Med Surge Final Exam

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further teaching? A. I should increase my fiber intake B. I will need to avoid caffeinated beverages C. I'm going to learn some stress reduction techniques D. I can have exacerbations and remissions with Crohn's disease

A A low-fiber diet may be prescribed, especially during periods of exacerbation If stress increases the symptoms of the disease, the client is taught stress management. Client is taught to avoid GI stimulants containing caffeine and how to follow a high-calorie, high protein diet

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event B. The client is experiencing early signs of ischemic bowel C. The client should not have the NG tube removed D. This indicates inadequate preoperative bowel preparation

A As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.

The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding? A. Elevated creatinine level B. Decreased hemoglobin level C. Decreased red blood cell count D. Increased number of white blood cells in the urine A

A Creatinine level is the most specific lab test to determine renal function

The nurse provides instructions to a client about measures to treat IBS. Which statement by the client indicates a need for further teaching? A. I need to limit my intake of dietary fiber B. I need to drink plenty, at least 8-10 cups daily C. I need to eat regular meals and chew my food well D. I will take the prescribed medications because they will regulate my bowel patterns

A Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8-10 cups of liquid a day, and chewing food slowly help promote normal bowel function Medication therapy depends on the main symptoms of IBS

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain

A Early manifestation of dumping syndrome occur 5-30 mins after eating; early symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. B and C are incorrect manifestations D is a later manifestation

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? A. Malaise B. Dark stools C. Weight gain D. Left upper quadrant discomfort

A Fatigue and malaise are common in hepatitis A Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Stools will be light or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile duct.

A client is admitted to the emergency department following a fall from a horse, and the provider prescribed insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood in the urinary meatus. The nurse should take which action? A. Notify the provider B. Use a small-sized catheter and an anesthetic gel as a lubricant C. Administer parenteral pain medication before inserting the catheter D. Clean the meatus with soap and water before opening the catheterization kit

A Presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the provider knowing that the client should not be catheterized until the cause of bleeding is determined by diagnostic testing

A client with a hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? A. Lying recumbent following meals B. Consuming small, frequent, bland meals C. Taking H2-receptor antagonist medication D. Raising the head of the bed on 6-inch (15 cm) blocks

A The client usually experiences pain from reflux caused by ingestion of irritating foods, lying down following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, bland meals; the use of H2-receptor antagonists and antacids; and elevation of the thorax following meals and during sleep

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodiaylsis. Which finding indicates that the fistula is patent? A. Palpation of a thrill over the fistula B. Presence of a radial pulse in the left wrist C. Visualization of enlarged blood vessels at the fistula site D. Capillary refill less than 3 seconds in the nailbeds of the fingers on the left hand

A The presence of a thrill or sound of a bruit indicate patency of the fistula. Large visible blood vessels at the fistula site is a normal observation but not indicative of patency B & C do not indicate fistula patency

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply A. Check the level of drainage in the bag B. Reposition the client to his or her side C. Place the client in good body alignment D. Check the peritoneal dialysis system for kinks E. Contact the provider F. Increase the flow rate of the peritoneal dialysis solution

A, B, C, D If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage.

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. A. Coffee B. Chocolate C. Peppermint D. Nonfat milk E. Fried chicken F. Scrambled eggs

A, B, C, E Foods that decrease lower esophageal sphincter pressure and irritate the esophagus will increase reflux and exacerbate symptoms of Gerd and should therefore be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. D & F do not produce this effect.

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? Select all that apply A. Place the client on a cardiac monitor B. Notify the primary health care provider C. Put the client on NPO status except for ice chips D. Review the client's medications to determine whether any contain or retain potassium E. Allow an extra 500 mL of IV fluid intake to dilute the electrolyte concentration

A, B, D Normal potassium level is 3.5-5.0. Clients with hyperkalemia are at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify the provider and also review medications to determine whether any contain potassium or are potassium retaining. The client does not need to be put on NPO status Fluid intake is not increased bc it contributes to fluid overload and would the serum potassium level significantly

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. A. Maintain NPO status B. Encourage coughing and deep breathing exercises C. Give small, frequent high-calorie feedings D. Maintain the client in a supine and flat position E. Give hydromorphone IV as prescribed for pain F. Maintain IV fluids at 10 mL/hr to keep vein open

A, B, E Client is placed on NPO status to rest the pancreas and suppress GI secretions, so adequate IV hydration is necessary. Because abdominal pain is a prominent symptom, pain medications should be given as prescribed.

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply A. Administer oxygen to the client B. Continue dialysis at a slower rate after checking the lines for air C. Notify the provider and Rapid Response Team D. Stop dialysis, and turn the client on the left side with head lower than feet E. Bolus the client with 500 mL of normal saline to break up the air embolus

A, C, D If client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air embolus is in the right side of the heart, notify the prover and rapid response team, and administer oxygen as needed. Slowing the dialysis treatment or giving IV bolus will not correct the air embolism or prevent complications

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. A. Administer stool softeners as prescribed B. Instruct the client to limit fluid intake to avoid urinary retention C. Encourage a high-fiber diet to promote bowel movements without straining D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed E. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

A, C, D Nursing interventions after this procedure are aimed at pain management and avoiding of bleeding and incision rupture; stool softeners and high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. B & E are incorrect

The nurse discusses for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply A. Hemodialysis B. Peritoneal dialysis C. Kidney transplant D. Bilateral nephrectomy E. Intense immunosuppression therapy

A, C, D Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys, Peritoneal dialysis is not a treatment option for cysts. The condition does not respond to immunosuppression

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. A. Fever B. Positive Cullen's sign C. Complaints of indigestion D. Palpable mass in left upper quadrant E. Pain in the upper right quadrant after a fatty meal F. Vague lower right quadrant abdominal discomfort

A, C, E During an acute episode of cholecystitis, client may complain of severe right upper quadrant pain that radiates to the right shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. D and E are incorrect because they are inconsistent with anatomical location of the bladder. B is associated with pancreatitis

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? A. "CPM increases range of motion of the joint." B. "CPM strengthens the muscles of the leg." C. "CPM delivers analgesic agents directly into the joint." D. "CPM prevents injury by limiting flexion of the knee."

