MEDICAL/SURGICAL FINAL 1

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? "A hepatitis B immunization is recommended for those who travel, especially military personnel." "A hepatitis B immunization is given to infants and children." "Hepatitis B is acquired by eating foods that are contaminated during handling." "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

"A hepatitis B immunization is given to infants and children." Rationale: Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The clients ask the nurse about the usual course of MS. Which of the following responses should the nurse make? "Each client is different; we cannot predict what will happen." "I can see that you are worried, but it's too soon to predict what will happen." "Acute episodes are usually followed by remissions, which can vary in duration." "It's too early to think about the future; let's focus on the present and take one day at a time."

"Acute episodes are usually followed by remissions, which can vary in duration." Rationale: The nurse should identify that the client is asking an information-seeking question. The nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder that is characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? "An aura is a sensory warning that a seizure is imminent." "An aura is a continuous seizure in which seizures occur in rapid succession." "An aura is a period of sleepiness following the seizure." "An aura is a brief loss of consciousness accompanied by staring."

"An aura is a sensory warning that a seizure is imminent." Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? "Place a warm compress on your forehead." "Darken the lights." "Light a scented candle." "Drink a caffeinated beverage."

"Darken the lights." Rationale: The nurse should instruct the client to lie down in a dark room to reduce migraine pain.

A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the attected arm adducted. which or the tolowing instructions should the nurse provide the client? affected arm adducted. Which of the following instructions should the nurse provide the client? "Keep your arm bent at the elbow." "Use a pillow to prop your shoulder up close to your ear." "Hold your arm against the side of your body." "Position your arm with the shoulder at a 90-degree angle."

"Hold your arm against the side of your body." Rationale: Adduction means to position toward the midline of the body. Therefore, the nurse should provide these instructions to explain the provider's prescription.

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? "I need to lie still in bed during my brachytherapy treatment." "I will have an implant placed once a month during my brachytherapy treatment." "I must stay at least 3 feet away from others between brachytherapy treatments." "I should expect some blood in my urine after each brachytherapy treatment."

"I need to lie still in bed during my brachytherapy treatment." Rationale: The nurse should confirm that the client understands the need to remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgment.

A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? "I will wear a continuous movement machine on my knee for 24 hours a day." "I should avoid taking NSAID medications for pain after surgery." "I should wear elastic stockings on both of my legs." "I will begin exercising my legs the day after surgery."

"I should wear elastic stockings on both of my legs." Rationale: The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as understanding of the teaching.

A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? "I will take the medication in the evening." "I will drink a full glass of milk with the medication." "I will take the medication at mealtime." "I will sit upright after taking the medication."

"I will sit upright after taking the medication." Rationale: A client taking alendronate should sit upright for 30 min after administration to prevent esophageal irritation and ulceration. Therefore, the nurse should identify this statement as indicating an understanding of the teaching.

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching?

"I will use lemon and glycerine swabs after meals." Rationale: The nurse should identify that this client statement indicates a need for further teaching. The nurse should instruct the client who has stomatitis to avoid the use of lemon-glycerine swabs because they cause drying and irritation of the mucous membranes.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? "Because most of my colon is still intact and functioning, my stool will be formed." "My stoma will appear large at first, but it will shrink over the next several weeks." "My colostomy will begin to function 2 to 6 days after surgery." "My diet will have to change to a soft diet after surgery."

"My diet will have to change to a soft diet after surgery." The nurse should identify that this statement requires further teaching. After surgery the client's diet quickly returns to a regular diet and there are not any food restrictions, unless the client chooses to decrease intake of foods that increase gas or odor.

A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? "Osteoarthritis is caused by autoimmune processes." "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." "Osteoarthritis affects other organ systems." "Osteoarthritis can impair a joint on a single side of the body."

"Osteoarthritis can impair a joint on a single side of the body." Rationale: The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment.

