part 12

Réussis tes devoirs et examens dès maintenant avec Quizwiz!

A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? "I cannot share my toothpaste with anyone." "I must flush the toilet three times after I use it." "I need to wash my clothes separately from everyone else's clothes." "I'm ready to hold my newborn grandson now."

How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)? Blocks reabsorption of sodium Increases blood pressure Increases cardiac output Works as an antidiuretic hormone (ADH) in the kidneys

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which of these questions by the nurse to the interdisciplinary health care team will result in reducing client exposure? a. "Should we filter air circulation?" b. "Can we use less radiographic contrast dye?" c. "Should we add low-dose dopamine?" d. "Should we increase IV rates?"

"Can we use less radiographic contrast dye?" Correct: Contrast dye is severely nephrotoxic and other options can be used in its place.

The nurse is providing discharge teaching to the client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching? "I can break in my shoes by wearing them all day." "I need to monitor my feet daily for blisters or skin breaks." "I should never go barefoot." "I should quit smoking."

"I can break in my shoes by wearing them all day."

The diabetic client has a hemoglobin (Hb)A1c level of 9.4. What does the nurse say to the client regarding this finding? "Keep up the good work." "This is not good at all." "What are you doing differently?" "You need more insulin."

"What are you doing differently?"

The nurse is teaching a client about how to monitor therapy effectiveness for syndrome of inappropriate antidiuretic hormone. What does the nurse tell the client to look for? Daily weight gain of less than 2 pounds Dry mucous membranes Increasing heart rate Muscle spasms

3. A client has a deficiency of aldosterone. Which assessment finding does the nurse correlate with this condition? a.Increased urine output b.Vasoconstriction c.Blood glucose, 98 mg/dL d.Serum sodium, 144 mEq/L

ANS: A Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Sodium and potassium levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia. Vasoconstriction is not related.

15. A client asks why a 24-hour urine collection is necessary to measure excreted hormones instead of a random voided specimen. Which response by the nurse is most accurate? a."We are testing for a hormone secreted on a circadian rhythm." b."The hormone is so dilute in urine, we need a large volume." c."We want to see when the hormone is secreted in both large and small amounts." d."You'd have to be here at a specific time of the day for a random urinalysis."

ANS: A Some hormones are secreted in a pulsatile, or circadian, cycle. When testing for these substances, a collection that occurs over 24 hours will most accurately reflect hormone secretion. The other responses are not accurate.

Which is the best referral that the nurse can suggest to a client newly diagnosed with diabetes? American Diabetes Association Centers for Disease Control and Prevention Health care provider office Pharmaceutical representative

American Diabetes Association

The nurse recognizes that which of these is the best indicator of kidney function? A BUN B Creatinine C AST D Alkaline phosphatase

The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? Client with Hashimoto's thyroiditis and a large goiter Client with hypothyroidism and an apical pulse of 51 beats/min Client with parathyroid adenoma and flank pain due to a kidney stone Client who had a parathyroidectomy yesterday and has muscle twitching

Which age-related change can cause nocturia? a. Decreased ability to concentrate urine b. Decreased production of antidiuretic hormone c. Increased production of erythropoietin d. Increased secretion of aldosterone

a. Decreased ability to concentrate urine

Which statement by the client with diabetic nephropathy indicates a need for further education about the disease? a. "Diabetes is the leading cause of kidney failure." b. "I need less insulin, so I am getting better." c. "I may need to reduce my insulin." d. "I must call my provider if the urine dipstick shows protein."

b. "I need less insulin, so I am getting better." When kidney function is reduced, the insulin is available for a longer time and thus less of it is needed. Unfortunately, many clients believe this means that their diabetes is improving.

*A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next?* A. Reduces the analgesic dose B. Gives diphenhydramine (Benadryl) C. Gives an antiemetic D. Calls the surgeon

*Answer: A* Rationale: Pruritus (itching) is a common side effect of epidural opioids and is first treated by reducing the analgesic dose. Because epidural-induced pruritus does not appear to be caused by histamine release, diphenhydramine (Benadryl) may not be effective in relieving itching and may work only via its sedating effects. Antiemetics are given to relieve nausea and vomiting. If a health care provider needs to be called, it would be the anesthesiologist, not the surgeon.

In reviewing the physician admission requests for the client admitted with hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis? 20 mEq KCl for each liter of IV fluid IV regular insulin at 2 units/hr IV normal saline at 100 mL/hr 1 ampule NaHCO3 IV now

1 ampule NaHCO3 IV now

The older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the nurse's best response? A "Have you tried using the toilet at least every couple of hours?" B "How does that make you feel?" C "We can fix that." D "That happens when we get older."

A client with an endocrine disorder says, "I can't, you know, satisfy my wife anymore." What is the nurse's best response? A."Can you please tell me more?" B."Don't worry. That is normal." C."How does she feel?" D."Should I make an appointment with a counselor?"

A Asking the client to explain his concerns in an open-ended question allows the nurse to explore his feelings more thoroughly. Telling a client that something is "normal" is dismissive; this is new to the client and is a concern for him. The focus of the nurse's response needs to be on the client, not on the wife initially. Referring the client to a counselor is not an appropriate first step; this dismisses the client's concerns and does not allow him to express his frustrations at the moment.

12. A new nurse is palpating a client's thyroid gland. Which action requires intervention from the nurse's mentor? a.The nurse stands behind, instead of in front of, the client. b.The client is asked to swallow while the nurse finds the thyroid gland. c.The nurse palpates the right lobe with his or her left hand. d.The client is placed in a sitting position with the chin tucked down.

ANS: C The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.

When caring for the client with uremia, the nurse assesses for which of these symptoms? A Tenderness at the costovertebral angle (CVA) B Cyanosis of the skin C Nausea and vomiting D Insomnia

Which laboratory result indicates that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)? Decreased hematocrit Decreased serum osmolality Increased serum sodium Increased urine specific gravity

When planning an assessment of the urethra, what does the nurse do first? A. Examines the meatus B. Notes any unusual discharge C. Records the presence of abnormalities D. Dons gloves

As the nurse is about to give the preoperative medication to the client going into surgery, it is discovered that the preoperative permit is not signed. What does the nurse do? A. Calls the surgeon B. Calls the anesthesiologist C. Gives the medication as ordered D. Has the client sign the permit

D. Has the client sign the permit Correct: The nurse may ask the client to sign the permit, after which the medication can be administered. Incorrect: A. Calls the surgeon Incorrect: Calling the surgeon is not necessary. B. Calls the anesthesiologist: Calling the anesthesiologist is not necessary. C. Gives the medication as ordered: It is illegal for the client to sign the permit after being sedated.

CHART EXHIBIT The nurse receives report on a 52-year-old client with type 2 diabetes. Assessment: Lungs clear Right great toe mottled Diagnostic: Glucose 179 Hemoglobin A1C 6.9 Prescriptions: Regular insulin 8 units if blood glucose 250 to 275 and cold to touch Regular insulin 10 units if glucose 275 to 300 Client states wears eyeglasses to read. Which complication of diabetes should the nurse report to the provider? Poor glucose control Visual changes Respiratory distress Peripheral tissue perfusion

Peripheral tissue perfusion

Which of these interventions is essential for the client in the oliguric phase of acute kidney injury (AKI)? a. Restrict fluids. b. Replace potassium. c. Administer blood transfusions. d. Monitor arterial blood gases (ABGs).

Restrict fluids. Correct: During the oliguric phase of AKI, the client will be at risk for fluid overload; fluid restriction is necessary to limit this problem .

The nurse assists the client with acute kidney injury (AKI) to modify the diet in which way? Select all that apply. a. Restricted protein b. Liberal sodium c. Fluid restriction d. Low potassium e. Low fat

Restricted protein Correct Fluid restriction Correct Low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen (BUN). Correct: Fluid is restricted during the oliguric stage. Correct: Potassium intoxication may occur; dietary potassium is restricted.

When caring for the client with acute kidney injury and a temporary subclavian hemodialysis catheter, which of these should the nurse report to the provider? a. Crackles at lung bases b. Temperature 100.8 c. +1 ankle edema d. Anorexia

Temperature 100.8 Correct: Infection is a major complication of temporary catheters. Report all symptoms of infection, including fever, to the provider. The catheter may have to be removed.

You have just received change-of-shift report on the endocrine unit. Which client should you see first? The type 1 diabetic client whose insulin pump is beeping "occlusion" The newly diagnosed type 1 diabetic client who is reporting thirst The type 2 diabetic client with a blood glucose of 150 mg/dL The type 2 diabetic client with a blood pressure of 150/90

The type 1 diabetic client whose insulin pump is beeping "occlusion"

The client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine? Day of discharge On admission When the client states readiness While performing the test in the hospital

While performing the test in the hospital

For which clients scheduled for a computed tomography (CT) scan with contrast does the nurse communicate safety concerns to the health care provider (HCP)? Select all that apply. a. Client with an allergy to shrimp b. Client with a history of asthma c. Client who requests morphine sulfate every 3 hours d. Client with a blood urea nitrogen of 62 mg/dL (22.1 mmol/L) and a creatinine of 2.0 mg/dL (177 umol/L) e. Client who took metformin (Glucophage) 4 hours ago

a, b, d, and e

Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? a. An 80-year-old man who has benign prostatic hyperplasia b. A 62-year-old woman with a known allergy to contrast media c. A 48-year-old woman with established urinary incontinence d. A 45-year-old man receiving oral and intravenous fluid therapy

a. An 80-year-old man who has benign prostatic hyperplasia

When obtaining a health history from a 22-year-old female client who has new onset urinary incontinence, which findings or factors does the nurse consider significant? (Select all that apply.) a. Chemical exposure in the workplace b. A burning sensation occurring on urination c. Urinating 10 times daily although fluid intake remains unchanged d. A recent change in the client's oral contraceptive prescription e. A new inability to hold urine (urgency) f. A "stinky" odor from the urine

b, c, e, and f

Which laboratory test is the best indicator of kidney function? a. Blood urea nitrogen (BUN) b. Creatinine c. Aspartate aminotransferase (AST) d. Alkaline phosphatase

b. Creatinine

Which percussion technique does the nurse use to assess a client who reports flank pain? a. Place outstretched fingers over the flank area and percuss with the fingertips. b. Place one hand with the palm down flat over the flank area and use the other fisted hand to thump the hand on the flank. c. Place one hand with the palm up over the flank area and cup the other hand to percuss the hand on the flank. d. Quickly tap the flank area with cupped hands.

b. Place one hand with the palm down flat over the flank area and use the other fisted hand to thump the hand on the flank.

The RN is caring for a client who has just had a kidney biopsy. Which action does the nurse perform first? a. Obtain blood urea nitrogen (BUN) and creatinine. b. Position the client supine. c. Administer pain medications. d. Check urine for hematuria.

b. Position the client supine.

Which interventions are helpful in preventing bladder cancer? Select all that apply. a. Drinking 2½ liters of fluid a day b. Showering after working with or around chemicals c. Stopping the use of tobacco d. Using pelvic floor muscle exercises e. Wearing a lead apron when working with chemicals f. Wearing gloves and a mask when working around chemicals and fumes

b. Showering after working with or around chemicals c. Stopping the use of tobacco f. Wearing gloves and a mask when working around chemicals and fumes (b)Certain chemicals (e.g., those used by professional hairdressers) are known to be carcinogenic in evaluating the risk for bladder cancer. Bathing after exposure to them is advisable. (c) Tobacco use is one of the highest if not the highest risk factor in the development of bladder cancer. (f) Certain chemicals (e.g., those used by professional hairdressers) are known to be carcinogenic in evaluating the risk for bladder cancer. Protective gear is advised. INCORRECT: (a) Increasing fluid intake is helpful for some urinary problems such as urinary tract infection (UTI), but no correlation has been noted between fluid intake and bladder cancer risk. (d) Using pelvic floor muscle strengthening exercises (Kegel) is helpful with certain types of incontinence; but no data show that these exercises prevent bladder cancer. (e) Precautions should be taken when working with chemicals; however, lead aprons are used to protect from radiation.

The nurse receives report on a client with hydronephrosis. Which laboratory study should the nurse monitor? a. Hemoglobin and hematocrit (H&H) b. White blood cell (WBC) count c. Blood urea nitrogen and creatinine d. Lipid levels

c. Blood urea nitrogen and creatinine With back pressure on the kidney, glomerular filtration is reduced or absent resulting in permanent kidney damage; BUN and creatinine are kidney function tests.

A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the health care provider before the ESWL procedure begins? a. "Blood in my urine has become less noticeable; maybe I don't need this procedure." b. "I have been taking cephalexin (Keflex) for an infection." c. "I previously had several ESWL procedures performed." d. "I take over-the-counter naproxen (Aleve) twice a day for joint pain."

d. "I take over-the-counter naproxen (Aleve) twice a day for joint pain." Because a high risk for bleeding during ESWL has been noted, clients should not take NSAIDs before this procedure. The ESWL will have to be rescheduled for this client.

One of the nurse's roles is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body areas? a. Children's terms that are easily understood b. Slang words and terms that are heard "socially" c. Technical and medical terminology d. Words that the client uses

d. Words that the client uses

A nurse is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body parts? a. Children's terms that are easily understood b. Slang words and terms that are heard "socially" c. Technical and medical terminology d. Words that the client uses

d. Words that the client uses The nurse should use the terms with which the client is most familiar, so there is no chance for the client to misunderstand information. Using the client's language ensures the comfort level for the client.

A nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates correct understanding of these procedures? a. "If I restrict my oral intake of fluids, the adjustment will be easier." b. "I must go to the restroom more often because my urine will be excreted through my anus." c. "I need to wear loose-fitting pants so the urine can flow into my ostomy bag." d."I will have to drain my pouch with a catheter."

d."I will have to drain my pouch with a catheter." For the client with a neobladder and a Kock pouch, urine is collected in a pouch and is drained with the use of a catheter.

The nurse is teaching the client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? "I should go barefoot in my house so that my feet are exposed to air." "I must inspect my shoes for foreign objects before putting them on." "I will soak my feet in warm water to soften calluses before trying to remove them." "I must wear canvas shoes as much as possible to decrease pressure on my feet."

"I must inspect my shoes for foreign objects before putting them on."

The nurse is teaching the client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? "I should begin exercising for at least an hour a day." "I should monitor my diet." "If I lose weight, I may not need to use the insulin anymore." "Weight loss can be a sign of diabetic ketoacidosis."

