorexia B. Tachycardia C. Weight gain D. Cold skin

B: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

The nurse is instructing the client with hypothyroidism who take levothyroxine 100mcg, digoxin and simvastaton. Teaching regarding medications is effective if the client will take: A. The levothyroxine with breakfast and the other medications after breakfast. B. The levothyroxine before breakfast and the other medications 4 hours later. C. All medications together 1 hour after eating breakfast. D. All medications before going to bed.

B: Levothyroxine must be given at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Other medications may impair the action of levothyroxine absorption; the client should separate doses of other medications by 4 to 5 hours.

Which statement by the nursing assistant indicates a correct understanding of the nursing assistant role? A. "I will turn off clients' IVs that have infiltrated." B. "I will take clients' vital signs after their procedures are over." C. "I will use unit written materials to teach clients before surgery." D. "I will help by giving medications to clients who are slow in taking pills."

B: Monitoring vital signs after procedures is within the scope of a nursing assistant's role. Options A,C,D is an intervention that should be performed by the RN or LVN, not UAP.

The nurse is providing teaching to the client with COPD about the purpose of pursed-lip breathing. Which explanation is most appropriate? A. It reduces upper airway inflammation. B. It strengthens the respiratory muscles. C. It improved inhaled drug effectiveness. D. It reduces anxiety by slowing the heart rate.

B: Pursed-lip breathing increases the strength of respiratory muscles and helps to keep alveoli open. Pursed-lip breathing does not have an effect on upper airway inflammation; it is not part of medication administration; and it may reduce the client's anxiety, but this effect is usually due to improved breathing and not to slowing of the heart rate.

A client is to start taking prednisone for treatment of rheumatoid arthritis (RA). Which client statement indicates that medication teaching was successful? A. "I will take the medication on an empty stomach to maximize absorption." B. "I will take the specific dose ordered at the same time every day." C. "I will not have to limit my sodium intake." D. "I will not have to adjust my insulin regimen."

B: Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take this medication at the same time each day and to become aware of tapered-dose effect. Steroids are usually taken with foods to minimize GI upset. Steroids cause fluid retention, and therefore sodium intake may be restricted. Steroids increase blood glucose, so insulin therapy dosages may have to be adjusted.

A nurse is responsible for supervising staff on a unit that includes registered nurses (RNs), licensed vocational nurses (LVNs), and unlicensed assistive personnel (UAPs). Which statement is related to the supervision of staff as opposed to the delegation of tasks? A. Statement to another RN: "Please start an IV on Mr. Jones in room 328." B. Statement to a health unit coordinator: "There are new orders on Mr. Smith's chart that need to be entered." C. Statement to a UAP: "Please answer the call light for the client in room 321." D. Statement to a LVN: "Please give 0800 medications to the client in room 322."

B: Supervision is the initial direction and periodic evaluation of a person performing an assigned task to ensure that he or she is meeting the standards of care. The RN is supervising the health unit coordinator to perform the task of completing orders. Delegation includes understanding that the authorized person is acting in the place of the RN and carrying out tasks such as starting an IV, answering a call light, or giving medications.

A 6-year-old child is hospitalized following an acute asthmatic episode. Which statement by the parents indicates that further teaching is needed? A. "Next time, we'll be sure he takes his cromolyn before soccer." B. "After this episode, he will need to quit the swim team." C. "We think this was an exercise-induced asthma episode." D. "We need to make sure he has his inhaler at all times."

B: Swimming is recommended for children with asthma because prolonged expiration under water is beneficial. Cromolyn sodium is used prophylactically to prevent exercise-induced asthma. When an asthma episode occurs in conjunction with high-level physical activity, it is considered to be an exercise-induced episode. Immediate access to a rescue inhaler is recommended.

The nurse reads in the medical record that a client's tumor is at stage T2, N0, M0. The nurse concludes that this staging indicates which of the following about the client's status? A. There is an advanced tumor with metastasis. B. The client has a measurable tumor with no indication of metastasis or involvement of nodes. C. There is an advanced tumor with indication of involvement of lymph nodes but no indication of metastasis. D. The client has an advanced tumor with indication of metastasis but no indication of involvement of lymph nodes.