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? "This procedure is performed to measure the presence of acid in your esophagus." "This procedure can determine how well the lower part of your esophagus works." "This procedure is performed while you are under general anesthesia." "This procedure can determine if you have colon cancer."

"This procedure can determine how well the lower part of your esophagus works." Rationale: An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? "This type of pain usually decreases over time as the limb becomes less sensitive." "Try to look at the surgical wound as a reminder the limb is gone." "Use a cold compress intermittently to decrease these pain sensations." "Grief over the lost limb can sometimes cause denial that the limb is really gone."

"This type of pain usually decreases over time as the limb becomes less sensitive." The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain.

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make? "You should try a little harder to stick to your diet." "Why do you think you've gained 3 pounds this week?" "Were there any issues last week that kept you from focusing on your diet?" "You should put this week behind you and adhere to your diet from this point forward."

"Were there any issues last week that kept you from focusing on your diet?" Rationale: The nurse should use an open-ended question that allows the client to reassess the past week in a non-threatening manner. The nurse's statement demonstrates concern without placing blame. The nurse should explain to the client that relapse is a normal part of making a behavior change, and that physical and emotional stress can play a part in his motivational level.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? "You can expect your vision to return immediately after the procedure." "You should avoid reading for 1 week." "You can remove eye shields when you're sleeping." "You should not lift objects that weigh more than 25 pounds."

"You should avoid reading for 1 week." Rationale: The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina.

A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? "You will be NPO for 8 hours following the procedure." "An allergy to shellfish is a contraindication to this procedure." "You will need to be on bed rest following the procedure." "A creatinine clearance is needed prior to the procedure."

"You will need to be on bed rest following the procedure." Rationale: A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney. The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hr following the procedure to reduce the risk for bleeding. The nurse can elevate the head of the bed.

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? "You will need to apply a cold pack to the site three times a day." "Your provider might ask you to walk frequently to increase circulation to the area." "You will need to limit consumption of high-protein foods." "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

"Your provider might prescribe a central catheter line for long-term antibiotic therapy." Rationale: Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy.

A nurse is caring for a client who has an upper GI bleed and a hematocrit of 24%. Prior to initiating a transfusion of PRBCs, which of the following actions should the nurse take? (Select all that apply.)

- Assess and document the client's vital signs - Verify with another nurse the blood type and Rh of the PRBCs - Change IV tubing to a set that has a filter Rationale: The nurse should assess and document the client's vital signs prior to initiating a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product. The nurse should verify the blood type and Rh of the packed RBCs with another RN and compare with the client's information for compatibility. This action decreases the risk of an ABO incompatibility reaction. The nurse should administer packed RBCs through IV tubing that has a filter to prevent the administration of aggregates and possible contaminants.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.)

- Take allopurinol as prescribed - Limit intake of foods high in purine - Exercise several times a week Rationale: The nurse should inform the client that allopurinol is an antigout medication that reduces levels of uric acid, which helps prevent uric acid stone formation. The nurse should inform the client that immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise, to help prevent stone formation. The nurse should inform the client that purine increases the risk for uric acid stone formation. The nurse should identify that organ meats, poultry, fish, red wine, and gravies are high in purine.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? 0.45% sodium chloride Dextrose 5% in 0.9% sodium chloride Dextrose 10% in water 0.9% sodium chloride

0.9% sodium chloride Rationale: Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? A TIA can cause irreversible hemiparesis. A TIA can be the result of cerebral bleeding. A TIA can cause cerebral edema. A TIA can precede an ischemic stroke.

A TIA can precede an ischemic stroke. Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following. clients should the nurse assess first? A client who has benign prostatic hyperplasia (BPH) and reports dysuria A client who has ulcerative colitis and reports diarrhea A client who has emphysema and reports dyspnea A client who has esophageal cancer and reports painful swallowing

A client who has emphysema and reports dyspnea Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the client who has emphysema and reports dyspnea, or shortness of breath, is the first client that the nurse should assess.

A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast. cancer?