"I should begin exercising for at least an hour a day."

The nurse is teaching the client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates correct understanding of hypoglycemia management? "I should drink a glass of water." "I should eat three graham crackers." "I should give myself 1 mg of glucagon." "I should sit down and rest."

"I should eat three graham crackers."

The nurse is providing discharge teaching to the client with newly diagnosed diabetes. Which statement by the client indicates correct understanding about the need to wear a medical alert bracelet? "If I become hyperglycemic, it is a medical emergency." "If I become hypoglycemic, I could become unconscious." "Medical personnel may need confirmation of my insurance." "I may need to be admitted to the hospital suddenly."

"If I become hypoglycemic, I could become unconscious."

When teaching the client who is to undergo kidney transplant surgery, the nurse includes which of these in the teaching session? a. "Your diseased kidneys will be removed at the same time the transplantation is performed." b. "The new kidney will be placed directly below one of your old kidneys." c. "It is essential for you to wash your hands and avoid people who are ill." d. "You will receive dialysis the day before surgery and for about a week after."

"It is essential for you to wash your hands and avoid people who are ill." Correct: Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential.

The client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? "It is overwhelming, isn't it?" "Let's see how much you can learn today, so you are less nervous." "Let's tackle it piece by piece. What is most scary to you?" "Other people do it just fine."

"Let's tackle it piece by piece. What is most scary to you?"

Discharge teaching has been provided for the client recovering from kidney transplantation. Which information indicates that the client understands the instructions? a. "I can stop my medications when my kidney function return to normal." b. "If my urine output is decreased, I should increase my fluids." c. "The anti-rejection medications will be taken for life." d. "I will drink 8 ounces of water with my medications."

"The anti-rejection medications will be taken for life." Correct: Immune suppressant therapy must be taken for life to prevent organ rejection.

The client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? a. "All of this is new. What can't you do?" b. "Are you afraid of dying?" c. "How are you doing this morning?" d. "What concerns do you have about your kidney disease?"

"What concerns do you have about your kidney disease?" Correct: This statement is open ended and specific to the client?s concerns.

The client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? a. "I'll talk to the doctor and have your name removed from the waiting list" b. "You sound frustrated with the situation." c. "You're right, the wait is endless for some people." d. "I'm sure you'll get a phone call soon that a kidney is available."

"You sound frustrated with the situation." Correct: This option reflects the feelings the client is having and offers assistance and support.

The client with type 2 diabetes has been admitted for surgery, and the physician has placed her on insulin. The client wants to know why she should have to take this. What is your best response? "Your diabetes is worse, so you will need to take insulin." "You can't take your metformin while in the hospital." "Your body is under more stress, so you will need to have insulin to support your medication." "You will have to take insulin from now on because the surgery will affect your diabetes."

"Your body is under more stress, so you will need to have insulin to support your medication."

*A client has a one-time order for morphine 2 mg IV push. The drug is available as 5 mg/mL. The nurse administers _____ mL of morphine for one dose.*

*Answer: 0.4* Rationale: The available 1 mL of solution contains 5 mg of the drug. Therefore, to give 2 mg, less than 1 mL would be given. Using dimensional analysis or ratio and proportion, 2/5 = 0.4. (Pg. 41)

*The nurse manager on the surgical unit is making assignments for the day. Who is assigned to check and program the patient-controlled analgesia (PCA) pumps on the unit?* A. A pharmacy technician B. One registered nurse (RN) C. One registered nurse (RN) and a certified nursing assistant (CNA) D. Two registered nurses (RNs)

*Answer: D* Rationale: To prevent drug errors, it is recommended that two RNs program the dosing parameters into the PCA delivery device to prevent drug errors. A pharmacy technician or CNA would not be authorized or credentialed to perform this task.

*A client had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan?* A. Encouraging diversional activities B. Incorporating activities of daily living as soon as possible C. Teaching key points of the relaxation response D. Using pre-emptive analgesia

*Answer: D* Rationale: Use of pre-emptive analgesia is a technique designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay. Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

1. 9. The client is newly diagnosed with a life-threatening cancer and has mixed feelings. Which complementary and alternative medicine therapy is best for the nurse to suggest? A. Aromatherapy B. Imagery C. Journaling D. Massage

9 Correct: Because the client has mixed feelings, journaling would allow an opportunity for the client to record those thoughts and feelings. This would provide an opportunity for self-reflection.

A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI? Desmopressin (DDAVP) Dopamine hydrochloride (Intropin) Prednisone Tolvaptan (Samsca)

A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? "I can return to my job at the nursing home." "I must call if my urine is dark." "I must faithfully take the drug every 8 hours." "I need to report weight gain."

A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L, K+ 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates? Administer insulin and dextrose in normal saline to shift potassium into cells. Give spironolactone (Aldactone) 100 mg orally. Initiate histamine2 (H2) blocker therapy with ranitidine for ulcer prophylaxis. Obtain arterial blood gases to assess for peaked T waves.

A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first? Force fluids Offer lip balm Perform a 24-hour urine test Withhold desmopressin acetate (DDAVP)

A client with iatrogenic Cushing's syndrome is a resident in a long-term care facility. Which nursing action included in the client's care would be best to delegate to unlicensed assistive personnel (UAP)? Assist with personal hygiene and skin care. Develop a plan of care to minimize risk for infection. Instruct the client on the reasons to avoid overeating. Monitor for signs and symptoms of fluid retention.

A client with pheochromocytoma is admitted for surgery. What does the nurse do for the admitting assessment? Avoids palpating the abdomen Monitors for pulmonary edema with a chest x-ray Obtains a 24-hour urine specimen on admission Places the client in a room with a roommate for distraction

After receiving change-of-shift report about these four clients, which client does the nurse attend to first? Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L Client with pituitary adenoma who is reporting a severe headache

The client has returned form a captopril renal scan. Which teaching should the nurse provide when the client returns? A "Arise slowly and call for assistance when ambulating." B "I must measure your intake and output (I&O)." C "We must save your urine because it is radioactive." D "I must attach you to this cardiac monitor."

When assessing the older adult, the nurse teaches the older adult that which age-related change causes nocturia? A Decreased ability to concentrate urine B Decreased production of antidiuretic hormone C Increased production of erythropoietin D Increased secretion of aldosterone

Which urinary assessment information indicates the potential need for increased fluids in the client? A Increased blood urea nitrogen B Increased creatinine C Pale-colored urine D Decreased sodium

The nurse should encourage fluids every 2 hours for older adult clients because of a decrease in which factor? A.Antidiuretic hormone (ADH) production B.General metabolism C.Glucose tolerance D.Ovarian production of estrogen

A A decrease in ADH production causes urine to be more dilute, so urine might not concentrate when fluid intake is low. The older adult is at greater risk for dehydration as a result of urine loss. A decrease in general metabolism causes decreased tolerance to cold, decreased appetite, and decreased heart rate and blood pressure; it is not related to fluid intake or hydration. A decrease in glucose tolerance does not affect fluid intake or hydration. A decrease in estrogen production causes a decrease in bone density and is not related to fluid intake and hydration.

The charge nurse on the medical-surgical unit is making client assignments for the shift. Which client is the most appropriate to assign to an LPN/LVN? A.Client with Cushing's syndrome who requires orthostatic vital signs assessments B.Client with diabetes mellitus who was admitted with a blood glucose of 45 mg/dL C.Client with exophthalmos who has many questions about endocrine function D.Client with possible pituitary adenoma who has just arrived on the nursing unit

A An LPN/LVN will be familiar with Cushing's syndrome and the method for assessment of orthostatic vital signs. The client with a blood glucose of 45 mg/dL, the client with questions about endocrine function, and the client with a possible pituitary adenoma all have complex needs that require the experience and scope of practice of an RN.

The nurse is teaching a client about maintaining a proper diet to prevent an endocrine disorder. Which food does the nurse suggest after the client indicates a dislike of fish? A.Iodized salt for cooking B.More red meat C.More green vegetables D.Salt substitute for cooking

A Dietary deficiencies in iodide-containing foods may be a cause of an endocrine disorder. For clients who do not eat saltwater fish on a regular basis, teach them to use iodized salt in food preparation. The client should eat a well-balanced diet that includes less animal fat. Eating vegetables contributes to a proper diet; however, this does not prevent an endocrine disorder. Using a salt substitute does not prevent an endocrine disorder; in addition, salt substitutes may contain high levels of potassium, which may lead to electrolyte imbalances.

The nurse is instructing a client who will undergo a suppression test. Which statement by the client indicates that teaching was effective? A."I am being tested to see whether my hormone glands are hyperactive." B."I am being tested to see whether my hormone glands are hypoactive." C."I am being tested to see whether my kidneys work at all." D."I will be given more hormones as a trigger."

A Suppression tests are used when hormone levels are high or in the upper range of normal. Failure of suppression of hormone production during testing indicates hyperfunction. A stimulation test assesses whether hormone glands are hypoactive. The adrenal glands are endocrine glands that are located on the kidneys; a suppression test does not measure kidney function. Hormones are given as a trigger in a stimulation test.

Which gland releases catecholamines? A.Adrenal B.Pancreas C.Parathyroid D.Thyroid

A The adrenal medulla releases catecholamines in response to stimulation of the sympathetic nervous system. The principal hormones of the pancreas are insulin, glucagon, and somatostatin. Parathyroid hormone is the principal hormone of the parathyroid gland. Triiodothyronine (T3), thyroxine (T4), and calcitonin are the principal hormones of the thyroid.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? A Creatinine, 1.9 mg/dL B Fasting glucose, 80 mg/dL C Potassium, 3.9 mEq/L D Sodium, 140 mEq/L

A Creatinine, 1.9 mg/dL Correct: This result is outside the normal range. B Fasting glucose, 80 mg/dL: This result is within normal limits. C Potassium, 3.9 mEq/L: This result is within normal limits. D Sodium, 140 mEq/L: This result is within normal limits.

The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? a. A client with chronic kidney failure who was just admitted with shortness of breath b. A client with kidney insufficiency who is scheduled to have an arteriovenous (AV) fistula inserted c. A client with azotemia whose blood urea nitrogen and creatinine are increasing d. A client receiving peritoneal dialysis who needs help changing the dialysate bag

A client with chronic kidney failure who was just admitted with shortness of breath Correct: This client's dyspnea may indicate pulmonary edema and should be assessed immediately.

The nurse reviews with the client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? A. "I may need to restrict my activities for several months." B. "The dressing should stay in place unless it gets wet." C. "The incision needs to be cleaned every 4 hours with hydrogen peroxide." D. "The wound will completely heal in about 2 months."

A. "I may need to restrict my activities for several months." Correct: To protect the integrity of the wound, activities may need to be restricted. Incorrect: B. "The dressing should stay in place unless it gets wet.": The wound will need to be open to air for healing. C. "The incision needs to be cleaned every 4 hours with hydrogen peroxide.": Using hydrogen peroxide can cause wound irritation, unless specifically ordered. D. "The wound will completely heal in about 2 months.": The length of time it takes for a wound to heal varies; a wound can take up to 2 years to heal.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client would the nurse care for first? A. A 43-year-old client who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing B. A 46-year-old client who had a thoracotomy 5 days ago and needs discharge teaching before going home C. A 48-year-old client who had bladder surgery earlier in the day and is complaining of pain when coughing D. A 49-year-old client who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

A. A 43-year-old client who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing Correct: New drainage on the fifth postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. Incorrect: B. A 46-year-old client who had a thoracotomy 5 days ago and needs discharge teaching before going home: This client is not in need of immediate care at this time. C. A 48-year-old client who had bladder surgery earlier in the day and is complaining of pain when coughing: This client is stable and does not require immediate action or care. D. A 49-year-old client who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C): This client is stable and does not require immediate action or care.

In conducting a postoperative assessment of the client, what is most important for the nurse to examine first? A. Breathing pattern B. Level of consciousness C. Oxygen saturation D. Surgical site

A. Breathing pattern Correct: Respiratory assessment is the most important. Incorrect: B. Level of consciousness: Assessing the level of consciousness is secondary. C. Oxygen saturation: Assessing oxygen saturation is secondary. D. Surgical site: Assessing the surgical site is secondary.

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? A. Circulating nurse B. Holding nurse C. Anesthesiologist D. Surgeon

A. Circulating nurse Correct: All are responsible, but the circulating nurse moves around the room and can see more of what is happening. Incorrect: B. Holding nurse: The holding nurse is not in the operating room. C. Anesthesiologist: All are responsible, but the anesthesiologist is focused on providing sedation to the client. D. Surgeon: All are responsible, but the surgeon is concentrating on the surgery and usually cannot monitor all staff.

Who is the most likely person to administer blood products in an operating suite? A. Circulating nurse B. Holding area nurse C. Scrub nurse D. Specialty nurse

A. Circulating nurse Correct: Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Incorrect: B. Holding area nurse: Holding area nurses manage the client's care before surgery. Blood would not yet be needed at this point. C. Scrub nurse: Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. D. Specialty nurse: Specialty nurses may be in charge of a particular type of surgical specialty. They are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.

The unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse who is verifying the informed consent do? A. Ensure written consultation of two noninvolved physicians. B. Read the surgeon's consult to determine whether the client's condition is life threatening. C. Sign the operative permit. D. Withhold surgery until the next of kin is notified.

A. Ensure written consultation of two noninvolved physicians. Correct: In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the physician. Incorrect: B. Read the surgeon's consult to determine whether the client's condition is life threatening: It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. C. Sign the operative permit: Signing documents on the client's behalf is not legal. D. Withhold surgery until the next of kin is notified: Withholding surgery is not in this client's best interests.

The client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? A. Supplemental pain reduction is needed. B. One dose is needed. C. This is an acute emergency. D. The client will be hostile.

A. Supplemental pain reduction is needed. Correct: The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Incorrect: B. One dose is needed: Several doses may be needed because naloxone has a shorter half-life. C. This is an acute emergency: This is a manageable situation. D. The client will be hostile: The client with opioid depression usually is not fully conscious.