B: T2 indicates a measurable tumor, NO indicates no regional node involvement, and M0 indicates no evidence of distant metastasis. The other options are either partially or totally incorrect.

Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? A. Sodium phosphate B. Calcium gluconate C. Echothiophate iodine D. Sodium bicarbonate

B: The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antigluacoma effect. Sodium bicarbonate is a potent systemic antacid.

The client with an intestinal obstruction continues to have acute pain even though the nasogastric (NG) tube is patent and draining. Which action by the nurse would be most appropriate? A. Reassure the client that the nasogastric tube is functioning. B. Assess the client for a rigid abdomen. C. Administer an opioid as prescribed. D. Reposition the client on the left side.

B: The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

A licensed vocational nurse is reporting observations to a registered nurse (RN). Based on the report, which client should the RN assess immediately? A. The client, 2 hours following a total knee replacement, who has 100mL bloody drainage in the suction container of an autotransfusion drainage system. B. The client with a crush injury to the arm who was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain. C. The client in a new body cast who was turned every 2 hours and supported with waterproof pillows. D. The client with an external fixator on the left leg, having serous drainage from the pin sites.

B: Throbbing, unrelenting pain could be the first sign of compartment syndrome. The neurovascular status of the extremity should be assessed. Unrelieved pressure can lead to compromised circulation and avascular necrosis. Postoperative drainage from a total knee replacement ranges from 200 to 400mL during the first 24 hours. This amount is neither alarming or sufficient enough to autotransfuse. The client in a body cast should be turned q2 hours to promote drying of the cast. To avoid cracking or denting of the cast, the client is supported with waterproof pillows that touch each other without open spaces. Some serous drainage, which is due to tissue trauma and edema, is expected from pin sites of an external fixator.

The nurse is assessing the client following an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites? A. Left-sided heart failure B. Pulmonic valve malfunction C. Right-sided heart failure D. Ruptured septum

C. Right-sided heart failure (HF) produces venous congestion in the systemic circulation, resulting in JVD an ascites (from vascular congestion in the GI tract). Additional signs include hepatomegaly, splenomegaly, and peripheral edema. Left-sided HF produces signs of pulmonary congestion, including crackles, S3 and S4 heart sounds, and pleural effusion. A characteristic finding of pulmonic valve malfunction would be a murmur. A murmur would be auscultated with a ruptured septum, and the client would experience signs of cardiogenic shock; these findings are not present.

A client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse asses the learned prevention and future coping strategies of the client? A. "How did you try to kill yourself?" B. "Do you have the phone number of the suicide prevention center?" C. "What skills can you utilize if you experience problems again?" D. "Why did you think life wasn't worth living?"

C: Asking the client directly regarding what skills he or she could utilize if similar problems occurred in the future provides the client with the opportunity to reflect on learned behaviors and to determine a plan for future prevention. How suicide was initially attempted would have been addressed during the initial assessment and does not determine future coping. Although asking the client if the suicide prevention center number is known would be helpful, the question does not determine learned coping strategies. Asking the client a "why" question is not helpful and conveys a judgmental attitude.

The nurse anticipates using postural drainage as a treatment modality for which of the following conditions? A. Epiglottits B. Foreign body aspiration C. Cystic fibrosis D. Bronchopulmonary dysplasia

C: Chest physiotherapy and postural drainage for children with cystic fibrosis help loosen pulmonary secretions and facilitate removal from airways. This treatment would not be helpful with the other conditions listed.

A client is taking warfarin for atrial fibrillation. The nurse would include in a teaching plan that the client will need to remain on drug therapy for what period of time? A. 6 months B. 2-3 months C. Indefinite, or long term D. 1 year

C: Clients who have atrial fibrillation are at risk to develop emboli. Therapy with warfarin is considered to be ongoing in nature, in order to prevent such an occurrence. Clients who have atrial fibrillation are at risk to develop emboli; six months is too short to achieve a preventative goal. In addition, the likelihood of emboli formation does not significantly diminish unless the client is anticoagulated on a long-term basis.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the client should eat which of the following? A. Bland foods. B. High-protein foods. C. Any foods that are tolerated. D. A glass of milk with each meal.