A nontender, hard lump that is palpated in one breast Rationale: The nurse should identify that cancerous tumors are typically hard, fixed, irregular in shape, and nontender to palpation. The nurse should instruct the client to notify the provider promptly if she palpates a hard, nontender lump.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? High-calorie diet Prior gastrointestinal illnesses Tobacco use Alcohol use

Alcohol use Rationale: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? Aldolase Lipase Amylase Lactic dehydrogenase

Amylase Rationale: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days.

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching One solid color Symmetrical in shape Less than 6 mm in diameter An irregular border

An irregular border Rationale: The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should instruct clients on the use of the ABCDE pneumonic when monitoring for skin lesions: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? Jaundice Anorexia Dark urine Pale feces

Anorexia Rationale: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? Perform passive range-of-motion exercises of the ankle hourly. Keep the affected extremity in a dependent position. Wrap a loose dressing around the affected ankle. Apply cold compresses to the extremity intermittently.

Apply cold compresses to the extremity intermittently. Rationale: Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 min at a time.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? Have the client gently blow clots from the nose every 5 min. Instruct the client to sit with his head hyperextended. Apply ice compresses to the back of the client's neck. Apply lateral pressure to the client's nose for 10 min.

Apply lateral pressure to the client's nose for 10 min. The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If after 10 min the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? Colchicine Naproxen Aspirin Prednisone

Aspirin Rationale: Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid interaction between probenecid and salicylate medications.

A nurse is caring for a client who is 72 hr postoperative following an AKA. Which of the following actions should the nurse take?

Assist the client to a prone position every 4 hr Rationale: The nurse should assist the client to a prone position for 20 to 30 min every 3 to 4 hr following an amputation because it reduces the risk of flexion contractures.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include? Avoid IM injections. Assess the client for ecchymosis once per shift. Do not allow the client to have visitors. Encourage daily flossing between teeth.

Avoid IM injections Rationale: The nurse should identify that the client's platelet count of 48,000/mm3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures, such as an IM injection, which can increase the client's risk for bleeding.

A nurse is providing teaching to a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching? Avoid bearing down Increase caffeine intake Avoid sudden movements Increase sodium intake

Avoid sudden movements Rationale: Ménière's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? Increased blood pressure Decreased heart rate Yellowing of the skin Boardlike abdomen

Boardlike abdomen Rationale: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? Misoprostol Dantrolene Celecoxib Colchicine

Celecoxib Rationale: Celecoxib is a type of NSAID, called cyclooxygenase-2 (COX-2) inhibitors, used to relieve some of the manifestations caused by RA in adults. The nurse should identify that the medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation.

A nurse in an ED is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? Estimation of burn injury Characteristics of the cough and sputum Extent of peripheral edema Amount of urine output

Characteristics of the cough and sputum Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury and the development of a brassy cough can indicate impending loss of airway.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? Administer 0.9% sodium chloride until TPN is available from the pharmacy. Check the client's capillary blood glucose level every 4 hr. Obtain the client's weight each week. Change the IV tubing every 3 days.

Check the client's capillary blood glucose level every 4 hr. Rationale: The nurse should check the client's capillary blood glucose level every 4 hr, or according to facility policy, due to the client's risk for hyperglycemia while receiving TPN. The dextrose concentration in TPN places the client at risk for this complication.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? Ecchymosis of the thigh Serous drainage at the pin site Chest petechiae Muscle spasms in the left leg

Chest petechiae Rationale: The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress into acute respiratory failure.

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? Orthopnea Cheyne-Strokes Paradoxical Kussmaul

Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A community health nurse is planning an education program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? Children Older adults Women who are pregnant Middle-aged men

Children Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact.

A nurse in an ED is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?

Clear fluid coming from the nares Rationale: The nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming from the nares or ears as an indication of a basilar skull fracture.

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? Vanilla pudding Apple juice Diet ginger ale Clear liquids

Clear liquids Rationale: Clear liquids, such as water or broth, can be given for the first oral feedings, but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.