The client is scheduled for intravenous urography. During the assessment, the nurse notes a previous reaction of urticaria, itching, and sneezing to contrast dye. Which precautions does the nurse take? Select all that apply. A Ensures that an antihistamine and a steroid are prescribed B Documents the reaction on the chart C Uses no contrast dye for the procedure D Cancels the procedure E Ensures that the health care provider is aware of the reaction

ABE

The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? (Select all that apply.) Calcium gluconate Emergency tracheotomy kit Furosemide (Lasix) Hypertonic saline Oxygen Suction

ABEF

17. The nurse is teaching a client about self-care after menopause. Which teaching topic is the priority? a.Weight-bearing exercise b.Skin care c.Intimacy needs d.Body image changes

ANS: A After menopause, the ovaries produce less estrogen. This leads to decreased bone mass. The client should engage in regular weight-bearing exercise to prevent fractures. The other topics are appropriate but do not take priority over safety needs.

18. The nursing assistant reports that while pouring urine into a 24-hour urine container, some urine splashed the nursing assistant's hand. Which action by the nurse is best? a.Ask the assistant if he or she washed the hands afterward. b.Call the laboratory to see if the container has preservative in it. c.Have the assistant fill out an incident report. d.Send the assistant to Employee Health right away.

ANS: A For safety, the nurse should find out if the assistant washed his or her hands. The nursing assistant should do this for two reasons. First, it is part of Standard Precautions to wash hands after client care. Second, if the container did have preservative in it, this would wash it away. The preservative may be caustic to the skin. The nurse can call the laboratory while the assistant is washing hands if needed. The nursing assistant would then need to fill out an incident or exposure report and may or may not need to go to Employee Health. The nursing assistant also needs further education on Standard Precautions, which include wearing gloves.

9. Which pulse rate finding in a client taking a drug that stimulates beta1 receptors requires immediate action by the nurse? a.50 beats/min b.95 beats/min c.85 beats/min d.100 beats/min

ANS: A Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other heart rates are within normal limits but on the higher end and would be considered a therapeutic response to the medication.

6. A client is admitted to the hospital with exacerbation of heart failure, which had been stable for several years. Which finding does the nurse associate with the client's current condition? a.Recent prescription for thyroid hormone replacement medication b.Recent onset of menopause c.Patchy areas of depigmentation on the face d.Absence of fish in the diet, but inclusion of the iodized form of table salt

ANS: A Thyroid hormones regulate metabolism. Starting on thyroid replacement therapy can lead to an increase in heart rate and tissue oxygen use, which can lead to an exacerbation of heart failure if the client's heart is not able to meet these increased demands. Menopause and vitiligo (depigmentation of the skin) would not be related. Thyroid function is needed to produce thyroid hormones. The client who does not eat shellfish should use iodized table salt.

11. A client has bilateral patchy areas of skin depigmentation on the arms and the face. Which action by the nurse is best? a.Assess the client's mucous membranes. b.Draw a laboratory specimen for thyroid hormone levels. c.Schedule the client for fasting blood glucose. d.Question the client about sexual functioning.

ANS: A Vitiligo, patchy areas of depigmentation of the skin, is associated with primary hypofunction of the adrenal glands. Other assessment findings in this condition include uneven pigmentation on the mucous membranes. The other assessments are not related to vitiligo.

1. Which are common key features of hormones? (Select all that apply.) a.Hormones may travel long distances to get to their target tissues. b.Continued hormone activity requires continued production and secretion. c.Control of hormone activity is caused by negative feedback mechanisms. d.Most hormones are stored in the target tissue for use later. e.Most hormones cause target tissues to change activities by changing gene activity.

ANS: A, B, C Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the body's needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

2. A client has a hypofunctioning anterior pituitary gland. Which hormones does the nurse expect to be affected by this? (Select all that apply.) a.Thyroid-stimulating hormone b.Vasopressin c.Follicle-stimulating hormone d.Calcitonin e.Growth hormone

ANS: A, C, E Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

16. An older client is being admitted to the hospital for pneumonia. The client has no other health problems. Which action by the nurse is best? a.Place the client on airborne precautions. b.Offer the client fluids every hour or two. c.Leave the bathroom light on at night. d.Palpate the client's thyroid gland on admission.

ANS: B A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more dilute urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with a simple pneumonia would not need Airborne Precautions. The client may or may not need/want the bathroom light left on at night. Palpating the client's thyroid gland is a part of a comprehensive examination but is not specifically related to this client.

5. A client has a condition of excessive catecholamine release. Which assessment finding does the nurse correlate with this condition? a.Decreased blood pressure b.Increased pulse c.Decreased respiratory rate d.No change in vital signs

ANS: B Catecholamines are responsible for the "fight-or-flight" stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. The other options are not correlated with excessive catecholamine release.

14. A female client with an endocrine problem has hirsutism. Which question or statement by the nurse is most appropriate? a."Do you have the money to pay for treatment?" b."I'm interested in knowing how you feel about yourself." c."Many treatment options are available for this problem." d."What can you do to prevent this from happening?"

ANS: B Hirsutism, excessive hair growth on the face and body, can result from endocrine disorders. This may cause a disruption in body image, especially for female clients. The nurse should gently inquire into the client's body image and self-perception. Asking about the client's financial status sounds judgmental. Simply stating that treatment options are available minimizes the client's concerns. The client is not doing anything to herself to cause the problem, so the last question is inappropriate.

A client is taking a drug that blocks a hormone's receptor site. What is the effect on the client's hormone response? a.Greater hormone metabolism b.Decreased hormone activity c.Increased hormone activity d.Unchanged hormone response

ANS: B Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cell's response is the same as when the level of the hormone is decreased.

4. A male client reports fluid secretion from his breasts. What does the nurse assess next in this client? a.Posterior pituitary hormones b.Adrenal medulla functioning c.Anterior pituitary hormones d.Parathyroid functioning

ANS: C Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones do not influence this process.

7. A client has abnormal calcium levels. Which hormone does the nurse anticipate testing for? a.Thyroxine (T4) b.Triiodothyronine (T3) c.Thyrocalcitonin (calcitonin) d.Propylthiouracil (PTU)

ANS: C Parafollicular cells produce thyrocalcitonin (calcitonin [TCT]), which helps regulate serum calcium levels. The other hormones are not related directly to calcium levels.

13. Which client statement indicates the need for clarification regarding the instructions for collecting a 24-hour urine specimen for assessment of endocrine function? a."I will continue to take all my prescribed medicine during the test." b."I will add the preservative to the container at the beginning of the test." c."I will start the collection by saving the first urine of the morning." d."At the end of 24 hours, I will urinate and save that last specimen."

ANS: C The 24-hour urine collection specimen is started when the client first arises and urinates. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time is noted. The client adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time and adds this specimen to the collection. The preservative, if used, must be added to the container at the beginning of the collection. Clients can continue to take all their normal medications during a timed urine collection. They should, however, avoid unnecessary medications.

2. How does a tropic hormone differ from other hormones? a.Tropic hormones are given to clients who have a hormone deficiency. b.Tropic hormones are exclusively involved in the production of sex hormones. c.Tropic hormones stimulate other endocrine glands to secrete hormones. d.Tropic hormones are not under negative feedback control.

ANS: C The target tissues for tropic hormones are other endocrine glands. The effect of these agents is to stimulate another endocrine gland to secrete its hormone. The other statements are inaccurate.

10. Which situation or condition is likely to result in increased production of thyroid hormones? a.Starvation b.Dehydration c.Adequate sleep d.Cold environmental temperature

ANS: D Cold environmental temperatures stimulate the hypothalamus to secrete thyrotropin-releasing hormone, which in turn stimulates the anterior pituitary gland to secrete thyroid-stimulating hormone (TSH). TSH then stimulates the thyroid gland to secrete thyroid hormones, which, when bound to target tissues, increase the rate of metabolism to maintain body temperature near normal. The other situations would not lead to an increase in thyroid hormone production.

8. Which is the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating hormone? a.Hypoglycemia and hyperkalemia b.Irritability and insomnia c.Increased urine output d.Darkening of the skin

ANS: D Melanocyte-stimulating hormone increases the size of melanocytes in the skin and increases the amount of pigment (melanin) that they produce. The other actions do not occur as the result of excessive melanocyte-stimulating hormone function.

Which finding in the first 24 hours after kidney transplantation requires immediate intervention? a. Abrupt decrease in urine output b. Blood-tinged urine c. Incisional pain d. Increase in urine output

Abrupt decrease in urine output Correct: An abrupt decrease in urine output may indicate complications such as rejection, acute tubular necrosis (ATN), thrombosis, or obstruction.

A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen (BUN) requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? a. An RN who has floated from pediatrics for this shift b. An LPN/LVN with experience working on the medical unit c. An RN who usually works on the general surgical unit d. A new graduate RN who just finished a 6-week orientation

An RN who usually works on the general surgical unit Correct: The nurse with experience in taking care of surgical clients will be most capable of monitoring this older client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure.

The nurse carefully observes for toxicity of drugs excreted through the kidney. Which of these represents a sign or symptom of digoxin toxicity? a. Serum digoxin level of 1.2 ng/mL b. Polyphagia c. Anorexia d. Serum potassium of 5.0 mEq/L

Anorexia Correct: Anorexia, nausea, and vomiting are symptoms of digoxin toxicity.

When caring for a group of clients, the nurse recognizes that which clients are at risk for acute kidney injury (AKI)? Select all that apply. a. Football player in preseason practice b. Client who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage d. Accountant with diabetes e. Client in the intensive care unit on high doses of antibiotics f. Client recovering from gastrointestinal influenza

Answer: Football player in preseason practice; Client who underwent contrast dye radiology; Accident victim recovering from a severe hemorrhage; Client in the intensive care unit on high doses of antibiotics; Client recovering from gastrointestinal influenza Rationale: Urge all people to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis. Contrast media may cause acute renal failure (ARF), especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause acute kidney injury. Certain antibiotics may cause nephrotoxicity. Dehydration reduces kidney blood flow and may cause acute kidney injury.

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1c) is 8.2%. Which action will the nurse plan to take next? Instruct the client to continue with the current diet and Glucophage use. Discuss the need to check blood glucose several times every day. Talk about the possibility of adding rapid-acting insulin to the regimen. Ask the client about current dietary intake and medication use.

Ask the client about current dietary intake and medication use.

Which of these nursing actions can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? Assist the client's spouse in choosing appropriate dietary items. Evaluate the client's use of a home blood glucose monitor. Inspect the extremities for evidence of poor circulation. Assist the client with washing his feet and applying moisturizing lotion.

Assist the client with washing his feet and applying moisturizing lotion.

When caring for the client with a left forearm arteriovenous (AV) fistula created for hemodialysis, the nurse must do which of these? Select all that apply. a. Check brachial pulses daily. b. Auscultate for a bruit each shift. c. Teach the client to palpate for a thrill over the site. d. Elevate the arm above heart level. e. Ensure that no blood pressures are taken in that arm.

Auscultate for a bruit each shift. Correct Teach the client to palpate for a thrill over the site. Correct Ensure that no blood pressures are taken in that arm. A bruit or swishing sound should be present, indicating patency of the fistula. A thrill or buzzing sensation upon palpation should be present, indicating patency of the fistula. No blood pressure, venipuncture, or compression such as lying on the fistula should occur.

The client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? a. Auscultate for pericardial friction rub. b. Assess for crackles. c. Monitor for decreased peripheral pulses. d. Determine whether the client is able to ambulate.

Auscultate for pericardial friction rub. Correct: The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST segment elevation.

Which teaching by the nurse will help the client prevent renal osteodystrophy? a. Low-calcium diet b. Avoiding peas, nuts, and legumes c. Drinking cola beverages only once daily d. Avoiding dairy enriched with vitamin D

Avoiding peas, nuts, and legumes Correct: Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes.

The client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? a. Avoiding venipuncture and blood pressure measurements in the affected arm b. Discussion on modifications to allow for complete arm rest c. Information on how to assess for bruit d. Information on proper nutrition

Avoiding venipuncture and blood pressure measurements in the affected arm Correct: Compression of vascular access causes decreased blood flow and may cause occlusion; dialysis will not be possible.

A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? Calls the provider Encourages the client to rest Immediately assesses cardiac status Tells the client to slow down

A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? Advise the client to go to a calming environment. Ask whether the client has increased cold sensitivity or weight gain. Instruct the client to see his health care provider immediately. Tell the client to check his pulse again and call back later.

A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? Edema at the surgical site Hoarseness Pain on moving the head Sore throat

A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder? Atenolol (Tenormin) Levothyroxine sodium (Synthroid) Methimazole (Tapazole) Propylthiouracil

A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? Encourages the client to cough and deep-breathe Instructs the client not to strain during a bowel movement Instructs the client to blow the nose for postnasal drip Places the client in the Trendelenburg position

A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8° F oral. Which nursing intervention is the highest priority for this client? Administering furosemide (Lasix) Providing isotonic fluids Replacing potassium losses Restricting sodium

A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next? Calls the health care provider Monitors intake and output Performs an immediate cardiac assessment Slows the rate of IV fluids

The RN is caring for a client who has just had a kidney biopsy. Which of these actions should the nurse perform first? A Obtain BUN and creatinine. B Position the client supine. C Administer pain medications. D Check urine for hematuria.

The charge nurse is making client assignments for the day shift. Which client would be best to assign to an LPN/LVN? A A client who has just returned from having a kidney artery angioplasty B A client with polycystic kidney disease who is having a kidney ultrasound C A client who is going for a cystoscopy and cystourethroscopy D A client with glomerulonephritis who is having a kidney biopsy

The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? Anxiety Headache Nausea Weight loss

What should the nurse teach the client who is undergoing a study using contrast media? A "You will need to have anesthesia or sedation." B "A feeling of heat or warmth occurs when the contrast is injected." C "Expect your urine to have a pink or red tinge after the procedure." D "You will not be able to eat or drink for 4 to 6 hours after the procedure."

Which percussion technique does the nurse use to assess the client with reports of flank pain? A Places fingers outstretched over the flank area and percusses with fingertips B Places one hand with palm down flat over the flank area and uses the other fisted hand to thump the hand on the flank C Places one hand with the palm up over the flank area and cups the other hand to percuss the hand on the flank D Quickly taps the flank area with cupped hands

The nurse is teaching a client about the correct procedure for a 24-hour urine test for creatinine clearance. Which statement by the client indicates a need for further teaching? A."I should keep the urine container cool in a separate refrigerator or cooler." B."I should not eat any protein when I am collecting urine for this test." C."I won't save the first urine sample." D."To end the collection, I must empty my bladder, adding it to the collection."

B Eating protein does not interfere with collection or testing of the urine sample. Because the specimen must be kept cool, it can be placed in an inexpensive cooler with ice; the client should not keep the specimen container with food or beverages. The timing of the 24-hour collection begins after the initial void. To end a 24-hour urine specimen, emptying the bladder and adding it to the collection is the proper procedure.