A. "CPM increases range of motion of the joint." CPM increases circulation and range of motion of the knee joint.

The home health nurse visits a client with a diagnosis of type 1 diabetes. The client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? A. "I need to stop my insulin" B. "I need to increase my fluid intake" C. "I need to monitor my blood glucose every 3-4 hours" D. "I need to call my provider because of these symptoms"

A. "I need to stop my insulin" When a client with diabetes is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the provider. The client should monitor the blood glucose level every 3-4 hours. The client should also monitor the urine for ketones during illness.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. "I sleep on three pillows each night." B. "My feet are bigger than normal." C. "My pants don't fit around my waist." D. "I don't have the same appetite I used to."

A. "I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

The nurse is caring for a client who had a permanent pacemaker surgically placed and is now ready for discharge. What statement made by the client indicates the need for more education? A. "We will be getting rid of our microwave oven so it will not affect my pacemaker." B. "I will check my pulse every day and report to the doctor if the rate is below the pacemaker setting." C. "I will call the doctor if my incision becomes swollen and red." D. "I will avoid any large magnets that may affect my pacemaker."

A. "We will be getting rid of our microwave oven so it will not affect my pacemaker." Permanent pacemaker generators have filters that protect them from electrical interference from most household devices, motors, and appliances, so the client can keep the microwave oven. Clients are taught to check pulses daily, avoid large magnets, and report any incisional redness or swelling.

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection? A. 10 to 15 minutes B. 30 to 40 minutes C. 1 to 2 hours D. 3 hours

A. 10 to 15 minutes The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the provider and prepares to implement which priority interventions? Select all that apply. A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide D. Administering morphine sulfate IV E. Transporting the client to the coronary care unit F. Placing the client in a low-Fowl'er's side-lying position

A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide D. Administering morphine sulfate IV Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. Oxygen is always prescribed, and the client is placed in high-Fowler's position to ease the work of breathing. Furosemide will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately, and also reduces the work of breathing

Which would the nurse stress as a lifelong necessity for a client managing infective endocarditis? A. Antibiotic therapy B. Antihypertensive medication C. Exercise regimen D. Potassium replacement

A. Antibiotic therapy The nurse informs the client that periodic antibiotic therapy is a lifelong necessity because the client will be vulnerable to diseases for the rest of his life. Antihypertensive therapy is not always prescribed. Limited activity is stressed. Potassium replacement is typical when combined with diuretic therapy.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? A. Arousable, sinus rhythm, blood pressure 116/72 mmHg B. Nonarousable, sinus rhythm, BP 88/60 mmHg C. Arousable, marked bradycardia, BP 86/54 mmHg D. Nonarousable, supraventricular tachycardia, BP 122/60 mmHg

A. Arousable, sinus rhythm, blood pressure 116/72 mmHg

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? A. Atelectasis B. Elevated blood glucose level C. Hyperkalemia D. Urinary tract infection (UTI)

A. Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? A. During the preoperative period B. Upon arrival to the surgical unit C. Following the surgical procedure D. At the time of discharge instructions

A. During the preoperative period The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time.

The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client? A. Dyspnea, fatigue, and weakness B. Dizziness, syncope, and palpitations C. Orthopnea, angina, and pulmonary edema D. Dry cough, wheezing, and hemoptysis

A. Dyspnea, fatigue, and weakness Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitation can cause dyspnea, fatigue, and weakness. Dizziness, syncope, and palpitations are usually symptoms of mitral valve prolapse. Orthopnea, angina, and pulmonary edema are more likely with aortic stenosis. Dry cough, wheezing, and hemoptysis are more likely with mitral stenosis.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? A. It can develop into ventricular fibrillation at any time. B. It is almost impossible to convert to a normal rhythm. C. It is uncomfortable for the client, giving a sense of impending doom. D. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

A. It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-threatning dysrhthmia that results from an irritable ectopic focus that takes over as the pacemaker of the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Clients frequently report a feeling of impending doom.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? A. Lower lumbar B. Upper lumbar C. Thoracic D. Cervical

A. Lower lumbar The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? A. Monitor blood pressure frequently B. Encourage the client to ambulate in room C. Titrate milrinone rate slowly before discontinuing D. Teach the client about safe home use of the medication

A. Monitor blood pressure frequently Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.

A client presents to the ED reporting anxiety and chest pain after shoveling heavy snow that morning. The client says that nitroglycerin has not been taken for months but upon experiencing this chest pain did take three nitroglycerin tablets. Although the pain has lessened, the client states, "They did not work all that well." The client shows the nurse the nitroglycerin bottle; the prescription was filled 12 months ago. The nurse anticipates which order by the physician? A. Nitroglycerin SL B. Chest x-ray C. Serum electrolytes D. Ativan 1 mg orally

A. Nitroglycerin SL Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired, and the nurse should anticipate administering nitroglycerin to assess whether the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the client's chest pain.

A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse? A. Numbness and weakness in the left arm B. Nausea and severe headache C. Chest pain score of 3 (on a scale of 1 to 10) D. Urine output of 40 mL over the past hour

A. Numbness and weakness in the left arm Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required. Urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? A. P wave B. PR interval C. QRS complex D. T wave

A. P wave The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. A. Pain B. Constricting dressings C. Abdominal distention D. Obesity E. Effects of analgesics and anesthesia

A. Pain B. Constricting dressings C. Abdominal distention D. Obesity Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.

Which intervention should the nurse implement with the client who has an external fixator? Select all that apply. A. Perform pin care as ordered. B. Turn the clamps by one-half every day. C. Supervise the client during transfers. D. Perform neurovascular assessment. E. Inspect pin sites for signs of infection.