A nurse is caring for a client who is receiving total parenteral nutrition (TP) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TP is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? Hypertension Excessive thirst Fever Diaphoresis

Diaphoresis Rationale: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? Reduced left-side motor function Difficulty with speech Impulsive behavior Neglect of the left side of the body

Difficulty with speech Rationale: The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.

A nurse is teaching a client who has myopia about laser-assisted in sit keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse effect of LASIK surgery? Eyelid twitching Photosensitivity Intraocular hemorrhage Dry eyes

Dry eyes Rationale: LASIK surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.

A nurse is performing a neurologic assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? Dysphagia Positive Babinski sign Decreased deep-tendon reflexes Ataxia

Dysphagia Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority? Dysphagia Emotional lability Impaired speech Self-care dependency

Dysphagia Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning, which is having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and should be the nurse's priority concern. When applying the ABC priority-setting framework, the airway is the priority because it must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead to aspiration.

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? Elevated glucose Elevated protein Presence of RBCs Presence of D-dimer

Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaOz of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? Hypovolemic shock Fat embolism syndrome Thrombophlebitis Avascular bone necrosis

Fat embolism syndrome Rationale: The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels.

A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? Maternal-fetal Fecal-oral contamination Genital sexual contact Blood to blood

Fecal-oral contamination Rationale: The nurse should identify that hepatitis A is most commonly transmitted by the fecal-oral route. Transmission occurs by ingesting food or liquid that has been infected with the virus. Outbreaks due to contaminated food are usually due to poor hygiene practices by food handlers or shellfish from contaminated water.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? Foods high in vitamin C Foods low in fat Foods high in fiber Foods low in calories

Foods high in fiber Rationale: The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.

A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? Gamma-glutamyl transferase (GGT) Alkaline phosphatase (ALP) Serum bilirubin Alanine aminotransferase (ALT)

Gamma-glutamyl transferase (GGT) Rationale: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? Remove the weight temporarily to reposition the client to the correct alignment in bed. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. Lift the rope off the pulley while the client rocks back and forth to reposition. Lift the weight manually while another staff member moves the client up in bed.

Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. Rationale: The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client up, making sure to maintain proper alignment of the extremity.

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? Decreased intake of phosphate-containing foods Spending several hours in the sun daily Increased estrogen levels History of anorexia nervosa

History of anorexia nervosa Rationale: The nurse should identify anorexia nervosa as a risk factor for osteoporosis. Inadequate protein intake can lead to a decreased bone density, increasing the risk for fractures.

A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? Hospitalization is required when administering each treatment. The maximum effect of the medication will occur in 6 months. Hypertension is a common adverse effect of this medication. Blood transfusions are needed with each treatment.

Hypertension is a common adverse effect of this medication. Rationale: The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.

A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? Infuse the heparin using an electronic IV pump. Administer vitamin K if the client has indications of hemorrhage. Adjust the dosage of heparin based on the client's PT levels. Inform the client that the heparin will dissolve the thrombus.

Infuse the heparin using an electronic IV pump. Rationale: The nurse should administer heparin using an electronic IV pump, rather than by gravity, to prevent an accidental increase or change in the rate of infusion.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan? Administer ferrous sulfate supplementation. Increase dietary intake of folic acid. Initiate weekly injections of vitamin B12. Initiate a blood transfusion.

Initiate weekly injections of vitamin B12. Rationale: The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.

A nurse is reviewing lab values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? Hypokalemia Lead poisoning Hypercalcemia Iron toxicity

Iron toxicity Rationale: The client who has received several blood transfusions is at risk for development of hemosiderosis, which is excess storage of iron in the body. The excessive iron can come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia.

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status? Vital signs Body posture Level of consciousness Examination of pupils

Level of consciousness Rationale: The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse is providing teaching to the family of a client who has stage I Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching? Place abstract pictures on the wall in the client's room. Provide music for the client using headphones. Reorient the client to reality frequently. Limit choices offered to the client.

