Monitoring for Health Problems (9)

A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should tell the client that: A. The test cannot be performed while the client is menstruating Correct B. Vaginal douching is required an hour before the test C. Spicy foods should not be eaten on the day of the test D. The test has absolutely no discomfort associated with it

A. The test cannot be performed while the client is menstruating Rationale: A Pap smear cannot be performed with accurate results during menstruation. The test is usually painless but may be slightly uncomfortable during placement of the speculum or while the cervical scraping is obtained. The client should not douche for at least 24 hours before the test. There is no reason to restrict consumption of spicy foods on the day of the test.

A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications he is taking. Which of the following serum creatinine results does the nurse document as normal?

B. 1.0 mg/dL Rationale: The normal serum creatinine level ranges from 0.6 to 1.3 mg/dL. A result of 0.2 mg/dL represents a low value; the other incorrect options are high values.

Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL B. 5.8 mg/dL C. 8.9 mg/dL D. 12.8 mg/dL

B. 5.8 mg/dL Rationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for females. Therefore the other options are incorrect.

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

A. "I didn't shampoo my hair." Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide (Lasix). Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the physician before administering the dose? A. 3.0 mEq/L B. 3.8 mEq/L C. 4.2 mEq/L D. 5.1 mEq/L

A. 3.0 mEq/L Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. A result of 3.0 mEq/L is low, 3.8 and 4.2 mEq/L are normal, and 5.1 mEq/L is high. Administering furosemide to a client with a low potassium level and a history of cardiovascular disease could precipitate ventricular dysrhythmias in the client. The normal and high levels do not require withholding of the dose. In fact, the high level may be lowered by administration of the medication, which is a potassium-losing diuretic.

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than: A. 7% B. 9% C. 10% D. 15%

A. 7% Rationale: An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less. Specific values may vary slightly, depending on the laboratory and the procedure. The other options indicate poor control of diabetes.

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements

A. Assess the patency of the airway Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then performs an assessment of cardiovascular function, the condition of the surgical site, the patency of tubes and drains for patency, and the function of the central nervous system. If the airway is not patent, immediate measures must be taken to help ensure the survival of the client.

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure?

A. Darken the examining room Rationale: Examination of the skin under a Wood light, or handheld long-wavelength UV light, is carried out in a darkened room. The light is used to illuminate areas of skin infection, which are seen as blue-green or red fluorescence. The skin does not need to be shaved, and a local anesthetic is not necessary. This is a noninvasive examination, so informed consent is not required.

A client with a history of lung disease is at risk for respiratory acidosis. For which of the following signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

A. Disorientation and dyspnea Rationale: The client with respiratory acidosis would exhibit the symptoms identified in the correct option. The client will experience dyspnea and may be disoriented as a result of hypoxia and retention of carbon dioxide. Metabolic acidosis and alkalosis are marked by drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively. The client with respiratory alkalosis is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities.

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A.Flat B.Semi-Fowler C.Side-lying, with the head of the bed elevated D.Sitting up in a recliner with the feet elevated

A. Flat Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other options are incorrect.

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply.

A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record all activity and symptoms Rationale: The nurse applies electrocardiogram (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor radio-sized monitor (walkie-talkie), which is worn around the chest or waist. Clients undergoing Holter monitoring are instructed to maintain a normal schedule and to keep a diary of all activity and symptoms. The client is told to avoid activities — such as operating heavy machinery, electric shavers, or hairdryers; bathing; or showering — that could interfere with the ECG recording. The client does not feel any shocks from the device.

A client has been given a diagnosis of multiple myeloma. Which of the following results does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis?

A. Increased calcium level Rationale: Multiple myeloma is characterized by hypercalcemia, anemia, increased BUN, and an increased number of plasma cells in the bone marrow. Hypercalcemia is a result of the release of calcium from deteriorating bone tissue. An increased WBC count may or may not be present and is not specifically related to this disease.

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims' position B. Lithotomy position C. Knee-chest position D. Right Sims' position

A. Left Sim's position Rationale: The client is placed in the left Sims' position, which utilizes the client's anatomy to advantage for introducing the colonoscope, for the procedure. The other options are incorrect.