A. Perform pin care as ordered. C. Supervise the client during transfers. D. Perform neurovascular assessment. E. Inspect pin sites for signs of infection. Nursing care of the client with an external fixator includes pin care, inspection of pin sites for signs of infection, neurovascular assessment, and supervision of the client during transfers. The nurse does not adjust the clamps on the external fixator frame; this is the responsibility of the physician.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? A. Peripheral pulses every 15 minutes after surgery B. Ankle-arm indices every 12 hours C. Blood pressure every 2 hours D. Color of the leg every 4 hours

A. Peripheral pulses every 15 minutes after surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

The nurse is monitoring a client newly diagnosed with diabetes for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? A. Polyuria B. Diaphoresis C. Pedal edema D. Decreased respiratory rate

A. Polyuria Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes; however, i does not predispose a client to the chronic complications of diabetes. Therefore, option B can be eliminated because this finding is characteristic of hypoglycemia. Options C and D are not associated with diabetes.

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)? A. Presence of islet cell antibodies B. Obesity C. Rare ketosis D. Requirement for oral hypoglycemic agents

A. Presence of islet cell antibodies Individuals with type 1 diabetes often have islet cell antibodies and are usually thin or demonstrate recent weight loss at the time of diagnosis. These individuals are prone to experiencing ketosis when insulin is absent and require exogenous insulin to preserve life.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? A. Pulmonary congestion B. Pedal edema C. Nausea D. Jugular venous distention

A. Pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? A. Risk for perioperative positioning injury related to positioning in the OR B. Risk of latex allergy response related to possible exposure in the OR environment C. Disturbed sensory perception related to the effects of general anesthesia D. Anxiety related to ineffective coping with surgical concerns

A. Risk for perioperative positioning injury related to positioning in the OR Pressure ulcers, nerve and blood vessel damage, impeded respiration, hyperextended joints, and discomfort are risks associated with the prolonged, awkward positioning required for some surgical procedures. The other choices are also potential nursing diagnoses or concerns related to surgery, but they are not related to the duration of the surgery.

A client's ECG strip shows atrial and ventricular rates of 110 bpm. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse interpret this rhythm? A. Sinus tachycardia B. Sinus bradycardia C. Sinus dysrhythmia D. Normal sinus rhythm

A. Sinus tachycardia

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an fibrillatory waves before each QRS complex. The nurse interprets that the client is experiencing which rhythm? A. Sinus tachycardia B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia

A. Sinus tachycardia

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. The nurse should assess for which associated signs or symptoms? Select all that apply. A. Syncope B. Dizziness C. Palpitations D. Hypertension E. Flat neck veins

A. Syncope B. Dizziness C. Palpitations

Which clinical manifestation is often the earliest sign of malignant hyperthermia? A. Tachycardia (heart rate >150 beats per minute) B. Hypotension C. Elevated temperature D. Oliguria

A. Tachycardia (heart rate >150 beats per minute) Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? A. The client demonstrates ability to tolerate more activity without chest pain. B. The client exhibits a heart rate above 100 beats/minute. C. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. D. The client states that sublingual nitroglycerin usually relieves his chest pain.

A. The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How should the nurse interpret the client's neurovascular status? A. The neurovascular status is normal because of increased blood flow through the leg B. The neurovascular status is moderately impaired and the surgeon should be called C. The neurovascular status is slightly deteriorating and should be monitored for another hour D. The neurovascular status shows adequate arterial flow, but venous complications are arising

A. The neurovascular status is normal because of increased blood flow through the leg

The nurse is monitoring a client who was diagnosed with type 1 diabetes and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. A. Tremors B. Anorexia C. Irritability D. Nervousness E. Hot, dry skin F. Muscle cramps

A. Tremors C. Irritability D. Nervousness Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option E is more likely to occur with hyperglycemia. Options B and F are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger.

The nurse is teaching a client about hypertension and the effects on the left ventricle. What diagnostic test will the nurse describe? A. echocardiography B. computed tomographic (CT) scan C. fluorescein angiography D. positron emission tomography (PET) scan

A. echocardiography Echocardiography will reveal an enlarged left ventricle. Fluorescein angiography reveals leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood pressure. A CT scan reveals structural abnormalities.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food". What instruction should the nurse give to the client to provide adequate nutrition? A. Select foods high in fat B. Increase intake of fluids, including juices C. Eat a good supper when anorexia is not as severe D. Eat less often, preferably only 3 large meals daily

B An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is important. Although no special diet is required to treat viral hepatitis, it is generally recommended that client consume a low-fat diet due to decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Often, appetite is better in the morning so it is better to eat a good breakfast.

The provider has determined that a client has contracted hepatitis A based on flu-like symptoms on jaundice. Which statement made by the client supports this medical diagnosis? A. I have had unprotected sex with multiple partners B. I ate shellfish about 2 weeks ago at a local restaurant C. I was an IV drug abuser in the past and shared needles D. I had a blood transfusion 30 years ago after major abdominal surgery

B Hepatitis A is transmitted via the fecal-oral route by contaminated food or water (especially improperly cooked shellfish) or infected food handlers Hepatitis B, C, and D are transmitted via infected bodily fluids such as blood or genital secretions.

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the provider? A. Stoma is beefy red and shiny B. Purple discoloration of the stoma C. Skin excoriation and the stoma D. Semiformed stool noted in the ostomy pouch

B Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require immediate attention as purple discoloration of the stoma Semiformed stool is a normal finding

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? A. "After age 40, height may show a gradual decrease as a result of spinal compression" B. "After menopause, the body's bone density declines, resulting in a gradual loss of height." C. "There may be some slight discrepancy between the measuring tools used." D. "The posture begins to stoop after middle age."