Limit choices offered to the client. Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and frustration.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? Endoscopic sclerotherapy Liver lobectomy Liver transplant Transjugular intrahepatic portal-systemic shunt placement

Liver transplant Rationale: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.) Place the client on respiratory isolation. Monitor vital signs every 2 hr. Assess neurological status every 4 hr. Maintain the client in a modified Trendelenburg position. Keep the client's room darkened.

Monitor vital signs every 2 hr Assess neurological status every 4 hr Keep the client's room darkened Rationale: he nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure. The nurse should monitor the client's neurological status at least every 4 hr, or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? Offer the client a bedpan every 2 hr. Limit the client's daily fluid intake until he is no longer incontinent. Request a prescription for an indwelling urinary catheter from the client's provider. Ambulate the client to the bathroom every 30 min.

Offer the client a bedpan every 2 hr. Rationale: Following a stroke, the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control. The nurse should encourage and assist the client to void every 2 hr while awake to promote bladder control. By offering a bedpan, the nurse promotes client safety.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? Metered-dose inhaler Continuous passive motion machine Oral-nasal suction equipment External defibrillator pads

Oral-nasal suction equipment Rationale: The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? Sensation of heat on the surface of the cast Paresthesias of the extremity Pruritus of the extremity Musty odor noted from cast materials

Paresthesias of the extremity Rationale: The nurse should identify paresthesias as a finding of compartment syndrome. Compartment syndrome involves the compression of nerves and blood vessels in an enclosed space, leading to impaired blood flow and nerve damage. Other findings include numbness, tingling, weakness, and pain that does not respond to medication.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? Plethoric appearance of facial skin Glossitis and weight loss Jaundice with an enlarged liver Petechiae and ecchymosis

Petechiae and ecchymosis Rationale: The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? Flush the tube with water. Place the client in semi-Fowler's position. Cleanse the skin around the tube site. Aspirate the tube for residual contents.

Place the client in semi-Fowler's position. Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? Obtain blood samples to test platelet function. Prepare for replacement of the missing clotting factor. Administer aspirin for the client's pain. Place the bleeding joint in the dependent position.

Prepare for replacement of the missing clotting factor. Rationale: Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes?

Preventing dislocation of the hip during position changes or movement Rationale: Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client's legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? Reorient the client. Protect the client's head. Loosen constrictive clothing. Turn the client on his side.

Protect the client's head. Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? Prothrombin time Serum lipase Bilirubin Calcium

Prothrombin time Rationale: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

A nurse is reviewing a client's repeat lab results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? Prothrombin time WBC count Platelet count Hematocrit

Prothrombin time Rationale: The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.

A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? Pneumonia Pulmonary embolus Tension pneumothorax Tuberculosis

Pulmonary embolus Rationale: Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately.

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? Continue to monitor for manifestations of a transfusion reaction. Remove the unit of plasma immediately and start an IV infusion of normal saline solution. Continue the transfusion and repeat the type and crossmatch. Prepare to administer a dose of diphenhydramine IV.

Remove the unit of plasma immediately and start an IV infusion of normal saline solution. Rationale: A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? Flushing of the lower extremities Hypotension Tachycardia Report of a headache

Report of a headache Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? Report of muscle spasms Inability to get dressed without assistance Report of feelings of anger Refusal to look at the affected limb

Report of muscle spasms Rationale: The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should identify the report of muscle spasms, a physiological need, as the priority client finding.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? Right shoulder pain Urine output 20 mL/hr Temperature 38.4° C (101.1° F) Oxygen saturation 92%

Right shoulder pain Rationale: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help with client comfort.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred?

Rigid abdomen Rationale: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension, results.

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? Trendelenburg Prone Semi-Fowler's Sims'

Semi-Fowler's Rationale: To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30º. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? Bulging in the area over the surgical incision Shortening of the right leg Sensation of warmth over the surgical incision Pallor following elevation of the right leg

Shortening of the right leg Rationale: The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally.