C: Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is not need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts. Foods that are not tolerated and known to aggravate the symptoms should be avoided.

Diltiazem is prescribed for a client with chronic, stable angina. Which statement by the client indicates to the clinic nurse that the client needs additional medication information? A. "I will call the physician if shortness of breath occurs." B. "I will rise slowly when getting out of bed." C. "I will take the medication after meals." D. "I may notice changes in mental alertness until my dose is regulated."

C: Diltiazem is usually administered before meals and at bedtime to increase the absorption of medication. The client should notify the physician if shortness of breath, irregular heartbeat, pronounced dizziness, nausea, or constipation develops. Postural hypotension can occur, so the client must be instructed to rise slowly to avoid dizziness and falling. The medication can cause a decrease in mental alertness until the body adjusts and the proper dosage is established.

The nurse has given medication instructions to the client receiving nicardipine for angina. What statement by the client would indicate to the nurse that the teaching needs to be reinforced? A. "I will keep track of angina episodes, and report them if they increase." B. "Edema or weight gain are expected side effects of the medication." C. "I will report a pulse rate of fewer than 50 beats per minute." D. "I will take any missed dose as soon as remembered, unless it is almost time for the next dose."

C: Diltiazem is usually administered before meals and at bedtime to increase the absorption of medication. The client should notify the physician if shortness of breath, irregular heartbeat, pronounced dizziness, nausea, or constipation develops. Postural hypotension can occur, so the client must be instructed to rise slowly to avoid dizziness and falling. The medication can cause a decrease in mental alertness until the body adjusts and the proper dosage is established.

In establishing a plan of care to manage pain for a client with rheumatoid arthritis (RA), what intervention would the nurse use to increase the client's mobility? A. Have the client work through pain by continuing exercise in order to establish endurance. B. Have the client use pain medication only when pain is present. C. Teach the client that both heat and cold applications may help to relieve pain. D. Teach the client to flex muscle groups when pain is felt in an extremity.

C: Head and cold applications can provide analgesia and relieve muscle spasms. The individual client will have to determine whether heat, cold, or alteration of both is most effective. Exercising in the presence of pain may only further exacerbate pain. Pain medication should be taken on a regular schedule if the client has chronic pain so that the pain threshold can be raised and pain relief maintained at a constant level. Flexing of muscle groups is not related to effective pain control.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? A. Have the client talk with a member of the clergy about these concerns. B. Tell the client to worry about those concerns after surgery. C. Arrange for a person with an ostomy to visit the client preoperatively. D. Notify the surgeon of the client's question.

C: If the client agrees, having a visit by a person who has successfully adjusted to living with an ileosotomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued post-operatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the physician should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.

The client with class II heart failure according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component? A. Diuretics B. A low-sodium diet C. Home oxygen therapy D. Angiotensin-converting enzyme (ACE) inhibitors

C: In Class II heart failure, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain. The symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics mobilize edematous fluid, act on the kidneys to promote excretion of sodium and water, and reduce preload and pulmonary venous pressure. Dietary restrictions of sodium aids in reducing edema. ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II, prevent the degradation of bradykinin and other vasodilatory prostaglandins, and increase plasma renin levels and reduce aldosterone levels. The net result is systemic vasodilation, reduced SVR, and impaired cardiac output.

When taking the nursing history of a child with cystic fibrosis, what piece of information about the child's newborn period would the nurse expect the mother to report? A. That the child required resuscitation in the delivery room B. That labor was longer than 24 hours C. That the child had a meconium ileus D. That labor was less than 4 hours

C: Meconium ileus in the newborn period is often the first indication of cystic fibrosis. The other options are not indications that a child has cystic fibrosis.