To best determine how well a client with diabetes mellitus is controlling blood glucose, which test does the nurse monitor? A.Fasting blood glucose B.Glycosylated hemoglobin (HbA1c) C.Oral glucose tolerance test D.Urine glucose level

B Glycosylated hemoglobin indicates the average blood glucose over several months and is the best indicator of overall blood glucose control. Fasting blood glucose can be used to monitor glucose control, but it is not the best method (although this may be the method that clients are most familiar with). Oral glucose testing and urine glucose levels look at one period of time and are not the best methods to look at overall effectiveness of treatment.

Which statement is true about hormones and their receptor sites? A.Hormone activity is dependent only on the function of the receptor site. B.Hormones need a specific receptor site to work. C.Hormones need to be plasma-bound to activate the receptor site. D.Hormone stores are available for activation until needed.

B In general, each receptor site type is specific for only one hormone. Hormone receptor actions work in a "lock and key" manner, in that only the correct hormone (key) can bind to and activate the receptor site (lock). Hormones travel through the blood to all body areas, but exert their actions only on target tissues. Not all hormones are plasma-bound; for example, thyroid hormones are plasma protein-bound, whereas posterior pituitary hormones are transported by axons. Only certain cells manufacture specific hormones and store the hormones in vesicles.

A client is hospitalized for pituitary function testing. Which nursing action included in the client's plan of care will be most appropriate for the RN to delegate to the LPN/LVN? A.Assess the client for clinical manifestations of hypopituitarism. B.Inject regular insulin for the growth hormone stimulation test. C.Palpate the thyroid gland for size and firmness. D.Teach the client about the adrenocorticotropic hormone stimulation test.

B Injection of insulin is within the LPN/LVN scope of practice. Client assessment for clinical manifestations of hypopituitarism, palpating the thyroid gland, and client education are complex skills requiring training and expertise, and are best performed by an RN.

In type 1 diabetes, insulin injections are necessary to maintain which action between insulin and glucose? A.Glucose intolerance B.Homeostasis C.Insulin intolerance D.Negative feedback

B Insulin injections maintain homeostasis, or normal balance, between insulin and glucose in the client with type 1 diabetes. Type 1 diabetes is a lack of insulin production, not glucose intolerance, and requires frequent doses of insulin. Negative feedback does not occur in type 1 diabetes because of lack of insulin.

The nurse is assessing a client for endocrine dysfunction. Which comment by the client indicates a need for further assessment? A."I am worried about losing my job because of cutbacks." B."I don't have any patience with my kids. I lose my temper faster." C."I don't seem to have any stressors now." D."My weight has been stable these past few years."

B Many endocrine problems can change a client's behavior, personality, and psychological responses; the client stating that he or she has become short-tempered warrants further assessment. Worrying about losing a job is a normal concern but does not give any indication of a need for further assessment. The nurse will need to assess the client's claim that he or she has no stressors at present because the client's response does not provide enough information to make this determination; however, the client's statement about losing patience is the priority. Weight gain or loss may or may not be an indication of an endocrine disorder.

Which client is at greatest risk for slow wound healing? A. 12-year-old healthy girl B. 47-year-old obese man with diabetes C. 48-year-old woman who smokes D. 98-year-old healthy man

B. 47-year-old obese man with diabetes Correct: Diabetes and obesity significantly contribute to slow wound healing. Incorrect: A. 12-year-old healthy girl: This client is not at highest risk. C. 48-year-old woman who smokes: This client is not at highest risk. D. 98-year-old healthy man: This client is not at highest risk.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? A. Contacts the anesthesiologist B. Contacts the surgeon C. Explains the procedure D. Has the client sign the form

B. Contacts the surgeon Correct: The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the physician and to dispel myths that the client or family may have about the surgical experience. Incorrect: A. Contacts the anesthesiologis: The anesthesiologist is responsible for the anesthesia, not the surgical details. C. Explains the procedur: The nurse is not responsible for providing detailed information about the surgical procedure. D. Has the client sign the form: Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified.

Which action does the nurse implement for the client with wound evisceration? A. Applies direct pressure to the wound B. Covers the wound with a sterile, warm, moist dressing C. Irrigates the wound with warm, sterile saline D. Replaces tissue protruding into the opening

B. Covers the wound with a sterile, warm, moist dressing Correct: Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Incorrect: A. Applies direct pressure to the wound: Applying direct pressure to a wound traumatizes the organs. C. Irrigates the wound with warm, sterile saline: Irrigating the wound is not necessary. D. Replaces tissue protruding into the opening: Replacing protruding tissue could induce infection.

An RN and an LPN/LVN are working together in caring for a client who needs all of the following actions after orthopedic surgery. Which actions would be best for the RN to accomplish? A. Reinforce the need to cough and deep breathe every 2 to 4 hours. B. Develop the discharge teaching plan in conjunction with the client. C. Administer narcotic pain medications before assisting the client with ambulation. D. Listen for bowel sounds, and monitor the abdomen for distention and pain.

B. Develop the discharge teaching plan in conjunction with the client. Correct: Education and preparation for discharge are within the scope of practice of the RN. Incorrect: A. Reinforce the need to cough and deep breathe every 2 to 4 hours: This is in the scope of the LVN/LPN nurse. C. Administer narcotic pain medications before assisting the client with ambulation: LPN/LVNs can administer pain medications. D. Listen for bowel sounds, and monitor the abdomen for distention and pain: Monitoring of the client is within the scope of the LVN/LPN and can be delegated.

The client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? A. Decreased sensation in the lower extremities B. Diminished peripheral pulses in the lower extremities C. Pale, cool extremities D. Reddened areas over bony prominences

B. Diminished peripheral pulses in the lower extremities Correct: Diminished peripheral pulses in the lower extremities indicate diminished blood flow. Incorrect: A. Decreased sensation in the lower extremities: Decreased sensation can be a normal occurrence in clients who have undergone a long surgical procedure. C. Pale, cool extremities: Pale, cool extremities can be a normal finding for clients who have undergone a long surgical procedure. D. Reddened areas over bony prominences: Reddened areas over bony prominences can be a normal occurrence for clients who have undergone a long surgical procedure.

The client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? A. Tells the client that she will be asleep B. Ensures that drapes will minimize perianal exposure C. Explains postoperative expectations D. Restricts the number of technicians in the procedure

B. Ensures that drapes will minimize perianal exposure Correct: Using drapes is the best action to take. A Tells the client that she will be asleep Incorrect: Telling the client that she will be asleep is not therapeutic. Incorrect: A. Tells the client that she will be asleep: Telling the client that she will be asleep is not therapeutic. C. Explains postoperative expectations: Explaining the procedure will not help with the client's concerns about modesty. D. Restricts the number of technicians in the procedure: The number of people involved in the procedure is not something the nurse can necessarily control.

What information about the postoperative client does the nurse include in the report to the postanesthesia care unit (PACU) nurse? A. Confirmation of informed consent B. Estimated blood loss C. Type of surgical instruments used D. Type of suture material used

B. Estimated blood loss Correct: Estimated blood loss is important to know, so that the client can be properly monitored. Incorrect: A. Confirmation of informed consent: Informed consent is taken care of before surgery. C. Type of surgical instruments used: It is not necessary for the PACU nurse to know what types of surgical instruments were used, unless they were out of the ordinary. D. Type of suture material used: It is not necessary for the PACU nurse to know what types of suture materials were used.

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? A. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. B. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. C. Obtain the medical history from a client who is scheduled for a total hip replacement. D. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

B. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Correct: Insertion of a catheter is within the scope of skills approved for the LPN/LVN. Incorrect: A. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter: Preoperative teaching is under the scope of the RN. C. Obtain the medical history from a client who is scheduled for a total hip replacement: History information would be completed by the RN on the unit. D. Assess the client who is being admitted for an elective laparoscopic cholecystectomy: Physical assessment of a preoperative client is within the scope of the RN.

The nurse assesses the client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? A. Crusting along the incision line B. Redness and swelling around the incision C. Sanguineous drainage at the suture site D. Serosanguineous drainage on the dressing

B. Redness and swelling around the incision Correct: Redness and swelling around the incision indicate an infection. Incorrect: A. Crusting along the incision line: Crusting along the incision line is normal. C. Sanguineous drainage at the suture site: Sanguineous drainage at the suture site is normal. D. Serosanguineous drainage on the dressing: Serosanguineous drainage on the dressing is normal.

The nurse in the urology clinic is providing teaching for a female client with cystitis. Which of these should be included in the teaching plan? Select all that apply. A Cleanse the perineum from back to front after using the bathroom. B Try to take in 64 ounces of fluid each day. C Be sure to complete the full course of antibiotics. D If your urine remains cloudy, call the clinic. E Expect some flank discomfort until the antibiotic has worked.

BCD

A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? "Don't mind this. The disease is causing this." "I need to check the client's cortisol level." "The disease can sometimes affect emotional responses." "Medication is available to help with this."

A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home? Frequent home care Handrails in the bath Increased thermostat setting Strict infection-control measures

The client is in the emergency department (ED) for an inability to void and for bladder distention. What is most important for the nurse to provide to the client? A Increased oral fluids B IV fluids C Privacy D Health history forms

The nurse is providing discharge instructions to a client on spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? "I must call the provider if I am more tired than usual." "I need to increase my salt intake." "I should eat a banana every day." "This drug will not control my heart rate."

The nurse is teaching the client how to provide a "clean catch" urine specimen. Which statement by the client indicates that teaching was effective? A "I must clean with the wipes and then urinate directly into the cup." B "I will have to drink 2 liters of fluid before providing the sample." C "I'll start to urinate in the toilet, stop, and then urinate into the cup." D "It is best to provide the sample while I am bathing."

When a diabetic client returns to the medical unit after IV urography, all of these interventions are prescribed. Which action will the nurse take first? A Give lisper (Humalog) insulin, 12 units subcutaneously. B Request a breakfast tray for the client. C Infuse 0.45% normal saline at 125 mL/hr. D DAdminister captopril (Capote).

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which of these? A Abdominal girth B Presence of urinary infection C History of hysterectomy D Hematuria

Which client does the nurse identify as being at highest risk for acute adrenal insufficiency resulting from corticosteroid use? Client with hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena Client with right upper quadrant pain unrelieved for the past 2 days, dark-brown urine, and clay-colored stools Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week Client with three emergency department visits in the past month for edema, shortness of breath, weight gain, and jugular venous distention

Which instruction does the nurse give the client who needs a clean catch urine specimen? A Save all urine for 24 hours. B I will collect the first specimen of the morning. C Do not touch the inside of the container. D You will receive an isotope injection, then I will collect your urine.

Which of the following would alarm the nurse immediately after return of the client from the operating room for cystoscopy performed under conscious sedation? A Pink-tinged urine B Urinary frequency C Temperature of 100.8 D Client lethargic

A client has suspected alterations in antidiuretic hormone (ADH) function. Which diagnostic test does the nurse anticipate will be requested for this client? A.Adrenocorticotropic hormone (ACTH) suppression test B.Chest x-ray C.Cranial computed tomography (CT) D.Renal sonography

C ADH is a hormone of the posterior pituitary. Brain abscess, tumor, or subarachnoid hemorrhage could cause alterations in ADH levels. These can be seen on a CT scan of the brain. ACTH triggers the release of cortisol from the adrenal cortex and is not related to ADH. A chest x-ray would not show a pituitary tumor or brain abscess. Even though ADH acts on distal convoluted tubules in the kidneys, a renal sonogram would diagnose the cause of syndrome of inappropriate antidiuretic hormone.

A client is hospitalized with a possible disorder of the adrenal cortex. Which nursing activity is best for the charge nurse to delegate to an experienced nursing assistant? A.Ask about risk factors for adrenocortical problems. B.Assess the client's response to physiologic stressors. C.Check the client's blood glucose levels every 4 hours. D.Teach the client how to do a 24-hour urine collection.

C Blood glucose monitoring is within the nursing assistant's scope of practice if the nursing assistant has received education and evaluation in the skill. Assessing risk factors for adrenocortical problems is not part of a nursing assistant's education. Assessing the client's response to physiologic stressors requires the more complex skill set of licensed nursing staff. Teaching the proper method for a 24-hour urine collection is a multi-step process; this task should not be delegated.

Which negative feedback response is responsible for preventing hypoglycemia during sleep in nondiabetic clients? A.Alpha cells of the pancreas B.Beta cells of the pancreas C.Glucagon release D.Insulin release

C Glucagon is the hormone that binds to receptors on liver cells. This causes the liver cells to convert glycogen to glucose, which keeps blood sugar levels normal during sleep. Alpha cells are responsible for synthesizing and secreting the hormone glucagon. Beta cells are responsible for synthesizing and secreting the hormone insulin. Insulin is the hormone responsible for lowering blood glucose. Insulin improves glucose uptake by the cell.

During a preoperative assessment, which statement by the client requires further investigation by the nurse to assess risk? A. "I am taking vitamins." B. "I drink a glass of wine a night." C. "I had a heart attack 4 months ago." D. "I don't like latex balloons."

C. "I had a heart attack 4 months ago." Correct: Cardiac problems increase surgical risks. The risk for a myocardial infarction (MI) during surgery is higher in clients who have heart problems. Incorrect: A. "I am taking vitamins.": The type of vitamins should be assessed, but this is not the highest risk. B. "I drink a glass of wine a night." Incorrect: Moderate alcohol consumption is not considered high-risk behavior. D. "I don't like latex balloons.": A dislike for latex is not the same as a latex allergy. However, it might be a good idea to ask why the client doesn't like latex balloons.

The nurse is instructing the client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? A. "I will take off my stockings one to three times a day for 30 minutes." B. "My stockings are too loose." C. "These stockings will prevent blood clots." D. "These stockings help promote blood flow."

C. "These stockings will prevent blood clots." Correct: Antiembolism stockings alone will not prevent deep venous thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Incorrect: A. "I will take off my stockings one to three times a day for 30 minutes.": Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. B. "My stockings are too loose.": Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). D. "These stockings help promote blood flow.": Antiembolism stockings may be used during and after surgery to promote venous return.

The client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? A. "Are you Mr. Smith?" B. "Good morning, Mr. Smith." C. "What is your name, and where were you born?" D. "What surgery are you having today?"