B. "After menopause, the body's bone density declines, resulting in a gradual loss of height." The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

A client with type 1 diabetes who takes NPH insulin daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? A. "I should not exercise since I am taking insulin" B. "The best time for me to exercise is after breakfast" C. "The best time for me to exercise is mid to late afternoon" D. "NPH is a basal insulin, so I should exercise in the evening"

B. "The best time for me to exercise is after breakfast" Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10-15 g carbohydrate snack, and they should check their blood glucose level before exercising. Option A is incorrect because clients with diabetes should exercise, though they should check with their provider before starting a new exercise program. Option C is incorrect; clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4-12 hours; therefore, afternoon exercise takes place during the peak of the medication. Option D is incorrect; NPH insulin is an intermediate-acting insulin, not a basal insulin.

A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in the left chest. The client is planning to go rifle hunting. How should the nurse respond? A. "Enjoy your hunting trip." B. "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." C. "Being that close to a rifle might make your ICD fire." D. "You'll need to take an extra dose of your antiarrhythmic before you shoot."

B. "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." The recoil from the rifle can damage the ICD, so the client should be warned against shooting a rifle with the left hand. Close proximity to a rifle won't cause the ICD to fire inadvertently. The client shouldn't take an extra dose of an antiarrhythmic.

After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm? A. 0.05 and 0.1 seconds. B. 0.12 and 0.2 seconds. C. 0.15 and 0.3 seconds. D. 0.25 and 0.4 seconds.

B. 0.12 and 0.2 seconds. The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. It measures the time needed for conduction through the AV node before ventricular depolarization. The normal range in adults is 0.12 to 0.2 seconds.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? A. Anxiety level of the client and family B. Activation status and settings of the device C. Presence of a MedicAlert card for the client to carry D. Knowledge of restrictions on postdischarge physical activity

B. Activation status and settings of the device

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of IV fluid. Urine output for the subsequent hour was 25 mL. Daily lab results indicate that the BUN is 45 mg/dL, and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? A. Hypovolemia B. Acute kidney injury C. Glomerulonephritis D. Urinary tract infection

B. Acute kidney injury The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased BUN and creatinine levels.

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? A. Pituitary B. Adrenal C. Thyroid D. Parathyroid

B. Adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? A. Blood pressure B. Airway patency C. Oxygen flow rate D. Level of consciousness

B. Airway patency

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? A. Discuss the risk for infection caused by wearing the ring. B. Allow the client to wear the ring and cover it with tape. C. Notify the surgeon to cancel surgery. D. Remove the ring once the client is sedated.

B. Allow the client to wear the ring and cover it with tape. Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring. The surgery should not be canceled and the ring should not be removed without permission.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? A. Call a code. B. Call the health care provider. C. Check the client's status and lead placement. D. Press the recorder button on the electrocardiogram console.

B. Call the health care provider. Sudden loss of ECG complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment

A client with a diagnosis of DKA is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. A. Increase in pH B. Comatose state C. Deep, rapid breathing D. Decreased urine output E. Elevated blood glucose level

B. Comatose state C. Deep, rapid breathing E. Elevated blood glucose level High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. A is incorrect because in acidosis the pH would be low D is incorrect because a high serum glucose level will result in an osmotic diuresis and the client will experience polyuria

A client with diabetes mellitus demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? A. Administer a sedative B. Convey empathy, trust, and respect toward the client C. Ignore the signs and symptoms of anxiety so that they will soon disappear D. Make sure the client knows all the correct medical terms to understand what is happening

B. Convey empathy, trust, and respect toward the client Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? A. Assisting the surgeon B. Coordinating the surgical team C. Setting up the sterile tables D. Passing instruments

B. Coordinating the surgical team The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds

B. Crackles Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum; auscultation reveals crackles

Informed consent from the surgical client is essential in all of the following categories of surgery except: A. Elective surgery B. Emergent surgery C. Required surgery D. Urgent surgery

B. Emergent surgery In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? A. Pulmonary embolism B. Heart failure C. Cardiac tamponade D. Tension pneumothorax

B. Heart failure A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hyponatremia

B. Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.

The nurse is preparing a plan of care for a client with diabetes who has hyperglycemia. The nurse places priority on which client problem? A. Lack of knowledge B. Inadequate fluid volume C. Compromised family coping D. Inadequate consumption of nutrients

B. Inadequate fluid volume An increased blood glucose level will cause the kidneys to excrete the glucose in urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? A. Glipizide B. Metformin C. Repaglinide D. Regular insulin

B. Metformin Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis.

The nurse is monitoring a client with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? A. Administer the prescribed medication B. Notify the provider C. Call and ask the operating room team to perform surgery as soon as possible D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen

B. Notify the provider On the basis of the signs and symptoms presented, the nurse should suspect peritonitis and notify the provider. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis bc of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice; however surgeon and provider would perform surgery earlier than prescheduled time.

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position? A. Flat on his back with his arms next to his sides B. On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle C. On his back, with his legs and thighs flexed at right angles D. On his side, with his uppermost leg adducted and flexed at the knee

B. On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is held in position by padded shoulder braces.

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? A. Keep the extremities elevated slightly. B. Participate in a regular walking program. C. Use a heating pad to promote warmth. D. Massage the calf muscles if pain occurs.

B. Participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? A. Pleurisy B. Pneumonia C. Hypoxemia D. Pulmonary edema

B. Pneumonia Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? A. Registered nurse first assistant B. Scrub role C. Circulating nurse D. Anesthetist

B. Scrub role The scrub role includes performing a surgical hand scrub, setting up the sterile tables, and preparing sutures, ligatures, and special equipment. The circulating nurse manages the operating room and protects patient safety. The registered nurse first assistant functions under the direct supervision of the surgeon. Responsibilities may include handling tissue, providing exposure of the operative field, suturing, and maintaining hemostasis. The anesthetist administers the anesthetic medications.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? A. Serum glucose level of 450 mg/dl B. Serum glucose level of 52 mg/dl C. Serum calcium level of 8.9 mg/dl D. Serum calcium level of 10.2 mg/dl

B. Serum glucose level of 52 mg/dl Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. A. Polyuria B. Shakiness C. Palpitations D. Blurred vision E. Lightheadedness F. Fruity breath odor

B. Shakiness C. Palpitations E. Lightheadedness Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglyecmia and would indicate the need for food or glucose. Polyuria, blurred vision, and fruity breath odor are manifestations of hyperglycemia

A patient is scheduled for a bone marrow biopsy. The nurse explains to the family that the bone marrow is located mainly in four areas. She tells the family that the site to be used would be the: A. Humerus. B. Sternum. C. Femur. D. Scapula.