A client is admitted to a secure psychiatric inpatient unit for the treatment of bipolar I disorder. The nurse begins the intake assessment but the client stands up and begins to walk around the room and shouts, "You can't do this to me! Do you know who I am? I want out of here??" The best action of the nurse at this time focuses on which of the following? A. Obtaining the assessment information limited to 20 minutes at a time, allowing for rest periods. B. Providing the client with adequate food and fluids to maintain homeostasis. C. Providing client and self with a safe environment. D. Administering the prescribed PRN neuroleptic medication to prevent escalation of behavior.

C: Providing safety for the nurse and the client is in the primary concern immediately after admission when the client is in a manic state. This is because the client is likely to be labile, hostile, and uncooperative. The information given in this question suggests that the client's elevated and angry mood poses potential safety hazards for the client and the nurse. While obtaining the intake assessment data is important, this activity can be delayed until safety issues have been addressed. When the client demonstrates an elevated angry mood, it poses a potential safety risk for the client and the nurse. It is this risk that requires the nurse's immediate focus, not nutritional imbalance, even though this is often a nursing diagnosis for a client in a manic episode. There is nothing in the question that indicates that the client's behavior is so extreme that medications must be given. The nurse should remember that prn neuroleptic medication is considered to be a chemical form of restraint. Other less restrictive measures, such as environmental manipulation, must always be used before the nurse administers prn medication.

During client assessment, the nurse finds that the client is trembling and restless, blood pressure and pulse are elevated, and the client reports dry mouth, shortness of breath, inability to relax, loss of appetite, and an upset stomach. The nurse should conclude that this client is experiencing which level of anxiety? A. Mild B. Moderate C. Severe D. Panic

C: Severe is correct. The client's complaints indicate the fight-or-flight response that occurs at the severe level of anxiety. Mild anxiety is associated with the tension of everyday life; the person is alert, the perceptual field is increased, and learning is facilitated. In moderate anxiety, the perceptual field is narrowed, and low-level sympathetic arousal occurs. In panic anxiety, the perceptual field is narrowed, and low-level sympathetic arousal occurs.

The client with asthma has pronounced wheezing and signs of a possible impending asthma attack. Which intervention should the nurse implement first? A. Have the client cough and deep breathe. B. Prepare the client for possible intubation. C. Give an inhaled beta-2-adrenergic agonist. D. Notify the client's health care provider.

C: The client with asthma who is experiencing wheezing and an impending attack is best treated with inhaled beta-2 adrenergic agonist drugs such as albuterol. Oxygen and corticosteroids may also be used. Neither coughing nor deep breathing will stop the attack. Intubation is not effective in treating the underlying cause of the attack, which is an inflammatory response, and would not be a first-line intervention. The client should be given a resuce medication before the HCP is notified.

The client with COPD is in the third postoperative day following right-sided thoracotomy. During the day shift, the client required 10L of oxygen by mask to keep oxygen saturation levels greater than 88%. Which action should be taken by the evening shift nurse? A. Work to wean oxygen down to 3L by mask. B. Call respiratory therapy for a nebulizer treatment. C. Check the respiratory rate and notify the HCP. D. Administer a dose of the prescribed analgesic.

C: The evening shift nurse check the client's respiratory rate and report these abnormal findings to the HCP. Although uncommon, clients with COPD on high flow oxygen can lose their respiratory drive, or the client may have developed a respiratory complication. Working to wean oxygen by mask below 3L will cause retention of CO2; oxygen by mask generally should be set at 4L or greater. Although a nebulizer treatment may assist the client, the immediate need is to determine if the high flow oxygen is affecting the client's respiratory drive and to further determine the cause of the low oxygen saturations. Analgesics may assist the client, but the immediate need is to determine if the high flow oxygen is affecting the client's respiratory drive and to further determine the cause of the low oxygen saturations.

The nurse assisting the client with obstructive pulmonary disease would use which of the following statements to explain why dyspnea occurs? A. "Decreased surfactant causes many of your alveoli to collapse." B. "You have difficulty breathing in enough air." C. "Your airways open wider on inspiration, and trap air on expiration." D. "Your lung compliance is decreased."