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PCO2 34 mm Hg, PO2 86 mm Hg, HCO3 14 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis Rationale: Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L; metabolic alkalosis is present when the HCO3 is greater than 27 mEq/L. This client's ABG values are consistent with metabolic acidosis.

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse calls the physician to report the finding and monitors the client closely for: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism, which are acidotic, can cause the condition known as diabetic ketoacidosis. The other options are incorrect and are not likely to occur in the client with diabetes mellitus.

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to: A. Notify the surgeon B. Continue the assessment C. Check the client's blood pressure D. Obtain a flashlight, gauze, and a curved hemostat

A. Notify the surgeon Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately.

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end-diastolic pressure

A. Pulse rate Rationale: Cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Remember that pulse rate multiplied by stroke volume equals cardiac output. An increase in pulse is often sufficient with small amounts of volume depletion to maintain the blood pressure. Pulmonary artery systolic pressure and pulmonary artery end-diastolic pressure, measurements obtained with the use of a pulmonary artery catheter, provide information about the pressures in the pulmonary artery and in the left ventricle at the end of diastole.

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. a. Setting the suction pressure to 60 mm Hg b. Applying suction throughout the procedure c. Assessing breath sounds before suctioning d. Placing the client in a supine position before the procedure Correct e. Hyperoxygenating the client with 100% oxygen before suctioning

A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure D. Placing the client in a supine position before the procedure Rationale: The client with a tracheostomy tube should be positioned with the head of the bed elevated. Correct suction pressure for the adult client is 80 to 120 mm Hg. Suction is applied intermittently during catheter withdrawal. Breath sounds should be assessed before the procedure to help determine the need for suctioning. The client should be hyperoxygenated with 100% oxygen before suctioning.

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.

A. That informed consent is required D. That food and fluids will be withheld before the procedure E. That multiple position changes may be necessary to pass the tube Rationale: The client must sign informed consent before the procedure, which takes about an hour to perform. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Food and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be necessary to facilitate the passage of the tube.

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply. A. Unequal chest expansion B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung E. Complaints of discomfort at the needle insertion site

A. Unequal chest expansion Correct D. Diminished breath sounds in the right lung Rationale: After thoracentesis, the nurse assesses the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Each of these signs must be reported to the physician immediately. Complaints of discomfort at the needle insertion site, a pulse rate of 82 beats/min, and a respiratory rate of 22 breaths/min are expected findings after this procedure.

A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose determination drawn in the morning. What does the nurse tell the client that it is acceptable to consume on the morning of the test?

A. Water Rationale: A client scheduled for a fasting blood glucose level draw should not eat or drink anything except water after midnight. This is done to ensure accurate test results, which forms the basis for adjustments or continuation of treatment. The other options are inaccurate, and the client should not consume these items before the test.

A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client's blood urea nitrogen (BUN) level is within the normal range? A. 2 mg/dL B. 18 mg/dL C. 25 mg/dL D. 35 mg/dL

B. 18 mg/dL Rationale: The normal BUN ranges from 5 to 20 mg/dL. Therefore 18 mg/dL is correct. Values such as 25 and 35 mg/dL are high, possibly indicating renal insufficiency. A result of 2 mg/dL reflects a lower-than-normal value, which may occur with disorders characterized by fluid overload.

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than: A. 140 mg/dL B. 200 mg/dL C. 250 mg/dL D. 300 mg/dL

B. 200 mg/dL Rationale: A normal cholesterol value ranges between 140 and 199 mg/dL. The client should be counseled to keep the total cholesterol level at 200 mg/dL or less. This reduces the risk of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

A client has just undergone a renal biopsy. Which intervention should the nurse include intervention in the post-procedure plan of care?

B. A Periodically testing the urine for occult blood Rationale: After renal biopsy, bed rest is maintained and the client's vital signs and puncture site are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid analgesics are often needed to manage the renal colic pain that some clients feel after this procedure.

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first:

B. Check for kinks in the drainage system Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs of respiratory distress or mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client's chest tube is done once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client's chest tube.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:

B. Decrease the client's oxygen-based respiratory Rationale: Normally the respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural drive becomes ineffective after exposure to a high carbon dioxide level over a prolonged period. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase the oxygen level independently because this could halt the respiratory drive, leading to respiratory failure.