C. "What is your name, and where were you born?" Correct: The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. Incorrect: A. "Are you Mr. Smith?": The client may respond inappropriately if he is anxious or sedated. B. "Good morning, Mr. Smith." Incorrect: The client may respond inappropriately if he is anxious or sedated. D. "What surgery are you having today?": Asking the client about his or her surgery does help with identification. However, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

Which of these RNs who have been floated to the postanesthesia care unit (PACU) for the day should the charge nurse assign to care for an 18-year-old diabetic client who has just arrived from the operating room (OR) after having laparoscopic abdominal surgery? A. An RN who usually works on the inpatient pediatric unit B. An RN who provides education to diabetic clients in a clinic C. An RN who has 5 years of experience in the delivery room D. An RN who ordinarily works as a scrub nurse in the OR

C. An RN who has 5 years of experience in the delivery room Correct: This RN would have experience with abdominal surgery and with postoperative care of clients with diabetes and would be aware of possible postoperative complications for this client. Incorrect: A. An RN who usually works on the inpatient pediatric unit: This RN would not be aware of potential complications and routine assessments for this client. B. An RN who provides education to diabetic clients in a clinic: This RN would be able to provide required care for the client's diabetes but not the postoperative aspect of care. D. An RN who ordinarily works as a scrub nurse in the OR: This RN would not have knowledge and understanding of routine postoperative care for this client.

The preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? A. Actively listens to this client's concerns B. Allows the client to wear the hearing aid to surgery C. Checks to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given D. Apologizes to the client and explains that it is hospital policy to remove a hearing aid before surgery

C. Checks to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given Correct: In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction. Incorrect: A. Actively listens to this client's concerns: Listening isn't always enough. More intervention is needed. B. Allows the client to wear the hearing aid to surgery: The OR staff may have a different policy, or the hearing aid may get lost. D. Apologizes to the client and explains that it is hospital policy to remove a hearing aid before surgery: Telling the client that a policy precludes the client's needs is not therapeutic.

The nurse completes the preoperative checklist on the client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? A. Age of 59 years B. General anesthesia complications experienced by the client's brother C. Diet-controlled diabetes mellitus D. Ten pounds over the client's ideal body weight

C. Diet-controlled diabetes mellitus Correct: Diabetes contributes an increased risk for surgery. Incorrect: A. Age of 59 years: Older adults are at greater risk for surgical procedures. This client is not classified as an older adult. B. General anesthesia complications experienced by the client's brother: Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. D. Ten pounds over the client's ideal body weight: Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese.

The surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation happens during surgery. What is the nurse's proper action? A. Call the legal department. B. Call the client's medical physician. C. Honor the DNR order. D. Resuscitate per OR procedure.

C. Honor the DNR order. Correct: According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination. A. Call the legal department: Calling the legal department is not an appropriate response. B. Call the client's medical physician: Calling the client's physician is not an appropriate response. D. Resuscitate per OR procedure: Resuscitating this client is illegal.

The nurse anesthetist notices that the surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action? A. Administer cardiopulmonary resuscitation (CPR). B. Continue as normal. C. Immediately stop all inhalation anesthetic agents and succinylcholine. D. Inform the surgeon.

C. Immediately stop all inhalation anesthetic agents and succinylcholine. Correct: The most sensitive indication of malignant hypothermia (MH) is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed. Incorrect: A. Administer cardiopulmonary resuscitation (CPR): This client does not require resuscitation. B. Continue as normal: This client is exhibiting early symptoms of malignant hypothermia (MH), and immediate intervention is required. D. Inform the surgeon: This client is exhibiting early symptoms of malignant hypothermia; immediate intervention is required, so informing the surgeon is not the priority.

Which intervention does the nurse implement for the older adult client to minimize skin breakdown related to surgical positioning? A. Applies elastic stocking to lower extremities B. Monitors for excessive blood loss C. Pads bony prominences D. Secures joints on a board in anatomic positions

C. Pads bony prominences Correct: Padding bony prominences best minimizes skin breakdown. Incorrect: A. Applies elastic stocking to lower extremities: Elastic stockings assist in increased venous return. B. Monitors for excessive blood loss: Monitoring for blood loss does not protect the skin. D. Secures joints on a board in anatomic positions: Securing joints does not protect the skin.

If a sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do for proper infection control? A. Helps the surgeon change the gown B. Picks the gauze up with a pair of sterile gloves C. Picks the gauze up without touching the surgeon D. Sprays an antimicrobial on the surgeon's gown

C. Picks the gauze up without touching the surgeon Correct: The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted. Incorrect: A. Helps the surgeon change the gown: A sterile gauze touching a sterile gown does not require a gown change. B. Picks the gauze up with a pair of sterile gloves: Once the gauze falls, it is no longer sterile. Sterile gloves are not needed to pick it up. D. Sprays an antimicrobial on the surgeon's gown: A sterile gauze touching a sterile gown requires no action. An antimicrobial spray is inappropriate.

After gastric surgery, a client arrives in the postanesthesia care unit (PACU). Which of these nursing actions is most appropriate for the RN to delegate to an experienced nursing assistant? A. Monitor respiratory rate and airway patency. B. Irrigate the nasogastric tube with saline. C. Position the client on the left side. D. Assess the client's pain level.

C. Position the client on the left side. Correct: This action can be delegated to a unlicensed care provider. Incorrect: A. Monitor respiratory rate and airway patency: Airway patency requires the care of a nurse in case of emergency management requirements. B. Irrigate the nasogastric tube with saline: This is a nursing skill and care by a nurse would be required. D. Assess the client's pain level: Pain assessment is within the scope of a nurse.

Which assessment finding in the postoperative client after general anesthesia requires immediate intervention? A. Heart rate of 58 B. Pale, cool extremities C. Respiratory rate of 6 D. Suppressed gag reflex

C. Respiratory rate of 6 Correct: The most important postoperative assessment is respiratory assessment, and a rate of 6 is too low. Incorrect: A. Heart rate of 58: A heart rate of 58 is a normal postoperative finding B. Pale, cool extremities: Pale, cool extremities are a normal postoperative finding. D. Suppressed gag reflex: A suppressed gag reflex is a normal postoperative finding.

How does the nurse position the client with postoperative respiratory depression? A. Flat in bed, with the head in alignment with the body B. Prone, with the head of the bed flat C. Side-lying, with the head in a neutral position D. Supine in bed, with the neck flexed

C. Side-lying, with the head in a neutral position Correct: The side-lying position is the most natural and effective. A. Flat in bed, with the head in alignment with the body: This position is not a neutral position. B. Prone, with the head of the bed flat: This position is unnatural. D. Supine in bed, with the neck flexed: This position is unnatural.

The client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? A. Pain at the surgical site B. Requirement for verbal stimuli to awaken C. Snoring sounds when inhaling D. Sore throat on swallowing

C. Snoring sounds when inhaling Correct: Snoring sounds when inhaling may indicate respiratory depression. Incorrect: A. Pain at the surgical site: Postsurgical pain at the surgical site is normal. B. Requirement for verbal stimuli to awaken: Requiring verbal stimuli to awaken is normal post sedation. D. Sore throat on swallowing: A sore throat on swallowing is normal post intubation.

The preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? A. Instructs the client to quit smoking B. Teaches about the dangers of tobacco C. Teaches the importance of incentive spirometry D. Tells the client where the smoking lounge

C. Teaches the importance of incentive spirometry Correct: Incentive spirometry is good for lung hygiene. It encourages deep breathing. Incorrect: A. Instructs the client to quit smoking: The nurse can suggest quitting, but it is not therapeutic to instruct it at this time. B. Teaches about the dangers of tobacco: The nurse can educate the client about the dangers of tobacco, but teaching on this topic would not be therapeutic at this time. D. Tells the client where the smoking lounge is: Directing the client to the smoking lounge is not helpful.

At 8 AM, the registered nurse is admitting to the outpatient surgery department a client who is scheduled for sinus surgery. Which information given by the client would be of most immediate concern to the nurse? A. The client has an allergy to iodine and shellfish. B. The client was nauseated after a previous surgery. C. The client had a small glass of juice at 7 AM. D. The client expresses anxiety about the surgery.

C. The client had a small glass of juice at 7 AM. Correct: Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery; the nurse needs to notify the surgeon and anesthesia for possible rescheduling. Incorrect: A. The client has an allergy to iodine and shellfish: The nurse should confirm that the information is charted, and that the client has the correct allergy band identification. B. The client was nauseated after a previous surgery: Many clients experience nausea after surgery. The nurse should document this in the client's information. D. The client expresses anxiety about the surgery: The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery.

Why is it important to wear sterile gloves during a dressing change? A. They protect the client from infection. B. They protect the nurse from infection. C. They protect both the client and the nurse from infection. D. Their use prevents lawsuits.

C. They protect both the client and the nurse from infection. Correct: Standard Precautions and infection control protect both the nurse and the client from infection. Incorrect: A. They protect the client from infection. Incorrec: This response is only partially correct. B. They protect the nurse from infection: This response is only partially correct. D. Their use prevents lawsuits: Preventing lawsuits is not the purpose of wearing sterile gloves.

The client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Causes and treatment of hyperglycemia Causes and treatment of hypoglycemia Dietary control Insulin administration

Causes and treatment of hypoglycemia

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." These are the client's vital signs: T 98.4° F (36.9º C), P 112, R 38, BP 91/54, and O2 saturation 99% on room air. Which action should the nurse take first? Check the blood glucose. Administer oxygen. Offer reassurance. Attach a cardiac monitor.

Check the blood glucose.

When caring for the client hoping to receive a kidney transplant, the nurse recognizes that which of these problems will exclude the client from transplantation? a. History of hiatal hernia b. Client with diabetes and HbA1c of 6.8 c. Basal cell carcinoma removed from nose 5 years ago d. Client with tuberculosis

Client with tuberculosis Correct: Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with immune suppressants required to prevent rejection.

To prevent prerenal acute kidney injury, which person is encouraged to increase fluid consumption? a. Construction worker b. Office secretary c. Schoolteacher d. Taxi cab driver

Construction worker Correct: Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place a construction worker at risk for dehydration and prerenal azotemia.

The nurse in the transplantation unit assesses for which of these signs and symptoms of rejection of the transplanted kidney. Select all that apply. a. Blood urea nitrogen (BUN) 21, creatinine 0.9 b. Crackles in lung fields c. Temperature 98.8 d. Blood pressure 164/98 e. +3 edema of lower extremities

Crackles in lung fields orrect Blood pressure 164/98 Correct +3 edema of lower extremities Signs and symptoms of fluid retention are symptoms of transplant rejection. Correct: Increased blood pressure is a symptom of transplant rejection. Correct: Signs and symptoms of fluid retention are symptoms of transplant rejection.

A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? Document symptoms of incisional infection or meningitis. Give over-the-counter laxatives if the client is constipated. Set up medications as prescribed for the day. Test any nasal drainage for the presence of glucose.

A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response? "You should see effects of this medication immediately." "You should see effects of this medication within 1 week." "You should see full effects from this medication within 1 to 2 days." "You should see some effects of this medication within 2 weeks."

A client with Cushing's disease says that she has lost 1 pound. What does the nurse do next? Auscultates the lungs for crackles Checks urine for specific gravity Forces fluids Weighs the client

A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? Assess skin turgor and mucous membranes for hydration status. Discuss the dietary restrictions needed for 24-hour urine testing. Plan ways to control the environment that will avoid stimulating the client. Remind the client to avoid drinking coffee and changing position suddenly.

The client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the provider visited the client the day before. What action does the nurse take? A Asks the client to sign the informed consent B Cancels the procedure C Asks the client's spouse to sign the form D Notifies the department and the provider

The nurse has the following assignment. Which client should be encouraged to consume 2 to 3 liters of fluid each day? A Client with chronic kidney disease B Client with heart failure C Client with complete bowel obstruction D Client with hyperparathyroidism

The nurse is caring for a client with hypercortisolism. The nurse begins to feel the onset of a cold but still has 4 hours left in the shift. What does the nurse do? Asks another nurse to care for the client Monitors the client for cold-like symptoms Refuses to care for the client Wears a facemask when caring for the client

The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next? Administers acetaminophen Alerts the Rapid Response Team Asks any visitors to leave Assesses the client's cardiac status completely

What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client? Bradycardia and decreased level of consciousness Decreased respiratory rate Hypotension and shock Hypertension and heart failure

Which technique does the nurse use to obtain a sterile urine specimen from the client with a Foley catheter? A Disconnects the Foley catheter from the drainage tube and collects urine directly from the Foley B Removes the existing catheter and obtains a sample during the process of inserting a new Foley C Uses a sterile syringe to withdraw urine from the urine collection bag D Clamps the tubing, attaches a syringe to the specimen, and withdraws at least 5 mL of urine

The nurse is reviewing the laboratory test results for a client admitted with a possible pituitary disorder. Which information has the most immediate implication for the client's care? A.Blood glucose 125 mg/dL B.Blood urea nitrogen (BUN) 40 mg/dL C.Serum potassium 5.2 mEq/L D.Serum sodium 110 mEq/L

D The normal range for serum sodium is 135 to 145 mEq/L; a result of 110 mEq/L is considered hyponatremia and is extremely dangerous. The client is at risk for increased intracranial pressure, seizures, and death. The RN must act rapidly because this situation requires immediate intervention. The normal range for fasting blood glucose is 60 to 110 mg/dL; 125 mg/dL is high, but is not considered dangerous. The normal range for BUN is 7 to 20 mg/dL; 40 mg/dL is high. An elevated BUN can be an indication of kidney failure, dehydration, fever, increased protein intake, and shock, so the client should have a creatinine drawn for a more complete picture of kidney function. The normal range for serum potassium is 3.5 to 5.2 mEq/L; 5.2 mEq/L is high normal.

The nurse is educating a preoperative client about colostomy surgery. The colostomy surgery is categorized as what type of surgery? A Cosmetic B Curative C Diagnostic D Palliative

D Palliative Palliative surgery is performed to relieve symptoms of a disease process but does not cure the disease. Incorrect: A Cosmetic: Cosmetic surgery is performed primarily to alter or enhance personal appearance. B Curative: Curative surgery is performed to resolve a health problem by repairing or removing the cause. C Diagnostic: Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? A. "I must cover my facial hair." B. "I don't need a sterile gown to be in the OR." C. "If I go into the OR, I must wear a protective mask." D. "My scrubs are sterile."