C: The primary physiological alterations occurring with COPD are alveolar air trapping and alveolar hyperinflation, which lead to alveolar rupture and loss of area available for gas exchange. Decreased surfactant production is associated with ARDS, and is not a primary alteration of COPD. The difficulty that a COPD client has with breathing in is related to alveolar air trapping and hyperinflation; newly inhaled air has no place to enter. Lung compliance is decreased, but this is due to the alveolar air trapping and hyperinflation.

A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain and nausea, and has vomited several times. Based on these data, which nursing action would have the highest priority for intervention at this time? A. Manage anxiety. B. Restore fluid loss. C. Manage the pain. D. Replace nutritional loss.

C: The priority for the nursing care at this time is to decrease the client's severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the client's likelihood of developing further complications, such as severe fluid loss and inadequate nutrition. There are no data to suggest that the client is anxious.

A client is newly prescribed tramadol hydrochloride for chronic pain. The client is also taking fluoxetine 40mg daily for depression. Which statement by the nurse accurately explains the interactions between the two drugs? A. "There is no major concern with this drug combination." B. "Tramadol hydrochloride may decrease the effectiveness of fluoxetine." C. "This drug combination can increase the risk of serotonin syndrome." D. "Selective serotonin reuptake inhibitors should not be taken within 14 days of the last dose of tramadol hydrochloride."

C: Tramadol hydrochloride is a centrally acting analgesic that binds to mu-opioid receptors. It inhibits the reuptake of serotonin and norepinephrine in the central nervous system inhibits the reuptake of serotonin in the CNS. The combination of tramadol hydrochloride and fluoxetine can overactive central serotonin receptors resulting in serotonin syndrome, a life-threatening but rare event. There is a significant potential for drug interaction with this drug combination. Tramadol hydrochloride intensifies the action of fluoxetine. SSRIs should not be taken within 14 days of an MAOI (monoamine oxidsase inhibitor).

The nurse observes that the client, 3 days post MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia, and has generalized edema. Which action by the nurse is most appropriate? A. Administer high-flow oxygen. B. Encourage the client to rest more. C. Continue to monitor the client's heart rhythm. D. Compare the client's admission and current weight.

D. A complication of MI is HF. Signs of HF include fatigue, dyspnea, tachycardia, edema, and weight gain. Other signs include nocturia, skin changes, behavioral changes, and chest pain. There is no indication that the client is hypoxic and in need of high-flow oxygen. To treat the dyspnea, oxygen by nasal cannula would be appropriate. The fatigue caused by decreased cardiac output, impaired perfusion to vital organs, decreased tissue oxygenation, and anemia. Rest alone will not relieve the fatigue. Interventions are needed to improve cardiac output and tissue oxygenation. Continuing to monitor the cleint's heart rhythm without further assessment, will delay an appropriate intervention.

The nurse assess the client returning from a coronary angiogram in which the femoral artery approach was used. The client's baseline BP during the procedure was 130/72mmHg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication? A. BP 154/78mmHg B. Pedal pulses palpable at 1+ C. Left groin soft to palpation with 1cm ecchymotic area D. Apical pulse 132 beats per minute with an irregular-irregular rhythm

D. An apical pulse of 132 bpm with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. A slight elevation of BP could be related to pain at the incision site. It is not indicative of a complication without additional information. Usually pulses are palpable at 2+, but without additional baseline information on the client's pulses, this warrants monitoring but is not indicative in itself of a complication. A soft groin area where the puncture site is located is a normal finding. Ecchymosis (bruising) does not indicate a complication.

While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test will entail. Which should be the nurse's correct response? A. "A CTA uses magnetic fields to visualize the major vessels within your body." B. "A CTA is an invasive procedure that requires a small incision into an artery." C. "A CTA is a quick procedure that requires anesthesia for about 20 minutes." D. "A CTA is a scan that includes a contrast dye injection to visualize your arteries."