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?

B. Encouraging fluid intake Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye. Medications do not have to be withheld. There is no reason to administer a laxative; also, a physician's prescription is needed for this intervention.

A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client's medical history? a. Pancreatitis b. Pacemaker insertion c. Type 1 diabetes mellitus d. Chronic airway limitation

B. Pacemaker insertion Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is conducted to determine whether any such metal objects, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the client. These may heat up in the magnetic field generated by the MRI device, become dislodged, or malfunction during the procedure. The other medical problems listed do not pose a risk or contraindication for this procedure.

A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to:

B. Remove all metal and jewelry before the test Rationale: A barium swallow, or esophagography, is an x-ray in which a substance called barium is used to provide contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications are withheld before the test. The client should self-monitor for constipation, which may occur as a result of the presence of barium in the GI tract, after the procedure.

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of: A. Bradycardia B. Respiratory distress C. Hematoma in the right groin D. Discomfort in the right groin

B. Respiratory distress Rationale: Signs of an allergic reaction to contrast dye include early signs, such as localized itching and edema, followed by more severe symptoms, such as respiratory distress, stridor, and decreased blood pressure. Discomfort in the catheter insertion area is to be expected and is not a sign of allergic reaction. Hematoma formation, which is abnormal and indicates bleeding, should be reported to the physician. Bradycardia is unrelated to the situation set forth in the question.

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease?

B. Serum bilirubin Rationale: Laboratory indicators of hepatitis include increased liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. An increased BUN may indicate renal dysfunction. The hemoglobin level is unrelated to this diagnosis.

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

B. Taping the connections between the chest tube and the drainage system Rationale: The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. Assessment for crepitus is performed once every 8 hours or more often if needed. Sterile water is only added to the suction control chamber as needed to replace evaporative loss.

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating: A. Improvement in the client B. The need for antiretroviral therapy C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV

B. The need for antiretroviral therapy Rationale: The normal CD4+ count is between 500 and 1600 cells/mcL. Antiretroviral therapy is recommended when the CD4+ count is less than 500 cells/mcL or below 25%, or when the client shows symptoms of HIV. The other options are incorrect.

A physician is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright C. Left side-lying D. Right side-lying

B. Upright Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally empties the bladder, and then sits upright in a chair with the feet flat on the floor. The other positions are incorrect for this procedure.

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin (Dilantin). Which result indicates that the prescribed dose of phenytoin is therapeutic?

C. 16 mcg/mL Rationale: The therapeutic serum phenytoin range is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above: A. 85% B. 89% C. 95% D. 100%

C. 95% Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected reading is at least 95%. Therefore the other options are incorrect. Readings of 85% and 89% are lower than what is desired in the postoperative period. A level of 100% is most desirable, but the level should remain at least 95%

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes D. Respiratory rate of 20 breaths/min

C. Absence of cough and gag reflexes Rationale: The absence of cough and gag reflexes is of greatest concern to the nurse because it indicates that the client does not have protective airway reflexes and is at risk of aspiration. Bilaterally equal breath sounds are a normal finding indicating an absence of complications such as hemothorax or pneumothorax. A respiratory rate of 20 breaths/min and an oxygen saturation of 97% are normal measurements.

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:

C. Administering oxygen by way of nasal cannula Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the physician is notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen.

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client has misunderstood the directions if the client indicates that as part of aftercare he plans to:

C. Apply cool compresses to the site twice a day for 20 minutes Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The physician may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy.

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:

C. Checks the client's overall intake and output record Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a 250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the physician. The physician is called once the nurse has gathered all necessary assessment data, including the overall fluid status and vital signs.

A nurse is monitoring a client who has undergone pleural biopsy. Which of the following findings causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath D. Capillary refill time of less than 3 seconds

C. Complains of shortness of breath Rationale: The nurse observes the client for dyspnea, excessive pain, pallor, and diaphoresis after pleural biopsy, each of which could indicate the presence of a complication such as hemothorax or intercostal nerve injury. Abnormal signs and symptoms should be reported to the physician. Mild pain is expected because the procedure itself is painful. Warm, dry skin and a capillary refill of less than 3 seconds are both normal findings.

A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth D. Complaints of feeling sweaty

C. Complaints of dry mouth Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry mouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect.