B. Sternum. The sternum, along with the ilium, vertebrae, and ribs are responsible for producing red blood cells and are used for bone marrow aspiration sites.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? A. Arterial insufficiency B. Venous insufficiency C. Neither venous nor arterial insufficiency D. Trauma

B. Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? A. Pulsus paradoxus B. Ventricular dysrhythmias C. Rising diastolic blood pressure D. Falling central venous pressure

B. Ventricular dysrhythmias Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock include low blood pressure and tachycardia.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is A. air plethysmography. B. contrast phlebography. C. lymphangiography. D. lymphoscintigraphy.

B. contrast phlebography Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine A. increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. B. decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. C. increases the heart rate, constricts arterioles, and increases the heart's ability to eject blood. D. decreases circulating blood volume.

B. decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. The nurse recommends smoking cessation for clients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Reduced oral fluids decrease the circulating blood volume.

The nurse is caring for a client with heart failure who is receiving a diuretic medication. What implementation will help the nurse evaluate the client's response of the medication? A. using mechanical ventilation B. measuring intake and output C. obtaining cardiac output with a pulmonary catheter D. asking the client about comfort level

B. measuring intake and output To evaluate response to a diuretic, intake and output are monitored. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. Asking the client about comfort level will not assess urinary output.

A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia does the client have? A. atrial bradycardia B. sinus bradycardia C. heart block D. none

B. sinus bradycardia Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (less than60 beats/minute) rate.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain relieved by food intake D. Pain radiating down the right arm

C A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer does not usually experience weight loss of nausea and vomiting. These symptoms are more common in gastric ulcers.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. how should the nurse assess for its presence? A. Dorsiflex the client's foot B. Measure the abdominal girth C. Ask the client to extend the arms D. Instruct the client to lean forward

C Asterixis = irregular flapping movements of the fingers and wrists when hands and arms are outstretched, with palms down, wrist bent up, and fingers spread. Most common and reliable sign that hepatic encephalopathy is developing.

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? A. Pyelonephritis B. Glomerulonephritis C. Trauma to the bladder or abdomen D. Renal cancer in the client's family

C Bladder trauma should be considered or suspected in the client with low abdominal pain and hematuria. Pyelonephritis and glomerulonephritis would be accompanied by a fever. Renal cancer would now cause pain that is felt in the low abdomen but rather the flank area.

The nurse is assessing a client 24 hours after a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. Clamp the T-tube B. Irrigate the T-tube C. Document the findings D. Notify the provider

C Drainage after cholecystectomy is initially bloody and then turns a greenish-brown color. The drainage is measured as output. Expected drainage is 500-1000 mL per day

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? A. Ambulate following a meal B. Eat high-carbohydrate foods C. Limit the fluids taken with meals D. Sit in a high-Fowler's position during meals

C Early manifestations of dumping syndrome occur within 30 mins of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to sit down. The nurse should instruct the client to decrease the amount of fluid taken at meals, including fluids such as fruit nectars. The nurse should instruct the client to avoid high-carbohydrate foods and to assume a low-Fowler's position during meals. The nurse should also instruct the patient to lie down for 30 minutes after eating to delay gastric emptying.

The nurse is caring for a client following a gastrojejunostomy. Which postoperative prescription should the nurse question & verify? A. Leg exercises B. Early ambulation C. Irrigating the nasogastric tube D. Coughing and deep breathing exercises

C In a gastrojejunostomy, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery unless specifically prescribed. Other options are all appropriate interventions

The nurse is reviewing laboratory results for a client with cirrhosis and notes the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? A. Roast pork B. Cheese omelet C. Pasta with sauce D. Tuna fish sandwich

C Normal serum ammonia interval is 10-80 mcg/dL; foods high in protein should be avoided, as the liver breaks down protein which results in the formation of ammonia

The nurse has taught the client about upcoming endoscopic retrograde cholangiopancreatography (ERCP). The nurse determines that the client needs further information if the client makes which statement? A. I know I must sign the consent form B. I hope the throat spray keeps me from gagging C. I'm glad i don't have to lie still for this procedure D. I'm glad some intravenous medication will be given to relax me

C The client does have to lie still for ERCP, which takes about 1 hour to perform. The client has to sign a consent form Intravenous medication is given to relax the client An anesthetic spray is used to help keep the client from gagging as the endoscope is passed

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature 101.2 F. Which nursing action is most appropriate? A. Encourage fluid intake B. Continue to monitor vital signs C. Notify the primary health provider D. Monitor the site of the shunt for infection

C A temp of 101.2 is significantly elevated and may indicate infection

A client with severe back pain and hematuria is found to have hydronephrosis due to urilithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply A. Peritoneal dialysis B. Analysis of urinary stone C. IV opioid analgesics D. Insertion of a nephrostomy tube E. Placement of a ureteral stent with ureteroscopy

C, D Urolithiasis is the condition that occurs when a stone forms in the urinary system. Hydronephrosis develops when the stone has blocked the ureter and urine backs up and dilates & damages the kidney. Priority treatment is to allow the urine to drain and relieve obstruction in the ureter

A client comes to the emergency department complaining of visual changes and severe headache and denies past medical history. The nurse measures the client's blood pressure at 210/120 mm Hg. What question will the nurse ask to explore the hypertension situation? A. "What have you eaten in the last 24 hours?" B. "Do you smoke cigarettes?" C. "Do you have hypertension in your family?" D. "Did you try an over-the-counter medication?"