D. The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. A CTA uses X-ray beams, not magnetic fields, to visualize vessels. A CTA is a noninvasive procedure and does not require any incision. CTA does not require anesthesia.

The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the health care provider? A. Q waves B. Flipped T waves C. Peaked T waves D. ST segment elevation

D. The nurse should be most concerned about ST elevation because it indicates an evolving MI. The presence of Q waves indicates an MI over 24 hours old. Flipped T waves indicate myocardial ischemia. Peaked T waves may indicate hyperkalemia and are concerning, but ST segment elevation is more concerning.

The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse's priority intervention? A. Draw blood for cardiac enzymes STAT B. Call the cardiac catheterization laboratory C. Apply 1 inch of nitroglycerin paste topically D. Apply 4 liters of oxygen via nasal cannula

D. The nurse's priority intervention should be to increase oxygen to the heart muscle. Cardiac enzymes would be a likely intervention but the second intervention. Cardiac catheterization would be likely intervention but the third intervention respectively. Topical nitroglycerin is never given in an acute situation because its route has a much slower rate of absorption

Which order written by a physician should be a priority for a nurse caring for a client who sustained an unstable pelvic fracture in a motor vehicle accident? A. Urinalysis B. Blood alcohol level C. Computed tomography (CT) scan of the pelvis D. Two units of cross-matched whole blood

D: A type and cross-match needs to be completed prior to administering blood, which takes time. Significant blood loss occurs because the pelvis is a highly vascular area. Approximately 20% of persons with unstable fractures require more than 15 units of blood products within the first 24 hours of injury. The client is at risk for fat emboli. Free fat may show in the urine, but this is not a priority. The administration of analgesics and anesthetics is affected by blood alcohol results, but this is not priority. CT of the pelvis will determine the extent of the fracture, but is not the priority.

The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE) shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client? A. Ineffective Health Maintenance B. Impaired Skin Integrity C. Ineffective Individual Coping D. Ineffective Protection

D: All identified nursing diagnoses are of concern for a client with SLE. However, the results of the laboratory test demonstrate an increased risk for infection that is due to the disease process and/or possible treatment measures such as steroids and immunosuppressive agents. A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection.

A nurse is interpreting the serum laboratory report for a client in an emergency department. The history and reports reveal that the client has been diagnosed with bipolar disorder and receives lithium carbonate. Based on the findings of the serum laboratory report, which result would explain the client's condition of impaired consciousness, nystagmus, and seizures? Creatinine 0.8mg/dL BUN 10mg/dL Na++ 140mEq/L Lithium 3.8mEq/L A. Creatinine B. BUN C. Na++ D. Lithium

D: Symptoms of lithium toxicity appear at levels greater than 1.5mEq/L. At a level greater than 3.5mEq/L, the symptoms of toxicity include coma, nystagmus, seizures, and cardiovascular collapse. The results of kidney function tests (blood urea nitrogen {BUN} and creatinine) are within normal limits (normal BUN values are 5-25mg/dL; normal creatinine is 0.5-1.5mg/dL). Normal sodium (Na++) is 135-145mEq/L.

A diabetic client is admitted with a tentative diagnosis of osteomyelitis secondary to a wound on the ankle. The client's ankle is painful, red, swollen, and warm, and the wound is persistently draining. The client's temperature is 102.2F. Based on the client's status, which written physician's order should a nurse plan to defer until later? A. Obtain a wound culture. B. Administer ceftriaxone 1 gram IV q 12 hours. C. Apply splint to immobilize ankle. D. Begin teaching on self-administration of home IV antibiotics.

D: The nurse should defer teaching. Pain and an elevated temperature are barriers to learning. The wound culture should be obtained before antibiotics are started. Ceftriaxone is a third-generation cephalosporin used in treating bone infections. The usual doses range from 1 to 2 grams every 12 or 24 hours. Immobilizing with a splint helps to decrease pain and muscle spasms.