A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 80 seconds. The client's baseline before the initiation of therapy was 30 seconds. Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

C. Decreasing the rate of the heparin Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client's aPTT is somewhat increased (75 is the upper therapeutic value for this client, in light of the baseline) but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding.

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

C. Hold the breath during tube removal Rationale: The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn. Bearing down and exhaling could each interfere with tube removal by increasing intrathoracic pressure. Normal breathing could result in aspiration of gastric secretions during inhalation.

A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to: A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client's nose D. Prevent fluid loss from the lungs during mouth breathing

C. Humidify the oxygen that is bypassing the client's nose Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. The remaining options are incorrect; additionally, a client who is breathing through the mouth is not at risk for nosebleeds.

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the nurse recognize in these findings? A. Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis

C. Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the PCO2 is increased. This is an expected finding in a client with respiratory distress, because the client may retain carbon dioxide as a result of ventilatory failure.

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's laboratory work that the client's hematocrit is normal? A.10% B.22% C.30% D.43%

D. 43% Rationale: The normal hematocrit for an adult female client ranges from 35% to 47%. The incorrect options are low hematocrit values.

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

C. Tachypnea, dizziness, and paresthesias Rationale: The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities. The client with respiratory acidosis would exhibit disorientation and dyspnea. The client with metabolic acidosis or alkalosis would exhibit symptoms such as drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively.

A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones D. Specific gravity of 1.018

C. The presence of ketones Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.

A nurse is watching as a nursing assistant measures the blood pressure (BP) of a hypertensive client. Which actions on the part of the assistant that would interfere with accurate measurement would prompt the nurse to intervene? Select all that apply.

C. Used a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports that he just drank a cup of coffee E. Allowing the client to talk as the blood pressure is being measured Rationale: The client should not smoke tobacco or drink a beverage containing caffeine for at least 30 minutes before having the BP measured. The bladder of the cuff should encircle at least 80% of the limb being measured. The client should be seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should rest quietly for 5 minutes before the reading is taken.

A nurse in a physician's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should tell the client to:

C. Wear comfortable rubber-soled shoes such as sneakers Rationale: The client should wear comfortable rubber-soled, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement. The client should be NPO after bedtime, or for a minimum of 2 hours before the test, and should avoid tobacco, alcohol, and caffeine on the day of the test.

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which of the following serum amylase values, noted by the nurse reviewing the results, would be expected in this client at this time?

D. 395 units/L Rationale: The normal serum amylase range is 25 to 151 units/L. In acute pancreatitis, the amylase level is greatly increased; the level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain.

A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?

D. Asking the client to swallow as the tube is being advanced Correct Rationale: To facilitate insertion, the nurse asks the client to lower the head slightly, swallow, and take sips of water (if allowed). The head is not hyperextended, because this would open the airway and could result in placement of the nasogastric tube in the trachea. The tube should be iced to make it stiff for easier insertion. If resistance is met, the tube may be withdrawn slightly, then readvanced.

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the following measures should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time

D. Asking the client to void, discarding the specimen, and noting the start time Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The collection should be refrigerated or placed on ice to help prevent changes in urine composition.

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately: a.Contacts the physician b.Documents the findings c.Places the client in a supine position with the legs flat d. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution

D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler's position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which of the following signs does the nurse anticipate that this client will exhibit?

D. Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and blood pressure, because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases, with corresponding drops in both heart rate and blood pressure.

A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that: A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation

D. Dye is injected and may cause a warm flushing sensation Correct Rationale: A contrast-aided CT scan involves the injection of dye to enhance the images that are obtained. The dye may cause a warm flushing sensation when it is injected. If an iodine dye is used, the client should be asked about allergies to seafood or iodine. The CT scan, which causes no pain, generally lasts between 15 and 60 minutes. Fluids are encouraged after the procedure to help eliminate dye by way of the kidneys.

A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which of the following signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea .C Tachypnea, dizziness, and paresthesias Incorrect D. Dysrhythmias and decreased respiratory rate and depth

D. Dysrhythmias and decreased respiratory rate and depth Rationale: The client with metabolic alkalosis is likely to exhibit dysrhythmias and a decreased respiratory rate and depth as a compensatory mechanism. The client with metabolic acidosis would exhibit the symptoms such as drowsiness, headache, and tachypnea. The client with respiratory acidosis or alkalosis would exhibit the disorientation and dyspnea or tachypnea, dizziness, and paresthesias, respectively.