C. "Do you have hypertension in your family?" Asking the client about family history is a pertinent question to help relate the hypertension. Untreated hypertension is the most common cause of malignant hypertension (hypertensive emergency). Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as those that occur with monoamine oxidase inhibitors and aged cheeses).

Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice? A. "Your insulin will begin to act in 15 minutes." B. "You should expect your insulin to reach its peak effectiveness by 12 noon if you take it at 8:00 AM." C. "You should take your insulin after you eat breakfast and dinner." D. "Your insulin will last 8 hours, and you will need to take it three times a day."

C. "You should take your insulin after you eat breakfast and dinner." NPH (Humulin N) insulin is an intermediate-acting insulin that has an onset of 2 to 4 hours, a peak effectiveness of 6 to 8 hours, and a duration of 12 to 16 hours. See Table 30-3 in the text.

The nurse expects informed consent to be obtained for insertion of: A. An indwelling urinary catheter B. An intravenous catheter C. A gastrostomy tube D. A nasogastric tube

C. A gastrostomy tube Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

Which statement is true regarding gestational diabetes? A. It occurs in most pregnancies. B. Onset usually occurs in the first trimester. C. A glucose challenge test should be performed between 24 and 28 weeks. D. There is a low risk for perinatal complications.

C. A glucose challenge test should be performed between 24 and 28 weeks. A glucose challenge test should be performed between 24 and 48 weeks in women at average risk. It occurs in 2% to 5% of all pregnancies. Onset usually occurs in the second or third trimester. There is an above-normal risk for perinatal complications.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A. Muffled heart sounds B. Client reports dyspnea C. A rise in blood pressure D. Jugular vein distention

C. A rise in blood pressure

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement? A. Notify the health care provider. B. Document that the pericarditis has resolved. C. Ask the patient to lean forward and listen again. D. Prepare to insert a unilateral chest tube.

C. Ask the patient to lean forward and listen again. The most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border. Having the patient lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. These assessment data are not life-threatening and do not require a call to the health care provider. The nurse should try multiple times to auscultate the friction rub before deciding that the rub is gone. Chest tubes are not the treatment of choice for not hearing friction rubs.

The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? A. Assess the client's mental and emotional status. B. Assess the skin of the client. C. Assess the characteristics of chest pain. D. Assess for any kind of drug abuse.

C. Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's first priority ? A. Notify the health care provider to request an increase in the warfarin dose. B. Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the results. C. Assess the client for bleeding and notify the health care provider of the results. D. Notify the next nurse on afternoon shift to hold the evening dose of warfarin.

C. Assess the client for bleeding and notify the health care provider of the results. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the health care provider of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a health care provider's order. The nurse should notify the health care provider before holding a medication scheduled to be administered during another shift.

A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed? A. Placement of an autograft valve B. Antibiotic therapy C. Balloon percutaneous valvuloplasty D. Placement of a xenograft valve

C. Balloon percutaneous valvuloplasty Definitive treatment for aortic stenosis is surgical replacement of the aortic valve. Clients who are symptomatic, but not good surgical candidates may benefit from a one or two balloon percutaneous valvuloplasty. Antibiotic therapy will not open the valve. The client does not want to have a valve replacement of any kind.

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? A. Arterial pH 7.25 B. Plasma bicarbonate 12 mEq/L C. Blood glucose level 1,100 mg/dl D. Blood urea nitrogen (BUN) 15 mg/dl

C. Blood glucose level 1,100 mg/dl HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? A. Blood urea nitrogen (BUN) B. Creatinine C. Brain natriuretic peptide (BNP) D. Complete blood count (CBC)

C. Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? A. Elevate the legs periodically for at least an hour. B. Avoid foods with iodine. C. Elevate the legs periodically for at least 15 to 20 minutes. D. Refrain from sexual activity for a week.

C. Elevate the legs periodically for at least 15 to 20 minutes. The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

During a follow-up visit 3 months after a new diagnosis of type 2 diabetes, a client reports exercising and following a reduced-calorie diet. Assessment reveals that the client has only lost 1 pound and did not bring the glucose-monitoring record. Which value should the nurse measure? A. Fasting blood glucose level B. Glucose via a urine dipstick test C. Glycosylated hemoglobin level D. Glucose via an oral glucose tolerance test

C. Glycosylated hemoglobin level Glycosylated hemoglobin is a blood test that reflects the average blood glucose concentration over a period of approximately 2 to 3 months. When blood glucose is elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycosylated hemoglobin level becomes.

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950 mg/dL. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL. The nurse would next prepare to administer which medication? A. An ampule of 50% dextrose B. NPH insulin subcutaneously C. IV fluids containing dextrose D. Phenytoin for the prevention of seizures

C. IV fluids containing dextrose Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose levels to 250 to 300 mg/dL, the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. 50% dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

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 provider's prescription? A. Endotracheal intubation B. 100 units of NPH insulin C. IV infusion of normal saline D. IV infusion of sodium bicarbonate

C. IV infusion of normal saline The primary goal of treatment in HHS is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in 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.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? A. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. B.Store the drug in a cool, well-lit place. C. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. D. Restrict alcohol intake to two drinks per day.

C. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

The nurse is reviewing an ECG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds and QRS complexes measure 0.06 seconds. The overall heart rate is 64 bpm. Which action should the nurse take? A. Check vital signs B. Check laboratory values C. Monitor for any rhythm change D. Notify the provider

C. Monitor for any rhythm change Normal sinus rhythm is defined as a regular rhythm, with overall rate of 60-100 bpm. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds.

