Med Surg HESI Practice
The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfusion. The nurse suspects a transfusion reaction based on clinical presentation. Based on this scenario, select the initial clinical findings for each suspected condition. Choose one or more options. 1. Acute hemolytic reaction 1. Back pain 2. Diff. breathing 3. Rash 4. Urticaria (hives) 5. Pruritus 2. Allergic rxn 1. Back pain 2. Diff. breathing 3. Rash 4. Urticaria 5. Pruritus 3. Fluid overload 1. Back pain 2. Diff. breathing 3. Rash 4. Urticaria 5. Pruritus
1. Acute hemolytic reaction -back pain 2. Allergic rxn -rash -urticaria -pruritus 3. Fluid overload -difficulty breathing *Rationale:* There are different types of blood transfusion reactions, including fluid volume overload, allergic reaction, and acute hemolytic reaction. In general, signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. An acute hemolytic reaction is usually characterized by back pain initially. An allergic reaction is manifested by rash, urticaria, and pruritis as initial signs. Fluid volume overload often is noted by difficulty breathing in the early phase.
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations
Answer: 1 *Rationale*: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1.Age younger than 50 years 2.History of colorectal polyps 3.Family history of colorectal cancer 4.Chronic inflammatory bowel disease
Answer: 1 *Rationale*: Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.
The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1.Increased calcium level 2.Increased white blood cells 3.Decreased blood urea nitrogen level 4.Decreased number of plasma cells in the bone marrow
Answer: 1 *Rationale*: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes
Answer: 1 *Rationale:* A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased HR 3. Decreased HCT and increased urinary output 4. Increased RR and increased BP
Answer: 1 *Rationale:* A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.
The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The hx 2. The physical assessment 3. The nursing plan of care 4. The readmission risk assessment
Answer: 1 *Rationale:* Intellectually disabled clients tend to be poor historians, and it may be necessary to take more time to ask questions in a variety of different ways when collecting the history data. The physical assessment, nursing plan of care, and readmission risk assessment portions, although they rely on the history, take less time because they require less client questioning.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000mm^3 (35 x 10^9/L) 2. Sodium 150 mEq/L (150mmol/L) 3. Potassium 5.0 mEq/L (5.0mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine 1mg/dL (88.3 mcmol/L) 6. White blood cells 3000mm^3 (3.0 x 10^9/L)
Answer: 1, 2, 4, 6 *Rationale:* The normal values include the following: platelets 150,000 to 400,000 mm3 (150 to 400 × 109/L); sodium 135 to 145 mEq/L (135 to 145 mmol/L); potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); segmented neutrophils 62% to 68% (0.62 to 0.68); serum creatinine male: 0.6 to 1.2 mg/dL (53 to 106 mcmol/L); female: 0.5 to 1.1 mg/dL (44 to 97 mcmol/L); and white blood cells 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply 1.Nuts 2.Corn 3.Liver 4.Apples 5.Lentils 6.Bananas
Answer: 1, 3, 5 *Rationale*: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.
The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 1.Facial edema in the morning 2.Weight loss of 20 lb (9 kg) in 1 month 3.Serum calcium level of 12 mg/dL (3.0 mmol/L) 4.Serum sodium level of 136 mg/dL (136 mmol/L) 5.Serum potassium level of 3.4 mg/dL (3.4 mmol/L) 6.Numbness and tingling of the lower extremities
Answer: 1, 3, 6 *Rationale*: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level.
Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
Answer: 1,2,4,5,6 *Rationale:* Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.
Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump 2. Monitor urine output during administration 3. Prepare the med for bolus administration 4. Monitor the IV site for signs of infiltration or phlebitis 5. Ensure the med is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution
Answer: 1,2,4,5,6 *Rationale:* Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely, because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the primary health care provider if the urinary output is less than 30 mL/hr.
The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? 1.Dysuria 2.Hematuria 3.Urgency on urination 4.Frequency of urination
Answer: 2 *Rationale*: The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness
Answer: 1,2,4,6 *Rationale:* Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis
A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply. 1.Radiation 2.Chemotherapy 3.Increased fluid intake 4.Decreased oral sodium intake 5.Serum sodium level determination 6.Medication that is antagonistic to antidiuretic hormone
Answer: 1,2,5,6 *Rationale*: Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.
The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply 1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST segment 5.Widened QRS complexes
Answer: 1,3,5 *Rationale*: The client with chronic kidney disease is at risk for hyperkalemia. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? 1.Rupture of the bladder 2.The development of a vesicovaginal fistula 3.Extreme stress caused by the diagnosis of cancer 4.Altered perineal sensation as a side effect of radiation therapy
Answer: 2 *Rationale*: A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts, and if this occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options 1, 3, or 4.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1.Placing cool compresses on the affected arm 2.Elevating the affected arm on a pillow above heart level 3.Avoiding arm exercises in the immediate postoperative period 4.Maintaining an intravenous site below the antecubital area on the affected side
Answer: 2 *Rationale*: Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1.Clamp the surgical drain. 2.Change the dressing as prescribed. 3.Notify the surgeon. 4.Remove and replace the perineal packing.