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first?

D. Lowering the head of the bed slowly until the dizziness is relieved Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved. The nurse then checks the client's pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken.

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting:

D. Pallor and coolness of the right leg Rationale: Complications of renal angiography include allergic reaction to the dye, dye-induced renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and embolism. The nurse detects these complications by monitoring the client for signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and signs of diminished circulation to the affected leg. The incorrect options are normal findings.

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily because: A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop Rationale: Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. In addition, the manual pressure could interfere with the flow of blood to the brain, possibly causing dizziness and syncope.

A nurse is preparing for intershift report when a nurse's aide pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?

D. Placing the client in a modified Trendelenburg position Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure. The nurse calls the physician, verifies the client's blood volume status by assessing urine output, and ensures that the IV infusion is proceeding without complications.

A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Correct

D. Respiratory alkalosis Rationale: Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In respiratory alkalosis the pH is increased and the PCO2 is decreased. The normal HCO3 is 22 to 27 mm Hg. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L; metabolic alkalosis is present when the HCO3 is greater than 27 mEq/L. This client's ABG findings are consistent with respiratory alkalosis.

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess: A. The client's vital signs B. The amount of drainage C. The client's lung sounds D. The chest tube connections

D. The chest tube connections Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's symptoms should resolve.

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should tell the client that:

D. The client may have feelings of warmth or flushing during the procedure Correct Rationale: The nurse tells the client about to undergo cardiac catheterization room that the procedure is performed in a darkened room in the radiology department. A local anesthetic is used, so there is little or no pain with catheter insertion. The procedure may take as long as 2 hours, during which time the client may feel various sensations including a feeling of warmth or flushing, with catheter passage and dye injection. The x-ray table is hard and may be tilted periodically to obtain the best possible views.

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should tell the client:

D. To report to the physician the development of fever or redness and heat at the site Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat at the site should be reported to the physician. The client may resume the usual diet immediately. The arm does not have to be completely immobilized once sensation has returned, but the client is usually encouraged to refrain from strenuous activity for at least a few days.

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. A. Hematocrit 30% B. Sodium 141 mEq/L C. Hemoglobin 8.9 g/dL D. Platelets 210,000 cells/mm3 E. Serum creatinine 0.8 mg/dL

A Hematocrit 30% C Hemoglobin 8.9 g/dL Rationale: Routine screening tests include complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood cell count includes the hemoglobin and hematocrit analysis. All of these values are within their normal ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit levels, the surgery may be postponed by the surgeon. The normal hemoglobin level ranges from 12 to 16.5 g/dL, and the hematocrit ranges from 35% to 52%.

A nurse is preparing a client for transfer to the operating room. Which of the following actions should the take in the care of this client at this time?

A. Assuring that the client has voided Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the physician writes a specific prescription outlining which medications may be given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours before surgery, not 24 hours. The time of transfer to the operating room is not the time to practice breathing exercises. This should have been done earlier.

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which of the following findings should the nurse assess the client?

A. Bleeding Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client?

A. Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal A.No fluctuation in the water seal chamber B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber

A. No fluctuation in the water seal chamber Rationale: When the client's lung is fully reexpanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has reexpanded and the pleural space is again a potential space. Continuous bubbling in the water seal chamber indicates an air leak in the system. Continuous gentle suction in the suction control chamber means that suction is being applied to the system.

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed B. Discard the residual volume properly and record it as output on the client's fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed Rationale: After checking the residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents, with the use of the syringe, into the nasogastric tube. Removal of the contents could disturb the client's electrolyte balance. The other options are incorrect.

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? a. Taking the client's vital signs Correct b. Giving the client a drink of water c. Monitoring the client for a sore throat d. Being alert to complaints of heartburn

A. Taking the clients vital signs Rationale: The nurse would first assess the client for the return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be checked next; a sudden sharp increase in temperature could indicate perforation of the gastrointestinal tract (this would be accompanied by other signs, such as pain, as well). Monitoring the client for sore throat and heartburn is also important but is of lesser priority than ensuring a patent airway. Water or any other fluid would not be given to the client until the gag reflex had returned and the client was stable.