D. "My scrubs are sterile." Correct: Scrub attire is provided by the hospital and is clean, not sterile. Incorrect: A. "I must cover my facial hair.": All members of the surgical team must cover their hair, including any facial hair. B. "I don't need a sterile gown to be in the OR.": Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile. They may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. C. "If I go into the OR, I must wear a protective mask.": Everyone who enters an OR in which a sterile field is present must wear a mask.

The nurse is educating the client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? A. "I will wake up with a tube in my throat." B. "I will have a bandage on my chest." C. "My family will not be able to see me right away." D. "Pain medication will take away my pain."

D. "Pain medication will take away my pain." Correct: Pain medication will minimize pain but will not take it away completely. Incorrect: A. "I will wake up with a tube in my throat.": This is an accurate statement. B. "I will have a bandage on my chest.": This is an accurate statement. C. "My family will not be able to see me right away.": This is an accurate statement.

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? A. A 20-year-old client who has a ruptured appendix and is having an emergency appendectomy B. A 28-year-old client with a fractured femur who is having an open reduction and internal fixation C. A 45-year-old client with coronary artery disease who is having coronary artery bypass grafting D. A 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

D. A 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed Correct: This is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience. Incorrect: A. A 20-year-old client who has a ruptured appendix and is having an emergency appendectomy: This is a less stable client who is at high risk for infection/sepsis. A more experienced nurse is required. B. A 28-year-old client with a fractured femur who is having an open reduction and internal fixation: This client is at high risk for clotting, infection, and aspiration owing to the surgery. A more experienced nurse would be better. C. A 45-year-old client with coronary artery disease who is having coronary artery bypass grafting: This client is having high-risk surgery with risk for multiple complications and requires an experienced operating room (OR) nurse.

Which of these staff members will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? A. A surgical technologist with 10 years of experience in the OR at this hospital B. A certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals C. A holding room RN who has worked in the hospital holding room for longer than 15 years D. A circulating RN who has been employed in the hospital OR for 7 years

D. A circulating RN who has been employed in the hospital OR for 7 years Correct: This nurse has the experience and background to write OR policy and has been employed in this hospital and is aware of hospital policy and procedures. Incorrect: A. A surgical technologist with 10 years of experience in the OR at this hospital: A surgical technologist does not have the background to write policy for nurses. B. A certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals: This nurse has worked in multiple hospitals but does not have a work history with this specific hospital to be aware of the unit policy. C. A holding room RN who has worked in the hospital holding room for longer than 15 years: A holding room or preoperative or postoperative care nurse would not be the choice to write OR policy.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which orders should the registered nurse accomplish first? A. Use electrical clippers to cut hair at the surgical site. B. Start an infusion of lactated Ringer's solution at 75 mL/hr. C. Administer one half of the client's usual lispro insulin dose. D. Draw blood for glucose, electrolyte, and complete blood count values.

D. Draw blood for glucose, electrolyte, and complete blood count values. Correct: If blood work is abnormal, the surgery may be rescheduled. The blood work needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. This is not of immediate concern. Incorrect: A. Use electrical clippers to cut hair at the surgical site: Removal of hair can be accomplished in the operating room directly before the start of surgery. While important, it is not of immediate concern. B. Start an infusion of lactated Ringer's solution at 75 mL/hr: The IV infusion is not the first task to accomplish for preoperative clients. This can be accomplished after the laboratory orders have been completed. This is not of immediate concern. C. Administer one half of the client's usual lispro insulin dose: The nurse should check blood glucose with the laboratory orders before administration of lispro.

What pain management does the client who has been admitted to the postanesthesia care unit typically receive? A. Intramuscular non-opioid analgesics B. Intramuscular opioid analgesics C. Intravenous non-opioid analgesics D. Intravenous opioid analgesics

D. Intravenous opioid analgesics Correct: IV opioids are given in small doses to provide pain relief but not to mask an anesthetic reaction. Incorrect: A. Intramuscular non-opioid analgesics: IM non-opioid analgesics are too long-acting. B. Intramuscular opioid analgesics: IM opioid analgesics are too long-acting. C. Intravenous non-opioid analgesics: IV non-opioid analgesics usually are not given within the first 48 hours after surgery.

The client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? A. Decreases expected blood loss during surgery B. Eliminates any risk of infection C. Ensures that the bowel is sterile D. Reduces the number of intestinal bacteria

D. Reduces the number of intestinal bacteria Correct: Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Incorrect A. Decreases expected blood loss during surgery: Decreasing expected blood loss is not the goal of a bowel preparation. B. Eliminates any risk of infection: Eliminating infection risk is not the goal of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection. C. Ensures that the bowel is sterile: Sterilizing the bowel is not the goal of a bowel preparation.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? A. Calls admissions B. Cancels the surgery C. Contacts the surgeon D. Talks to the operating team

D. T alks to the operating team Correct: The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Incorrect: A. Calls admissions: Calling admissions is not the first step. The stamp is correct. B. Cancels the surgery: Canceling surgery is not done by the floor nurse. C. Contacts the surgeon: This is an administrative issue, not one for the surgeon.

The older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Calls the legal department to draft the paperwork B. Documents this in the chart C. Thanks the person and does nothing D. Talks to the client

D. Talks to the client Correct: The nurse should determine the client's wishes and state of mind. Incorrect: A. Calls the legal department to draft the paperwork: Calling the legal department is not what the nurse should do first. B. Documents this in the chart: Documenting this in the chart is not what the nurse should do first. C. Thanks the person and does nothing: Doing nothing is not appropriate.

The nurse recognizes that the client with end-stage kidney disease has difficulty adhering to the fluid restriction when which of these is found? a. Blood pressure 118/78 b. Weight loss of 3 lbs during hospitalization c. Dyspnea and anxiety at rest d. Central venous pressure (CVP) of 6 mm Hg

Dyspnea and anxiety at rest Correct: Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse assists the client in correlating symptoms of fluid overload with nonadherence to fluid restriction.

The client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction about the disease and its management? Current lifestyle Educational and literacy level Sexual orientation Current energy level

Educational and literacy level

When assisting the client with kidney failure to restrict dietary protein to 40 g/day, the nurse recommends that the client select which of these proteins? a. Eggs b. Ham c. Eggplant d. Macaroni

Eggs Correct: Suggested protein-containing foods are milk, meat, and eggs.

The client is receiving immune suppressive therapy after kidney transplantation. Which measure is most important for the nurse to implement? a. Adherence to therapy b. Handwashing c. Monitoring for low-grade fever d. Strict clean technique

Handwashing Correct: The most important infection control measure is handwashing.

The client with chronic kidney disease presents with bradycardia, prolonged PR interval, and diminished bowel sounds. For which of these should the nurse monitor? a. Hyperchloremia b. Hypomagnesemia c. Hyperkalemia d. Hypercalcemia

Hyperkalemia Correct: Hyperkalemia may be present; electrocardiographic changes and paralytic ileus may develop.

Which clinical manifestation indicates the need for increased fluids in the client with kidney failure? a. Increased blood urea nitrogen b. Increased creatinine c. Pale urine d. Decreased sodium

Increased blood urea nitrogen Correct: An increase in blood urea nitrogen can be an indication of dehydration, and an increase in fluids is needed.

Which of the following represents a positive response to administration of erythropoietin (Epogen, Procrit)? a. Hematocrit of 26.7% b. Potassium within normal range c. Free from spontaneous fractures d. Less fatigue

Less fatigue Correct: Treatment of anemia with erythropoietin will result in increased (H&H) and decreased shortness of breath (SOB) and fatigue.

When administering medications to the client with chronic kidney disease, the nurse recognizes that which of these medications is most effective in slowing the progression of kidney failure? a. Diltiazem (Cardizem) b. Lisinopril (Zestril) c. Clonidine (Catapres) d. Doxazosin (Cardura)

Lisinopril (Zestril) Correct: Angiotensin-converting enzyme (ACE) inhibitors appear to be the most effective drugs to slow the progression of kidney failure.

The nurse teaches the client recovering from acute kidney disease to avoid which of these? a. Nonsteroidal anti-inflammatory drugs b. Angiotensin-converting enzyme (ACE) inhibitors c. Opiates d. Acetaminophen

Nonsteroidal anti-inflammatory drugs Correct: Nonsteroidal anti-inflammatory drugs may be nephrotoxic.

The nurse caring for four diabetic clients has the following activities to perform. Which of these is appropriate to delegate to the nursing assistant? Perform hourly bedside blood glucose checks for a client with hyperglycemia. Verify the infusion rate on a continuous infusion insulin pump. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability. Check on a client who is reporting palpitations and anxiety.

Perform hourly bedside blood glucose checks for a client with hyperglycemia.

The intensive care client with ketoacidosis (DKA) is receiving insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make? Urine output 12-lead electrocardiogram (ECG) Potassium level Rate of IV fluids

Potassium level

Which action is correct when drawing up a single dose of insulin? Wash hands thoroughly and don sterile gloves. Shake the bottle of insulin vigorously to mix the insulin. Pull back plunger to draw air into the syringe equal to the insulin dose. Recap the needle and save the syringe for the next dose of insulin.

Pull back plunger to draw air into the syringe equal to the insulin dose.

When preparing a mixed insulin injection, which action does the nurse perform first? Draws up the longer-acting insulin Draws up the short-acting insulin Puts air in the longer-acting insulin vial Puts air in the shorter-acting insulin vial

Puts air in the longer-acting insulin vial

When caring for a client who receives peritoneal dialysis (PD), which of these findings must the nurse report to the provider immediately? a. Pulse oximetry reading of 95% b. Sinus bradycardia, rate of 58 c. Blood pressure of 148/90 d. Temperature of 101.2

Temperature of 101.2 Correct: Peritonitis is the major complication of PD caused by intra-abdominal catheter site contamination; use meticulous aseptic technique when caring for PD equipment.

You have just taken change-of-shift report on a group of clients on the medical unit. Which client should you assess first? The client taking repaglinide (Prandin) who has nausea and back pain The client taking glyburide (Diabeta) who is dizzy and sweaty The client taking metformin (Glucophage) who has abdominal cramps The client taking pioglitazone (Actos) who has bilateral ankle swelling

The client taking glyburide (Diabeta) who is dizzy and sweaty

Which explanation best assists the client in differentiating type 1 diabetes from type 2 diabetes? Most clients with type 1 diabetes are born with it. People with type 1 diabetes are often obese. Those with type 2 diabetes make insulin, but in inadequate amounts. People with type 2 diabetes do not develop typical diabetic complications.

Those with type 2 diabetes make insulin, but in inadequate amounts.

A client has returned from a captopril renal scan. Which teaching does the nurse provide when the client returns to the unit? a. "Arise slowly and call for assistance when ambulating." b. "I must measure your intake and output." c. "We must save your urine because it is radioactive." d. "I must attach you to this cardiac monitor."

a. "Arise slowly and call for assistance when ambulating."

Situation: A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. What information does a nurse provide to this client about taking her prescribed trimethoprim/sulfamethoxazole (Bactrim)? Select all that apply. a. "Be certain to wear sunscreen and protective clothing." b. "Drink at least 3 liters of fluids every day." c. "Take this drug with 8 ounces of water." d. "Try to urinate frequently to keep your bladder empty." e. "You will need to take all of this drug to get the benefits."

a. "Be certain to wear sunscreen and protective clothing." b. "Drink at least 3 liters of fluids every day." c. "Take this drug with 8 ounces of water." e. "You will need to take all of this drug to get the benefits." (a) Wearing sunscreen and protective clothing is important to do while on this drug. Increased sensitivity to the sun can lead to severe sunburn. (b, c) Sulfamethoxazole can form crystals that precipitate in the kidney tubules. Fluid intake prevents this complication. (e) Clients should be cautioned to take all of the drug that is prescribed for them, even if their symptoms improve or disappear soon. INCORRECT: (d)Emptying the bladder is important-but not keeping it empty-as is stated here. The client should be advised to urinate every 3 to 4 hours or more often if he or she feels the urge.

The client, who is a mother of two, has autosomal dominant polycystic kidney disease (ADPKD). Which statement by the client indicates a need for further education about her disease? a. "By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." b. "Even though my children don't have symptoms at the same age I did, they can still have ADPKD." c. "If my children have the ADPKD gene, they will have cysts by the age of 30." d. "My children have a 50% chance of inheriting the ADPKD gene that causes the disease."

a. "By maintaining a low-salt diet in our house, I can prevent ADPKD in my children." There is no way to prevent ADPKD, although early detection and management of hypertension may slow the progression of kidney damage. Limiting salt intake can help control blood pressure.

The school nurse is counseling a teenage student about how to prevent renal trauma. Which statement by the student indicates a need for further teaching? a. "I can't play any type of contact sports because my brother had kidney cancer." b. "I avoid riding motorcycles." c. "I always wear pads when playing football." d. "I always wear a seat belt in the car."

a. "I can't play any type of contact sports because my brother had kidney cancer." Contact sports and high-risk activities should be avoided if a person has only one kidney. A family history of kidney cancer does not prohibit this type of activity.

A nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences of them. Which client statement shows correct understanding of what the nurse has taught? a. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." b. "It is a good idea for me to reduce germs by taking a tub bath daily." c. "Trying to get to the bathroom to urinate every 6 hours is important for me." d. "Urinating 1000 mL on a daily basis is a good amount for me."

a. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." To reduce the number of UTIs, clients should be drinking a minimum of 1.5 to 2.5 liters of fluid (mostly water) each day.

A nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? Select all that apply. a. Dysuria b. Enuresis c. Frequency d. Nocturia e. Urgency f. Polyuria

a. "I should be drinking at least 1.5 to 2.5 liters of fluids every day." c. Frequency d. Nocturia e. Urgency (a) Dysuria-painful urination-is a symptom of a UTI. (c) Frequency-frequent urinating and in small amounts-is a sign of a UTI. (d) Nocturia-urinating at night-is (or can be) a symptom of a UTI. (e) Urgency-having the urge to urinate quickly-is a symptom of a UTI. INCORRECT: (b) Enuresis-bed-wetting-is not a sign of a UTI. (f) Polyuria-increased amounts of urine production-is not a sign of a UTI.

The nurse is questioning the female client with a urinary tract infection (UTI) about her antibiotic drug regimen. Which statement by the client indicates a need for further instruction? a. "I take my medication only when I have symptoms." b. "I always wipe front to back." c. "I don't use bubble baths and other scented bath products." d. "I try to drink 3 liters of fluid a day."

a. "I take my medication only when I have symptoms." Clients with UTIs must complete all prescribed antibiotic therapy, even when symptoms of infection are absent.