Answer: 2 *Rationale*: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped, because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.
The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client? 1.Administer the iron at mealtimes. 2.Administer the iron through a straw. 3.Mix the iron with cereal to administer. 4.Add the iron to apple juice for easy administration
Answer: 2 *Rationale*: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The client should be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with cereal or other food items.
The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? 1.Lesbian persons 2.Men-who-have-sex-with-men (MSM) 3.Women-who-have-sex-with-women (WSW) 4.Female-to-male (FTM) transgender persons
Answer: 2 *Rationale*: MSM (men-who-have-sex-with-men) are at a higher risk for HIV and acquired immunodeficiency syndrome (AIDS). Although anyone who is sexually active should be counseled on prevention of sexually transmitted infection, the other populations mentioned are not at an increased risk for HIV/AIDS
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
Answer: 2 *Rationale:* Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.
The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the temp 2. Isolate the client in a private room 3. Check a complete set of vitals 4. Contact the primary health care provider
Answer: 2 *Rationale:* The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0° C (100.4° F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.
The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2.Positive culture results 3.Abnormal biopsy results 4.Wood's light examination indicative of infection
Answer: 2 *Rationale:* With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. 1.Lesion is painful to touch. 2.Lesion is highly metastatic. 3.Lesion is a nevus that has changes in color. 4.Skin under the lesion is reddened and warm to touch. 5.Lesion occurs in body areas exposed to outdoor sunlight.
Answer: 2, 3 *Rationale*: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent.
A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. 1.Flatulence 2.Peritonitis 3.Hemorrhage 4.Fistula formation 5.Bowel perforation 6.Lactose intolerance
Answer: 2,3,4 *Rationale*: Complications of intestinal tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor.
A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? 1."You can take aspirin as needed for headache." 2."You can drink beverages containing alcohol in moderate amounts each evening." 3."You need to consult with the primary health care provider (PHCP) before receiving immunizations." 4."It is fine to receive a flu vaccine at the local health fair without PHCP approval because the flu is so contagious."
Answer: 3 *Rationale*: Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the PHCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.
The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? 1.Anemia 2.Decreased platelets 3.Increased uric acid level 4.Decreased leukocyte count
Answer: 3 *Rationale*: Hyperuricemia is especially common following treatment for leukemias and lymphomas, because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family
Answer: 3 *Rationale*: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? 1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline 4.Intravenous infusion of sodium bicarbonate
Answer: 3 *Rationale*: The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS
The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week." 2."I change the appliance in the morning." 3."I empty the urinary collection bag when it is two-thirds full." 4."When I'm in the shower I direct the flow of water away from my stoma."
Answer: 3 *Rationale*: The urinary collection bag should be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma.
Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy? 1.Measure the client's abdominal girth. 2.Calculate the client's body mass index. 3.Measure the client's current weight and height. 4.Ask the client about his or her weight and height.
Answer: 3 *Rationale*: To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total BSA, which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished
Answer: 3 *Rationale:* Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? 1. An involuntary, rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
Answer: 3 *Rationale:* In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system disease.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)
Answer: 3 *Rationale:*A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.Fiery red skin with edema in the nailbeds 3.Black fingertips surrounded by an erythematous rash 4.A white color to the skin, which is insensitive to touch
Answer: 4 *Rationale*: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? 1.Diarrhea 2.Hypermenorrhea 3.Abnormal bleeding 4.Abdominal distention
Answer: 4 *Rationale*: Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency? 1.Headache 2.Dysphagia 3.Constipation 4.Electrocardiographic changes
Answer: 4 *Rationale*: Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.
The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1.Intact skin 2.Full-thickness skin loss 3.Exposed bone, tendon, or muscle 4.Partial-thickness skin loss of the dermis
Answer: 4 *Rationale*: In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1.Elevated hemoglobin level 2.Decreased reticulocyte count 3.Elevated red blood cell count 4.Red blood cells that are microcytic and hypochromic
Answer: 4 *Rationale*: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.
Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown and shoe protectors 4. Gloves, gown, goggles and mask or face shield
Answer: 4 *Rationale:* Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1. Milk 2. Chicken 3. Broccoli 4. Legumes
Answer: 4 *Rationale:* The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Legumes are especially rich in this vitamin. Other good food sources include nuts, whole-grain cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid.
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn
Answer: 4 *Rationale:* The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. 1.An irregularly shaped lesion 2.A small papule with a dry, rough scale 3.A firm, nodular lesion topped with crust 4.A pearly papule with a central crater and a waxy border 5.Location in the bald spot atop the head that is exposed to outdoor sunlight
Answer: 4,5 *Rationale*: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment
Answer: 4,5 *Rationale:* A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