A nurse is performing nasotracheal suctioning on a client. Which of the following observations should be cause for concern to the nurse? Select all that apply. A.The client becomes cyanotic. B. Secretions are becoming bloody. C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min.

A. The client becomes cyanotic. B. Secretions are becoming bloody. Rationale: The nurse monitors the client for adverse effects of suctioning, which include cyanosis, an excessively rapid or slow heart rate, and the sudden appearance of bloody secretions. If any of these findings is noted, the nurse stops suctioning and contacts the physician immediately. The descriptions in the other options are expected findings and not a reason for concern.

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:

A. The tube is patent Rationale: With normal breathing and a patent chest tube, the fluid level in the water seal chamber rises with inspiration and falls with expiration. The system should not be affected by airway secretions, because the chest tube drains fluid (not airway secretions) from the pleural space. The other options are incorrect interpretations.

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician's prescriptions to ensure that the prescribed flow is not greater than: A. 1 L/min B. 3 L/min C. 4 L/min D. 6 L/min

B. 3 L/min Rationale: Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure. The client with emphysema usually receives oxygen at a flow rate of 1 to 2 (and no more than 3) L/min.

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first: A. Continue suctioning to remove the blood B. Check the degree of suction being applied C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth

B. Check the degree of suction being applied Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions.

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis Rationale: Oral antacids commonly contain sodium or calcium bicarbonate or other alkaline components. These substances bind to the hydrochloric acid in the stomach to neutralize it. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis over time.

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client?

B. Metabolic alkalosis Rationale: Loss of gastric fluid by way of nasogastric suction or vomiting results in metabolic alkalosis. This is because of the loss of hydrochloric acid, a potent acid. The situation results in an alkalotic condition. The respiratory system is not involved.

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of: A.Compensated metabolic acidosis B. Compensated respiratory alkalosis C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis

B.Compensated respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. The normal HCO3 is 22 to 27 mm Hg. In a respiratory condition, opposite effects will be seen in pH and PCO2. In respiratory alkalosis, pH is increased and PCO2 is decreased. Compensation occurs when the pH returns to within the normal range, even though either the carbon dioxide or bicarbonate (or both) is abnormal value. In a metabolic condition, pH and bicarbonate move in the same direction. Clients with pneumonia are at risk for respiratory alkalosis as a result of hypoxemia.

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).

C. Assessing the system for an external air leak E. Documenting assessment findings, actions taken, and client response Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the physician is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency's policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client's medical record.

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? A.Decreasing pulse B.Rising blood pressure C.Distant muffled heart sounds D.Falling central venous pressure (CVP)

C. Distant muffled heart sounds Rationale: After effective pericardiocentesis, an increase in blood pressure and a decrease in CVP are expected. The pulse may slow because less cardiac work is needed to produce adequate cardiac output. Distant muffled heart sounds that were noted before the test should become clear with effective pericardiocentesis. A return of distant muffled heart sounds indicates returning pericardial effusion and possible tamponade.

Polyethylene glycol-electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?

C. Documenting the diarrhea in the medical record Rationale: GoLYTELY is a bowel evacuant used in preparation for colonoscopy to cleanse the bowel. It is expected to cause mild diarrhea and will clear the bowel in 4 to 5 hours. Therefore the nurse should document the results in the medical record. The other options are incorrect or unnecessary.

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure?

C. Drink 6 to 8 glasses of water without voiding Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure Correct D. Loss of cough reflex

C. Low blood pressure Rationale: Hypotension, shock, and the use of peripheral vasoconstricting medications may each result in inaccurate pulse oximetry readings because of the impairment of peripheral perfusion. The other options listed would not produce inaccurate readings.

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PCO2 58 mm Hg, PO2 75 mm Hg, HCO3 27 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis

C. Respiratory acidosis Rationale: Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect is seen between the pH and the PCO2. In respiratory acidosis, the pH is decreased and the PCO2 is increased. The normal HCO3 is 22 to 27 mm Hg. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L; metabolic alkalosis is present when the HCO3 is greater than 27 mEq/L. This client's ABG values are consistent with respiratory acidosis.