The nurse positions the client in the lithotomy position in preparation for A. Renal surgery B. Pelvic surgery C. Perineal surgery D. Abdominal surgery

C. Perineal surgery The client undergoing perineal surgery will be placed in the lithotomy position.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? A. Necrotic and hard B. Pale yet able to blanch with digital pressure C. Pink to red and soft, noting that it bleeds easily D. White with long, thin areas of scar tissue

C. Pink to red and soft, noting that it bleeds easily Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? A. Causative factors, such as caffeine B. Sensation of fluttering or palpitations C. Precipitating factors, such as infection D. Blood pressure and oxygen saturation

C. Precipitating factors, such as infection Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoexmia; any number of physiological stressors, such as infection, illness surgery, or trauma; and intake of caffeine, nicotine, and alcohol

The nurse performs a physical assessment on a client with type 2 diabetes. Findings include a fasting blood glucose level of 70 mg/dL, temperature of 101 degrees F, pulse of 82 bpm, respirations of 20 breaths per minute, and blood pressure of 118/68 mmHg. Which finding would be the priority concern to the nurse A. Pulse B. Respiration C. Temperature D. Blood pressure

C. Temperature In the client with type 2 diabetes, an elevated temperature may indicate infection. Infection is a leading cause of HHS in the client with type 2 diabetes. The other findings are within normal limits.

The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed? A. The leg will look as it did prior to the cast being applied. B. The leg will look moist and will have small bumps that will go away in a few days. C. The skin may be covered with a yellowish crust that will shed in a few days. D. The leg strength is enforced by the wearing of the cast.

C. The skin may be covered with a yellowish crust that will shed in a few days. Once the cast is off, the skin appears mottled and may be covered with a yellowish crust composed of accumulated body oil and dead skin. The client usually sheds this residue in a few days. The leg will not look as it did prior to the cast but will regain the same shape and status as the other leg. There should be no bumps underneath the cast. The leg may be weak and stiff for some time after the cast is removed, not stronger.

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? A. Arthrodesis B. Hemiarthroplasty C. Total arthroplasty D. Osteotomy

C. Total arthroplasty A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? A. A biopsy B. A face-lift C. Tumor excision D. Placement of gastrostomy tube

C. Tumor excision An example of a curative surgical procedure is tumor excision. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? A. Asystole B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

C. Ventricular fibrillation

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 bpm. The nurse determines that the client is experiencing which dysrhythmia? A. Sinus tachycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions

C. Ventricular tachycardia Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute

The nurse is caring for a client with second-degree atrioventricular block, Type I with symptomatic bradycardia. What is the most likely medication the nurse will administer? A. nadolol B. diltiazem C. atropine sulfate D. atenolol

C. atropine sulfate Atropine blocks acetylcholine at parasympathetic neuroeffector sites and blocks vagal stimulation. The client will be treated with an anticholinergic that blocks the effects of the vagal nerve. Atenolol and nadolol are beta blockers that are used for chest pain, myocardial infarction, and hypertension. Diltiazem is a calcium channel blocker used to treat angina or slow the heart rate.

The primary objective in the immediate postoperative period is A. controlling nausea and vomiting. B. relieving pain. C. maintaining pulmonary ventilation. D. monitoring for hypotension.

C. maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating A. dyspnea upon exertion. B. hyperpnea. C. orthopnea. D. paroxysmal nocturnal dyspnea.

C. orthopnea. Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

According to the classification of hypertension diagnosed in older adults, hypertension that can be attributed to an underlying cause is termed A. primary. B. essential. C. secondary. D. isolated systolic.

C. secondary. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromocytoma). Primary, or essential, hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which client surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? A. nutrient deficiencies B. respiratory complications C. wound healing D. liver dysfunction

C. wound healing In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance

D A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by IV infusion until the client can tolerate a diet orally Intestinal obstruction is a less frequent complication Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period

A week after kidney transplantation, a client develops a temperature of 101 F, BP is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? A. Antibiotic therapy B. Peritoneal dialysis C. Removal of the transplanted kidney D. Increased immunosuppression therapy

D Acute rejection often occurs within 1 week after transplant but can occur any time.

The nurse is collecting data from a client. Which symptom described is a characteristic of an early symptom of benign prostatic hyperplasia? A. Nocturia B. Scrotal edema C. Occasional constipation D. Decreased force in the stream of urine

D Decreased force in the stream of urine is an early symptom of BPH; the stream later becomes weak and dribbling

The client is newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequillibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? A. Hypertension, tachycardia, and fever B. Hypotension, bradycardia, and hypothermia C. Restlessness, irritability, and generalized weakness D. Headache, deteriorating level of consciousness, and twitching

D Disequillibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? A. Monitor the client B. Elevate the head of the bed C. Assess the fistula site and dressing D. Notify the provider

D Disequillibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The provider must be notified

A client has undergone esophagogastroduodenoscopy. The nurse should place the highest priority on which item as part of the client's plan? A. Monitoring the temperature B. Monitoring complaints of heartburn C. Giving warm gargles for a sore throat D. Assessing for the return of the gag reflex

D Highest priority is assessing for the return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vitals and for sudden increase in temperature, which could indicate perforation; this would be accompanied by other signs as well such as pain. Monitoring for a sore throat and heartburn are also important; however, the client's airway is the priority.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A. Bradycardia B. Numbness in the legs C. Nausea and vomiting D. A rigid, board-like abdomen

D Perforation of an ulcer is a surgical emergency & is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric region and spreading over the abdomen, which becomes rigid and board-like. Nausea & vomiting may or may not occur. Tachycardia may occur as hypovolemic shock develops. Numbness in legs is not an expected finding.

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? A. Warmth, redness, and pain in the left hand B. Ecchymosis and audible bruit over the fistula C. Edema and reddish discoloration of the left arm D. Pallor, diminished pulse, and pain in the left hand

D The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate exam for which characteristics of this disorder? A. Soft and swollen prostate gland B. Swollen and boggy prostate gland C. Tender and edematous prostate gland D. Tender, indurated prostate gland that is warm to the touch

D The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? A. Hematuria and pyuria B. Dysuria and proteinuria C. Hematuria and urgency D. Dysuria and penile discharge

D Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. A. Diarrhea B. Black, tarry stools C. Hyperactive bowel sounds D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain w radiation to the back

D, E, F Gray-bluish discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from peritoneal cavity. Client may demonstrate abdominal guarding and may complain of tenderness with palpation. Pain associated with acute pancreatitis is often sudden in onset and is location in the epigastric region or left upper quadrant with radiation to the back. Other answers are incorrect.