A nurse gives a medication without checking the medication administration record (MAR). When the nurse documents the medication given, the nurse notices that the medication was also given 15 minutes earlier by another nurse, resulting in the client receiving a double dose. The nurse notifies a supervisor and a physician of the event. Which action should the nurse who administer the second medication dose expect? A. Assignment of fewer clients at one time. B. Disciplinary action to the first nurse for giving the first dose. C. Disciplinary action possibly including suspension or termination. D. Completion of a variance report that would be reviewed by management.

D: The nurse who made the error should expect the completion of a variance report with review by management. A complete review of the situation needs to occur, including the type of medication, dose, outcome of the client, and steps of medication administration, including documentation. The nurse should not expect a change in client assignments. Although disciplinary action varies by organization, generally a pattern of incompetent actions must be demonstrated for suspension or termination.

A nurse gives a medication without checking the medication administration record (MAR). When the nurse documents the medication given, the nurse notices that the medication was also given 15 minutes earlier by another nurse, resulting in the client receiving a double dose. The nurse notifies a supervisor and a physician of the event. Which action should the nurse who administered the second medication dose expect? A. Assignment of fewer clients at one time. B. Disciplinary action to the first nurse for giving the first dose. C. Disciplinary action possibly including suspension or termination. D. Completion of a variance report that would be reviewed my management.

D: The nurse who made the error should expect the completion of a variance report with review by management. A complete review of the situation needs to occur, including the type of medication, dose, outcome of the client, and steps of medication administration, including documentation. The nurse should not expect a change in client assignments. Although disciplinary action varies by organization, generally a pattern of incompetent actions must be demonstrated for suspension or termination.

The client hospitalized with severe pneumonia asks the nurse, "Why do I need to spit in this sputum specimen container?" Which response is most appropriate? A. "It is used to identify the color and amount of your secretions." B. "It is used to differentiate between pneumonia and atelectasis." C. "It helps you clear secretions from your lungs into a container." D. "It helps select the most appropriate antibiotic for treatment."

D: The sputum specimen is obtained to culture for the causative organism. Testing sensitivities of the organism to various antibiotics aids in identifying the most effective antibiotic that should be used for treating the client's pneumonia. The color of secretions can be identified by having the client expectorate into a tissue; the amount of secretions cannot be determined. The client with atelectasis may get pneumonia, but generally this is not a test used to diagnose atelectasis. Although secretions are expectorated to obtain a sputum sample, the collection itself does not encourage further expectoration of secretions.

When providing discharge teaching for a client with uric acid calculi, the nurse should include an instruction to avoid which type of food? A. Cottage cheese B. Beets C. Spinach D. Organ meats

D: To control uric acid calculi, the client should avoid high-purine foods such as organ meats. Beets and spinach are high in oxalate. Cottage cheese is high in calcium.

The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply. A. "If I have chest pain, I should contact my physician immediately." B. "I should carry my nitroglycerin in my front pants pocket so it is handy." C. "If I have chest pain, I stop activity and chew a nitroglycerin tablet." D. "I should always take three nitroglycerin tablets, 5 minutes apart." E. "I plan to avoid being around people when they are smoking." F. "I plan on walking on most days of the week for at least 30 minutes."

E, F: Passive smoke can cause vasoconstriction and decrease blood flow velocity even in healthy young adults. The American Heart Association recommends exercising for 30 minutes on most days of the week. Medical attention is required only if pain persists, and then the client should call 911 rather than the physician because emergency treatment may be necessary. Nitroglycerin loses its potency if stored in warm, moist areas, making the client's pants pocket an undesirable location for storage. Stopping activity decreases the body's demand for oxygen. One nitroglycerin tablet should be taken sublingually, not chewed. The nitroglycerin dilates coronary arteries and increases oxygen to the myocardium. If pain is unrelieved, a second tablet should be taken 5 minutes later. If pain is relieved after one tablet, another tablet is not required. The standard dose for nitroglycerin is one tablet or spray 5 minutes apart until pain is relieved, to a maximum of three tablets or sprays.