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items does the nurse ensure is available in the client's room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment D. Oxygen saturation monitor

C. Suction epuipment Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nurse checks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort.

A nurse is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above: A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi D. The area connecting the oropharynx to the laryngopharynx

C. The bifurcation of the right and left main stem bronchi Rationale: The carina is a cartilaginous ridge that separates the openings of the two main stem (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main stem bronchus as a result of the natural curvature of the airway. This is hazardous because only the right lung will be ventilated. It is easily detected, however, because only the right lung will have breath sounds and rise and fall with ventilation. The other options are incorrect.

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that: a. HIV infection has been confirmed b. The client probably has an opportunistic infection c, The test will need to be confirmed with the use of a Western blot d. A positive test is a normal result and does not mean that the client is infected with HIV

C. The test will need to be confirmed with the use of a Western blot Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western Blot. The other options are incorrect.

A client's baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which of the following respiratory rates would the nurse anticipate as part of the body's response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min

D. 22 breaths/min Rationale: Increases in body temperature cause a corresponding increase in respiratory rate because the metabolic needs of the body increase with fever, necessitating more oxygen. The client who has a decrease in body temperature will experience a decrease in respiratory rate.

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. Immediately after the tube is placed in the trachea, the nurse should: A. Tape the tube in place B. Send the client for a chest x-ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds

D. Auscultate both lungs for the presence of breath sounds Rationale: Immediately after an endotracheal tube is inserted, tube placement is verified. Initially the lungs are assessed for bilateral breath sounds and the chest is observed to see whether it rises and falls symmetrically with ventilation. After it has been determined that the client is being adequately ventilated, the tube is taped in place and placement is verified by means of chest x-ray. The depth of tube insertion is documented.

A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? a. Ambulating the client b. Administering pain medication c. Encouraging copious fluid intake d. Checking for the return of the gag reflex

D. Checking for the return of the gag reflex Correct Rationale: After bronchoscopy, the nurse assesses the client for the return of the gag and swallow reflexes and keeps the client on nothing-by-mouth status until these protective reflexes return. Preoperative sedation and local anesthesia can impair the swallowing and protective laryngeal reflexes for several hours. Encouraging large amounts of fluids is unnecessary, because there is no use of contrast dye in this procedure. Additionally, fluids would not be given until the gag reflex had returned. Ambulation is not indicated until the client is alert and awake. Pain medication is usually not needed.

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. The immediate priority on the part of the nurse is

D. Covering the insertion site with a sterile occlusive dressing Correct Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The physician will reinsert the chest tube as necessary.

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. The nurse would first:

D. Disconnect the suction source from the catheter Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.

A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete?

D. Head of the bed elevated 30 to 45 degrees Rationale: Aspiration is a complication of nasogastric tube feeding. The head of the bed should be elevated 30 to 45 degrees for 30 to 60 minutes after each bolus tube feeding to help prevent vomiting and aspiration. The right lateral position is also helpful in that gravity facilitates gastric emptying, which also reduces the risk of vomiting. The flat or supine position should be avoided for at least the first 30 minutes after a tube feeding.

A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

D. Nausea and vomiting Rationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is not used to treat any of the problems identified in the other options.

A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?

D. Oranges Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in vitamin C. Meats are high in protein. Dairy products are high in calcium.

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important?

D. Questioning the client about allergies to iodine or shellfish Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction, manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is injected intravenously. The client may or may not receive premedication. Nothing-by-mouth status is generally imposed after midnight on the day before the test.

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which of the following measures should the nurse take before the procedure? A. Imposing nothing-by-mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Rationale: In echocardiography, ultrasound is used to evaluate the heart's structure and motion. It is a noninvasive, risk-free, pain-free test that involves no special preparation and is commonly performed at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. The other options are incorrect.

A woman has been scheduled for a routine mammogram. The nurse should tell the client:

D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test Correct Rationale: The client should avoid using deodorants, powders, or creams on the day of the mammogram; such products used in the axillary or breast must be washed off before the test. The client may experience some discomfort because it is necessary to compress the breast tissue to obtain a clear image. The client may eat and drink before the procedure, which generally takes 15 to 30 minutes to complete.