A client with endocarditis is being discharged home. What statement indicates effectiveness of client teaching about preventing recurrence of the infection? A. "I will start an antibiotic when I am exposed to anyone with infections." B. "I am going to take an aspirin a day to prevent lesions around my valve." C. "I will always be on antibiotic therapy." D. "I will ask for antibiotics whenever I have dental work done."

D. "I will ask for antibiotics whenever I have dental work done." The patient should take antibiotics for dental procedures that involve manipulation of gingival tissue or the periapical area of the teeth or perforation of the oral mucosa. Exceptions include routine anesthetic injections through noninfected tissue, placement of orthodontic brackets, loss of deciduous teeth, bleeding from trauma to the lips or oral mucosa, dental x-rays, adjustment of orthodontic appliances, and placement of removable prosthodontic or orthodontic appliances.

The nurse provides instructions to a client newly diagnosed with type 1 diabetes. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement? A. "I will stop taking my insulin if I'm too sick to eat" B. "I will decrease my insulin dose during times of illness" C. "I will adjust my insulin dose according to the level of glucose in my urine" D. "I will notify my provider if my blood glucose level is higher than 250 mg/dL"

D. "I will notify my provider if my blood glucose level is higher than 250 mg/dL" During illness, the client with type 1 diabetes is at increased is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and notify the provider if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the provider'd advice and are usually adjusted without the provider's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? A."I should notify my doctor if my feet or legs start to swell." B. "My doctor told me to call his office if my pulse rate decreases below 60." C. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." D. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

D. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? A. 2.6 B. 3.0 C. 3.4 D. 3.8

D. 3.8 Warfarin patients usually have individualized target international normalized ratios (INRs) between 2 to 3.5 to maintain adequate anticoagulation. Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.

A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? A.50 J B. 120 J C. 200 J D. 360 J

D. 360 J

The nurse is caring for a client admitted to the ED with DKA. In the acute phase, the nurse plans for which priority intervention? A. Correct the acidosis. B. Administer 5% dextrose via IV C. Apply a monitor for an ECG D. Administer short-acting insulin IV

D. Administer short-acting insulin IV Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short or rapid-acting), IV fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying and ECG is not the priority action

A patient is scheduled for a procedure that will allow the physician to visualize the knee joint in order to diagnose the patient's pain. What procedure will the nurse prepare the patient for? A. Arthrocentesis B. Bone scan C. Electromyography D. Arthroscopy

D. Arthroscopy Arthroscopy is a procedure that allows direct visualization of a joint through the use of a fiberoptic endoscope. Thus, it is a useful adjunct to diagnosing joint disorders.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 is most recent). The client's BUN is 35 mg/dL and the serum creatinine is 1.8 mg/dL measured this morning. Which nursing action is the priority? A. Check the serum albumin level B. Check the urine specific gravity C. Continue monitoring urine output D. Call the provider

D. Call the provider

Which is an indicator of neurovascular compromise? A. Warm skin temperature B. Diminished pain C. Pain upon active stretch D. Capillary refill of more than 3 seconds

D. Capillary refill of more than 3 seconds Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain upon passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain upon passive stretch is an indicator of neurovascular compromise.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? A. Ensure that the client has been intubated B. Set the defibrillator to the "synchronize" mode C. Administer an amiodarone bolus IV D. Confirm that the rhythm in ventricular fibrillation

D. Confirm that the rhythm in ventricular fibrillation

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have? A. Secondary B. Pathologic C. Malignant D. Essential (primary)

D. Essential (primary) Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause. This client does not have secondary, pathologic, or malignant hypertension.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Excess fluid volume related to peripheral vascular disease C. Risk for injury related to edema D. Ineffective peripheral tissue perfusion related to venous congestion

D. Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? A. Ignore the comment. B. Report the resident to the attending surgeon. C. Discuss concerns regarding the comments with the charge nurse. D. Inform the resident that all communication needs to remain professional.

D. Inform the resident that all communication needs to remain professional. The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? A. It is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals B. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels C. It is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream D. It gives a small continuously dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose form the pump before each meal

D. It gives a small continuously dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose form the pump before each meal An insulin pump provides a small continuous dose of rapid-acting insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? A. Defibrillate the client. B. Administer digoxin (Lanoxin). C. Continue to monitor the client. D. Prepare for transcutaneous pacing.

D. Prepare for transcutaneous pacing. Sinus bradycardia is noted with a heart rate less than 60 bpm. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? A. Painful skin that is swollen and pale in color B. Cold, red skin C. Small, localized blackened area of skin D. Red, swollen skin with inflammation spreading to surrounding tissues

D. Red, swollen skin with inflammation spreading to surrounding tissues Cellulitis, an inflammation of soft tissues, can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.

The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order? A. Provides best information on the body's ability to maintain normal blood functioning B. Best indicator for the nutritional state of the client C. Is less costly than performing daily blood sugar test D. Reflects the amount of glucose stored in hemoglobin over past several months.

D. Reflects the amount of glucose stored in hemoglobin over past several months. Hemoglobin A1c tests reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. This test provides a more accurate picture of overall glucose control in a client. Glycosylated hemoglobin test does not indicate normal blood functioning or nutritional state of the client. Self-monitoring with a glucometer is still encouraged in clients who are taking insulin or have unstable blood glucose levels.

A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize? A. Client complains of tingling and numbness in the right shoulder. B. Right shoulder is elevated above the left. C. Client complains of pain in the unaffected shoulder D. Right shoulder slopes downward and droops inward.

D. Right shoulder slopes downward and droops inward. The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.

A client vomits postoperatively. What is the most important nursing intervention? A. Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. B. Offer tepid water and juices to replace lost fluids and electrolytes. C. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. D. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

D. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? A. Hypotension B. Contractures C. Phlebitis D. Wound dehiscence

D. Wound dehiscence Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.