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? Blood urea nitrogen (BUN) Blood glucose Urine ketones Specific gravity

Specific gravity Rationale: Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

A nurse is administering a unit of PRBCs to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first? Maintain the IV access with 0.9% sodium chloride. Stop the infusion of blood. Send the blood container and tubing to the blood bank. Obtain a urine sample.

Stop the infusion of blood Rationale: The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? Swelling behind the affected ear Facial drooping on the affected side Nystagmus on the affected side Pearly gray color of the affected eardrum

Swelling behind the affected ear Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? The client has a new tattoo. The client is unable to sit upright. The client has a history of peripheral vascular disease. The client has a pacemaker.

The client has a pacemaker. Rationale: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? The client rigidly extends his arms. The client internally flexes his wrists. The client curls into a fetal position. The client internally rotates his legs.

The client rigidly extends his arms. Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? The client's serum osmolarity is 310 mOsm/L. The client's pupils are dilated. The client's heart rate is 56/min. The client is restless.

The client's serum osmolarity is 310 mOsm/L. Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? A full pitcher of water is sitting on the client's bedside table within the client's reach. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. The client is lying on the right side with a visible dependent loop in the feeding tube. The head of the bed is elevated 20°.

The head of the bed is elevated 20°. Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (ECG). Which of the following instructions should the nurse include in the teaching? Remain NPO 6 to 8 hr prior to the EEG. Take a sedative the night prior to the EEG. Thoroughly shampoo hair prior to the EEG. Sleep for at least 8 hr the night prior to the test.

Thoroughly shampoo hair prior to the EEG. Rationale: The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? To visualize polyps in the colon To detect an ulceration in the stomach To identify an obstruction in the biliary tract To determine the presence of free air in the abdomen

To detect an ulceration in the stomach An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? Toes cold to the touch Serous drainage from the pin sites Blanching of the toenail beds with pressure Pink tissue around the fixator insertion sites

Toes cold to the touch Rationale: The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch.

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? Turn the client from side to side. Elevate the height of the dialysate bag. Lower the head of the client's bed. Advance the catheter approximately 2.5 cm (1 in) further.

Turn the client from side to side. Rationale: The nurse should assist the client in turning from side to side to facilitate removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter.

A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? Use a hair dryer on a cool setting to blow air into the cast. Ask the provider to bivalve the cast. Provide the client with a sterile cotton swab to rub the affected skin. Wrap the extremity with a dry heating pad.

Use a hair dryer on a cool setting to blow air into the cast. Rationale: The nurse should provide relief for the report of itching by blowing cool air into the cast using a hair dryer on a cool setting or an empty 60-mL plunger syringe.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? Famotidine Esomeprazole Vasopressin Omeprazole

Vasopressin Rationale: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? Output equal to the instilled irrigant Report of bladder spasms Viscous urinary output with clots Report of a strong urge to urinate

Viscous urinary output with clots Rationale: The nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider because this is an indication of arterial bleeding.

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? Sensory dysfunction Weakness of the distal extremities Decreased vision Altered temperature regulation

Weakness of the distal extremities Rationale: ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? Tonic-clonic seizures Report of a severe headache Weakness of the lower extremities Decreased level of consciousness

Weakness of the lower extremities Rationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? Wheat toast Tapioca pudding Hard-boiled egg Mashed potatoes

Wheat toast Rationale: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray.

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? Widened pulse pressure Tachycardia Periorbital edema Decrease in urine output

Widened pulse pressure Rationale: A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting. *Cushing's Triad*

A nurse is preparing to transfuse a unit of PRBCs to a client who has anemia. Which of the following actions should the nurse take first? Hang an IV infusion of 0.9% sodium chloride with the blood. Check the client's identification number with the number on the blood. Witness the informed consent. Obtain pretransfusion vital signs.

Witness the informed consent. Rationale: The nurse should apply the least invasive priority-setting framework. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, as witnessing the informed consent is the least invasive, it is the action that should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion to a client.