Situation: A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. She is started on antibiotics and sent home. She returns to the clinic 3 days later-with the same symptoms. When asked about the previous UTI and medication regimen, she states, "I only took the first dose because after that, I felt better." How does the nurse respond? a. "Not completing your medication can lead to return of your infection." b. "That means your treatment will be prolonged with this new infection." c. "This means you will now have to take two drugs instead of one." d. "What you did was okay; however, let's get you started on something else."

a. "Not completing your medication can lead to return of your infection." Not completing the drug regimen can lead to recurrence of an infection and to bacterial drug resistance.

A client with these assessment data is preparing to undergo a computed tomography (CT) scan with contrast Assessment Data: BUN 54 mg/dL Creatinine 2.4 mg/dL Ca 8.5 mg/dL Which medication does the nurse plan to administer before the procedure? a. Acetylcysteine (Mucomyst) b. Metformin (Glucophage) c. Captopril (Capoten) d. Acetaminophen (Tylenol)

a. Acetylcysteine (Mucomyst)

When caring for the client with nephrotic syndrome, which of the following should be included in the plan of care? a. Administering angiotensin-converting enzyme (ACE) inhibitors to decrease protein loss b. Administering heparin to prevent deep vein thrombosis (DVT) c. Providing antibiotics to decrease infection d. Providing transfusion of clotting factors

a. Administering angiotensin-converting enzyme (ACE) inhibitors to decrease protein loss ACE inhibitors can decrease protein loss in the urine.

A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first? a. Administers morphine sulfate 4 mg IV b. Begins an infusion of metoclopramide (Reglan) 10 mg IV c. Obtains a urine specimen for urinalysis d. Starts an infusion of 0.9% normal saline at 100 mL/hr

a. Administers morphine sulfate 4 mg IV Morphine administered IV will decrease the pain and the associated sympathetic nervous system reactions of nausea and hypotension.

When preparing a client for nephrostomy tube insertion, it is essential for the nurse to monitor which of these before the procedure? a. BUN and creatinine b. Hemoglobin and hematocrit (H&H) c. Intake and output (I&O) d. Prothrombin time (PT) and international normalized ratio (INR)

a. BUN and creatinine Nephrostomy tubes are placed to prevent and treat kidney damage; this is important but is not essential before the procedure.

The nurse is caring for a client who has just returned to the surgical unit after a radical nephrectomy. Which assessment information alarms the nurse? a. Blood pressure is 98/56; heart rate is 118. b. Urine output over the past hour was 80 mL. c. Pain is at a level 4 (on a 0 to 10 scale). d. Dressing has a 1-cm area of bleeding.

a. Blood pressure is 98/56; heart rate is 118. Bleeding is a complication of radical nephrectomy; tachycardia and hypotension may indicate impending hypovolemic or hemorrhagic shock. Notify the surgeon immediately and plan to administer fluids, check the complete blood count (CBC), and administer blood if necessary.

When caring for the client 24 hours after a nephrectomy, the nurse notes that the client's abdomen is distended. Which assessment should be made next? a. Check the vital signs. b. Notify the surgeon. c. Continue to monitor. d. Insert a nasogastric (NG) tube

a. Check the vital signs. The client's abdomen may be distended from bleeding. Hemorrhage or adrenal insufficiency causes hypotension, so vital signs should be taken to see if a change in blood pressure has occurred.

A nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? a. 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4° F (37.4° C) b. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours c. 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy d. 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

b. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client may be oversedated and may not be aware of any discomfort caused by bladder distention.

The nurse anticipates that the client who develops hypotension and oliguria post nephrectomy may need addition of which of these to the regimen? a. Increase in analgesics b. Addition of a corticosteroid c. Administration of a diuretic d. A course of antibiotic therapy

b. Addition of a corticosteroid Loss of water and sodium occurs in clients with adrenal insufficiency; this is followed by hypotension and oliguria; corticosteroids may be needed.

The RN is working with a nursing assistant in caring for a group of clients. Which of these actions will be best for the RN to delegate to the nursing assistant? a. Assess the vital signs for a client who was just admitted with blunt flank trauma and hematuria. b. Assist a client who had a radical nephrectomy 2 days ago to turn in bed. c. Help the physician with a kidney biopsy for a client admitted with acute glomerulonephritis. d. Palpate for bladder distention on a client recently admitted with a ureteral stricture.

b. Assist a client who had a radical nephrectomy 2 days ago to turn in bed. The nursing assistant would be working within legal guidelines when assisting a client to turn in bed.

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? a. Client who has just returned from having a kidney artery angioplasty b. Client with polycystic kidney disease who is having a kidney ultrasound c. Client who is going for a cystoscopy and cystourethroscopy d. Client with glomerulonephritis who is having a kidney biopsy

b. Client with polycystic kidney disease who is having a kidney ultrasound

Situation: A 53-year-old postmenopausal woman reports "leaking urine" when she laughs. She has five children, all delivered vaginally. She is in good health and has tried pelvic floor (Kegel) exercises, which have not helped. She is not taking any medications and has no allergies to medication. She is diagnosed with stress incontinence and is started on propantheline (Pro-Banthine). What interventions does the nurse suggest to alleviate the side effects of this anticholinergic drug? Select all that apply. a. Administer the drug at bedtime. b. Encourage increased fluids. c. Increase fiber. d. Limit the intake of dairy products. e. Offer hard candy for "dry" mouth.

b. Encourage increased fluids. c. Increase fiber. e. Offer hard candy for "dry" mouth. (b) Anticholinergics cause constipation. Increasing fluids will help with this problem. (c) Anticholinergics cause constipation. An increase in daily fiber in the client's diet will help. (e) Anticholinergics cause extreme dry mouth. INCORRECT: (a) Taking the drug at night will not have an effect on the complications encountered-dry mouth and constipation. The drug is usually taken three to four times a day. (d) Limiting dairy products does not have an effect on the complications encountered-dry mouth and constipation.

Situation: A 53-year-old postmenopausal woman reports "leaking urine" when she laughs. She has five children, all delivered vaginally. She is in good health and has tried pelvic floor (Kegel) exercises, which have not helped. She is not taking any medications and has no allergies to medication. She is diagnosed with stress incontinence. The health care provider prescribes the drug, estrogen (Premarin). Which risks does the nurse tell the client to expect? Select all that apply. a. Dry mouth b. Endometrial cancer c. Increased intraocular pressure d. Thrombophlebitis e. Vaginitis

b. Endometrial cancer d. Thrombophlebitis (b) Estrogen use can increase the risk for endometrial cancer. (d) Estrogen use can increase the risk for thrombophlebitis. Women who smoke-especially-should not use this drug. INCORRECT: (a) Dry mouth is not a side effect of estrogen use. (c) Increased intraocular pressure is not a side effect of estrogen use. It is a problem with anticholinergic use. (e) Vaginitis is not a side effect of estrogen use. However, clients should report any unusual vaginal bleeding.

When assessing the client with pyelonephritis, which finding does the nurse anticipate will be present? Select all that apply. a. Suprapubic pain b. Vomiting c. Chills d. Dysuria e. Oliguria

b. Vomiting c. Chills d. Dysuria (b) Nausea and vomiting are symptoms of pyelonephritis. (c) Chills along with fever may occur. (d) Burning (dysuria), urgency, and frequency are symptoms of pyelonephritis. INCORRECT: (a) Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). (e) This is related to kidney impairment from severe or long-standing pyelonephritis.

After receiving the change-of-shift report on the urology unit, which of these clients should the nurse assess first? a. A client post radical nephrectomy whose temperature is 99.8° F (37.6° C) b. A client with glomerulonephritis who has cola-colored urine c. A client who was involved in a motor vehicle accident and has hematuria d. A client with nephrotic syndrome who has gained 2 kg since yesterday

c. A client who was involved in a motor vehicle accident and has hematuria The nurse should be aware of the risk for kidney trauma after a motor vehicle accident. The client needs further assessment and evaluation to determine the extent of blood loss and the reason for the hematuria.

A newly admitted client who is diabetic and has pyelonephritis and prescriptions for intravenous antibiotics, blood glucose monitoring every 2 hours, and insulin administration should be cared for by which staff member? a. An RN whose other assignments include a client receiving chemotherapy for renal cell carcinoma b. An RN who is caring for a client who just returned after having renal artery balloon angioplasty c. An RN who has just completed preoperative teaching for a client who is scheduled for nephrectomy d. An RN who is currently admitting a client with acute hypertension and possible renal artery stenosis

c. An RN who has just completed preoperative teaching for a client who is scheduled for nephrectomy This RN is caring for the most stable client and will have time to do the frequent monitoring and interventions that are needed for the newly admitted client.

A cognitively impaired client has urge incontinence. Which method for achieving continence does a nurse include in the client's care plan? a. Bladder training b. Credé method c. Habit training d. Kegel exercises

c. Habit training Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis.

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? a. Abdominal girth b. Presence of urinary infection c. History of hysterectomy d. Hematuria

c. History of hysterectomy

The nurse is reviewing the medical record for a client with polycystic kidney disease who is scheduled for computed tomographic angiography with contrast: Assessment Data: BUN 26 mg/dL Creatinine 1.0 mg/dL) HbA1c 6.9% Glucose 132 mg/dL Which intervention is essential for the nurse to perform? a. Obtain a thyroid-stimulating hormone (TSH) level. b. Report the blood urea nitrogen (BUN) and creatinine. c. Hold the metformin 24 hours before and on the day of the procedure. d. Notify the provider regarding blood glucose and glycosylated hemoglobin (HbA1c) values.

c. Hold the metformin 24 hours before and on the day of the procedure.

When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention does the nurse implement first? a. Give lispro (Humalog) insulin, 12 units subcutaneously. b. Request a breakfast tray for the client. c. Infuse 0.45% normal saline at 125 mL/hr. d. Administer captopril (Capoten).

c. Infuse 0.45% normal saline at 125 mL/hr.

The nurse is teaching a client with diabetes the importance of preventing kidney damage. Which information suggests that the client may be in early stages of kidney damage? a. Elevation in blood urea nitrogen (BUN) b. Oliguria c. Microalbuminuria d. Painless hematuria

c. Microalbuminuria Microlevels of albumin are first detected in the urine. Progressive kidney damage occurs before dipstick procedures can detect protein in the urine.

When caring for a client with uremia, the nurse assesses for which symptom? a. Tenderness at the costovertebral angle (CVA) b. Cyanosis of the skin c. Nausea and vomiting d. Insomnia

c. Nausea and vomiting

The nurse visualizes blood clots in a client's urinary catheter after a cystoscopy. What nursing intervention does the nurse perform first? a. Administer heparin intravenously. b. Remove the urinary catheter. c. Notify the health care provider (HCP). d. Irrigate the catheter with sterile saline.

c. Notify the health care provider (HCP).

Which client does the nurse manager on a medical unit assign to an experienced LPN/LVN? a. 42-year-old with painless hematuria who needs an admission assessment b. 46-year-old scheduled for cystectomy who needs help in selecting a stoma site c. 48-year-old receiving intravesical chemotherapy for bladder cancer d. 55-year-old with incontinence who has intermittent catheterization prescribed

d. 55-year-old with incontinence who has intermittent catheterization prescribed Insertion of catheters is within the education and legal scope of practice for LPNs/LVNs.

Which of these staff members should be assigned to a client who has benign prostatic hyperplasia and hydronephrosis and needs an indwelling catheter inserted? a. An RN float nurse who has 10 years of experience with pediatric clients b. An LPN/LVN who has worked in the hospital's kidney dialysis unit until recently c. An RN without recent experience who has just completed an RN refresher course d. An LPN/LVN with 5 years of experience in an outpatient urology surgery center

d. An LPN/LVN with 5 years of experience in an outpatient urology surgery center Catheterization of a client with an enlarged prostate, a skill within the scope of practice of the LPN/LVN, would be performed frequently in a urology center.

Which technique does the nurse use to obtain a sterile urine specimen from a client with a Foley catheter? a. Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. b. Remove the existing catheter and obtain a sample during the process of inserting a new Foley. c. Use a sterile syringe to withdraw urine from the urine collection bag. d. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine.

d. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine.

The nurse has these client assignments. Which client does the nurse encourage to consume 2 to 3 liters of fluid each day? a. Client with chronic kidney disease b. Client with heart failure c. Client with complete bowel obstruction d. Client with hyperparathyroidism

d. Client with hyperparathyroidism

When planning an assessment of the urethra, what does the nurse do first? a. Examine the meatus. b. Note any unusual discharge. c. Record the presence of abnormalities. d. Don gloves.

d. Don gloves.

What does the nurse teach the client to prevent the risk for urinary tract infection (UTI)? a. Limit fluid intake. b. Increase caffeine consumption. c. Limit sugar intake. d. Drink about 3 liters of fluid daily.

d. Drink about 3 liters of fluid daily. Drinking about 3 liters of fluid daily, if another medical problem does not require fluid restriction, helps prevent dehydration and UTIs.

Which goal for the client with diabetes will best help to prevent diabetic nephropathy? a. Heed the urge to void. b. Avoid carbohydrates in the diet. c. Take insulin at the same time every day. d. Maintain HbA1c

d. Maintain HbA1c Maintaining long-term control of blood glucose will help prevent the progression of diabetic nephropathy.

When caring for the client with hemorrhage secondary to kidney trauma, the nurse provides volume expansion. Which of these does the nurse anticipate should be used? a. Fresh-frozen plasma b. Platelet infusions c. 5% dextrose in water d. Normal saline solution

d. Normal saline solution Isotonic solutions and crystalloid solutions are administered for volume expansion; 0.9% sodium chloride (NSS) and 5% dextrose in 0.45% sodium chloride may be used.

A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the health care provider (HCP) visited the client the day before. What action does the nurse take? a. Asks the client to sign the informed consent b. Cancels the procedure c. Asks the client's spouse to sign the form d. Notifies the department and the HCP

d. Notifies the department and the HCP

A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? a. Maintaining bedrest b. Medicating for pain c. Monitoring for hematuria d. Promoting fluid intake

d. Promoting fluid intake

The client with pyelonephritis has been prescribed urinary antiseptic medication. What purpose does this medication serve? a. Decreases bacterial count b. Destroys white blood cells c. Enhances the action of antibiotics d. Provides comfort

d. Provides comfort Urinary antiseptic drugs such as nitrofurantoin (Macrodantin) are prescribed to provide comfort for clients with pyelonephritis.

Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? a. Encouraging them to drink fluids b. Irrigating all catheters daily with sterile saline c. Recommending catheters should be placed in all clients d. Re-evaluating periodically the need for indwelling catheters

d. Re-evaluating periodically the need for indwelling catheters Studies have shown that re-evaluating the need for indwelling catheters in clients is the most effective way to prevent UTI in the hospital setting.

A client who is 6 months pregnant comes to the Prenatal Clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client? a. Discharges the client to her home for strict bedrest for the duration of the pregnancy b. Instructs the client to drink a minimum of 3 liters of fluids, especially water, every day to "flush out" bacteria c. Recommends that the client refrain from having sexual intercourse until after she has delivered her baby d. Refers the client to the Clinic Nurse Practitioner (CNP) for immediate follow-up

d. Refers the client to the Clinic Nurse Practitioner (CNP) for immediate follow-up Pregnant women with UTI require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor-with adverse effects for the fetus.

The client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse?

167 drops/min

What is the appropriate range of urine output for the adult client weighing 110 lbs? _______ to _______ mL/hr

25 to 30 mL/hr Adult urine output expectations are 0.5 to 1 mL/kg/hr.

The client had IV urography 8 hours ago. Which nursing intervention is the priority for this client? A Maintaining bedrest B Medicating for pain C Monitoring for hematuria D Promoting fluid intake

The client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the nurse's best response? a. "Because the kidneys cannot get rid of fluid, blood pressure goes up." b. "The damaged kidneys no longer release a hormone that prevents high blood pressure." c. "The waste products in the blood interfere with other mechanisms that control blood pressure." d. "This is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products."

a. "Because the kidneys cannot get rid of fluid, blood pressure goes up." In chronic kidney disease, fluid levels increase in the circulatory system.

An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the nurse's best response? a. "Have you tried using the toilet at least every couple of hours?" b. "How does that make you feel?" c. "We can fix that." d. "That happens when we get older."

a. "Have you tried using the toilet at least every couple of hours?"

Which client with a long-term urinary problem does the nurse refer to community resources and support groups? Select all that apply. a. 32-year-old with a cystectomy b. 44-year-old with a Kock pouch c. 48-year-old with urinary calculi d. 78-year-old with urinary incontinence e. 80-year-old with dementia

a. 32-year-old with a cystectomy b. 44-year-old with a Kock pouch d. 78-year-old with urinary incontinence (a) The client with a cystectomy would benefit from community resources and support groups. Others who have had their bladders removed are good sources for information and for help in establishing coping mechanisms. (b) The client with a Kock pouch would benefit from community resources and support groups. Others who have had their bladders removed and are using an alternate method for urinating are good sources for information and for help in establishing coping mechanisms. (d) The older adult client with urinary incontinence would benefit from community resources and support groups. Others who have had this problem can provide methods of living with the problem or methods of curing (or minimizing) it.

Which of the following findings does the nurse expect in the client with kidney cancer? Select all that apply. a. Erythrocytosis b. Hypokalemia c. Hypercalcemia d. Hepatic dysfunction e. Increased sedimentation rate

a. Erythrocytosis c. Hypercalcemia d. Hepatic dysfunction e. Increased sedimentation rate (a) Erythrocytosis alternating with anemia may occur. (c) Parathyroid hormone produced by tumor cells can cause hypercalcemia. (d) Hepatic dysfunction with elevated liver enzymes may occur. (e) Elevation in sedimentation rate may occur in paraneoplastic syndromes. INCORRECT: Potassium levels are not altered in kidney cancer; hypercalcemia is present.

Which urinary assessment information for a client indicates the potential need for increased fluids? a. Increased blood urea nitrogen b. Increased creatinine c. Pale-colored urine d. Decreased sodium

a. Increased blood urea nitrogen

When caring for the client with polycystic kidney disease, the nurse recognizes that which of these goals is most important? a. Preventing progression of the disease b. Performing genetic testing c. Assessing for related causes d. Consulting with the dialysis unit

a. Preventing progression of the disease Preventing complications and progression is the goal.

When taking the health history of a client with acute glomerulonephritis, the nurse questions the client about which related cause of the problem? a. Recent respiratory infection b. Hypertension c. Unexplained weight loss d. Neoplastic disease

a. Recent respiratory infection An infection often occurs before the kidney manifestations of acute glomerulonephritis (GN). The onset of symptoms is about 10 days from the time of infection.

When assessing a client with pyelonephritis, the nurse recognizes that which of these conditions may predispose the client to the problem? a. Spinal cord injury b. Cardiomyopathy c. Hepatic failure{ d. Glomerulonephritis

a. Spinal cord injury Chronic pyelonephritis occurs with spinal cord injury, bladder tumor, prostate enlargement, or urinary tract stones.

When assessing the client with acute glomerulonephritis, of which of these findings does the nurse notify the provider? a. Purulent wound on leg b. Crackles throughout the lung fields c. History of diabetes d. Cola-colored urine

b. Crackles throughout the lung fields Crackles indicate fluid overload resulting from kidney damage; shortness of breath (SOB) and dyspnea are typically associated. The provider should be notified.

The nurse is admitting a client who has type 2 diabetes (T2D) and is scheduled for surgery. Which laboratory findings from this client's admission panel does the nurse report as indicating possible abnormal kidney function? (Select all that apply.) a. Presence of ammonia in the urine b. Urine microalbumin 240 mcg/24 hour (0.240 g/24 hour) c. Urine specific gravity of 1.028 d. Blood urea nitrogen of 38 mg/dL (13.5 mmol/L) f. Serum creatinine 2.2 mg/dL (294.3 mcmol/L) g. Blood osmolarity 290 mOsm/kg (290 mmol/kg)

b, d, and f

Which clinical manifestation in the client with pyelonephritis indicates that treatment has been effective? a. Decreased urine output b. Decreased urine white blood cells c. Increased red blood cell count d. Increased urine specific gravity

b. Decreased urine white blood cells A decreased presence of white blood cells indicates the eradication of infection.

A male client being treated for bladder cancer has a live virus compound instilled into his bladder as a treatment. What instructions does the nurse provide for postprocedure home care? a. "After 12 hours, your toilet should be cleaned with a 10% solution of bleach." b. "Do not share your toilet with family members for the next 24 hours." c. "Please be sure to stand when you are urinating." d. "Your underwear worn during the procedure and for the first 12 hours afterward should be bagged and discarded."

b. "Do not share your toilet with family members for the next 24 hours." The toilet should not be shared for 24 hours following the procedure because others using the toilet could be infected with the live virus that was instilled into the client. If the toilet must be shared, then specific cleaning precautions need to be taken each time the client uses the toilet. The best scenario is for the client not to share the toilet.

A nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification? a. "A small-lumen catheter will help prevent injury to my urethra." b. "I will use a new, sterile catheter each time I do the procedure." c. "My family members can be taught to help me if I need it." d. "Proper handwashing before I start the procedure is very important."

b. "I will use a new, sterile catheter each time I do the procedure." Catheters are cleaned and re-used. Proper handwashing and cleaning of the catheter have shown no increase in bacterial complications. Catheters are replaced when they show signs of deteriorating.

The client is hesitant to talk to the nurse about genitourinary dysfunction symptoms. What is the nurse's best response? a. "Don't worry, no one else will know." b. "Take your time. What is bothering you the most?" c. "Why are you hesitant?" d. "You need to tell me so we can determine what is wrong."

b. "Take your time. What is bothering you the most?" This statement is patient and understanding and tries to identify the client's problem.

Which factor is an indicator for a diagnosis of hydronephrosis? a. History of nocturia b. History of urinary stones c. Recent weight loss d. Urinary incontinence

b. History of urinary stones Causes of hydronephrosis or hydroureter include tumors, stones, trauma, structural defects, and fibrosis.

Which sign or symptom when found in the client with chronic glomerulonephritis warrants a call to the health care provider? a. Mild proteinuria b. Third heart sound c. Serum potassium 5.0 mEq/L d. Itchy skin

b. Third heart sound S3 indicates fluid overload secondary to failing kidney; the physician should be notified and instructions obtained.

Which instruction does the nurse give a client who needs a clean-catch urine specimen? a. "Save all urine for 24 hours." b. "Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." c. "Do not touch the inside of the container." d. "You will receive an isotope injection, then I will collect your urine."

c. "Do not touch the inside of the container."

A nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective? a. "I must avoid drinking carbonated beverages." b. "I need to douche vaginally once a week." c. "I should drink 2½ liters of fluid every day." d. "I will not drink fluids after 8 PM each evening."

c. "I should drink 2½ liters of fluid every day." Drinking 2½ liters of fluid a day flushes out the urinary system and helps reduce the risk for cystitis.

The nurse is teaching a client how to provide a clean-catch urine specimen. Which statement by the client indicates that teaching was effective? a. "I must clean with the wipes and then urinate directly into the cup." b. "I will have to drink 2 liters of fluid before providing the sample." c. "I'll start to urinate in the toilet, stop, and then urinate into the cup." d. "It is best to provide the sample while I am bathing."

c. "I'll start to urinate in the toilet, stop, and then urinate into the cup."

Situation: A 53-year-old postmenopausal woman reports "leaking urine" when she laughs. She has five children, all delivered vaginally. She is in good health and has tried pelvic floor (Kegel) exercises, which have not helped. She is not taking any medications and has no allergies to medication. She is diagnosed with stress incontinence. What does the nurse tell the client about how certain drugs may be able to help with her stress incontinence? a. "They can relieve your anxiety associated with incontinence." b. "They help your bladder to empty." c. "They may be used to improve urethral resistance." d. "They decrease your bladder's tone."

c. "They may be used to improve urethral resistance." Bladder pressure is greater than urethral resistance; drugs may be used to improve urethral resistance.

A nurse is educating a female about hygiene measures to reduce her risk for urinary tract infection. What does the nurse instruct the client to do? a. "Douche-but only once a month." b. "Use only white toilet paper." c. "Wipe from your front to your back." d. "Wipe with the softest toilet paper available."

c. "Wipe from your front to your back." Wiping front to back keeps organisms in the stool from coming close to the urethra, which increases the risk for infection.

A client is in the emergency department for an inability to void and for bladder distention. What is most important for the nurse to provide to the client? a. Increased oral fluids b. IV fluids c. Privacy d. Health history forms

c. Privacy

The certified wound, ostomy, continence nurse (CWOCN) or enterostomal therapist (ET) teaches a client who has had a cystectomy about which care principles for the client's post-discharge activities? a. Nutritional and dietary care b. Respiratory care c. Stoma and pouch care d. Wiping from front to back (asepsis)

c. Stoma and pouch care The enterostomal therapist demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms.

Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise? a. Functional b. Overflow c. Stress d. Urge

c. Stress Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence.

Which assessment finding alarms the nurse immediately after a client returns from the operating room for cystoscopy performed under conscious sedation? a. Pink-tinged urine b. Urinary frequency c. Temperature of 100.8°F (38.2°C) d. Lethargy

c. Temperature of 100.8°F (38.2°C)

Situation: A 32-year-old female with a urinary tract infection reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. Which drug does the nurse expect the health care provider to prescribe? a. Nitrofurantoin after intercourse b. Premarin c. Trimethoprim/sulfamethoxazole d. Trimethoprim with intercourse

c. Trimethoprim/sulfamethoxazole Guidelines indicate that a 3-day course of trimethoprim/sulfamethoxazole or fosfomycin is effective in treating uncomplicated, community-acquired UTI in women.

When caring for a client who had a nephrostomy tube inserted 4 hours ago, which is essential to report to the physician? a. Dark pink-colored urine b. Small amount of urine leaking around the catheter c. Tube has stopped draining d. Creatinine 1.8

c. Tube has stopped draining Notify the provider when a nephrostomy tube does not drain; it could be obstructed or dislodged.

The nurse is performing discharge teaching for the client after a nephrectomy for renal cell carcinoma. Which statement by the client indicates that teaching has been effective? a. "Because renal cell carcinoma usually affects both kidneys, I'll need to be watched closely." b. "I'll eventually require some type of renal replacement therapy." c. "I'll need to decrease my fluid intake to prevent stress to my remaining kidney." d. "My remaining kidney should provide me with normal kidney function."

d. "My remaining kidney should provide me with normal kidney function." After a nephrectomy, the second kidney is expected to provide adequate kidney function, but this may take days or weeks.

An older adult woman confides to a nurse, "I am so embarrassed about buying adult diapers for myself." How does the nurse respond? a. "Don't worry about it. You need them." b. "Shop at night-when stores are less crowded." c. "Tell everyone that they are for your husband." d. "That is tough. What do you think might help?"

d. "That is tough. What do you think might help?" This response acknowledges the client's concerns and attempts to help the client think of methods to solve her problem.

A nurse is teaching a client about pelvic muscle exercises. What information does the nurse include? a. "For the best effect, perform all your exercises while you are seated on the toilet." b. "Limit your exercises to 5 minutes twice a day, or you will injure yourself." c. "Results should be visible to you within 72 hours." d. "You know that you are exercising correct muscles if you can stop urine flow in midstream."

d. "You know that you are exercising correct muscles if you can stop urine flow in midstream." When the client can start and stop the urine stream, the pelvic muscles are being used.

A health care provider requests phenazopyridine (Pyridium) for a client with cystitis. What does the nurse tell the client about the drug? a. "It will act as an antibacterial drug." b. "This drug will treat your infection, not the symptoms of it." c. "You need to take the drug on an empty stomach." d. "Your urine will turn red or orange while on the drug."

d. "Your urine will turn red or orange while on the drug." Phenazopyridine (Pyridium) will turn the client's urine red or orange. Care should be taken because it will stain undergarments. Clients should be warned about this effect of the drug because it will be alarming to them if they are not informed.

A nurse is caring for clients on a renal/kidney medical-surgical unit. Which drug, requested by a health care provider, for a client with a urinary tract infection (UTI) does the nurse question? a. Bactrim b. Cipro c. Noroxin d. Tegretol

d. Tegretol Drug alerts state that confusion is frequent (sound alike and look alike) between the drugs Tequin and Tegretol. The former is used for UTI, and the latter is prescribed as an oral anticonvulsant.

Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? a. The client experiences nausea and vomiting after drinking juice. b. The biopsy site is tender to light palpation. c. The abdomen is distended and the client reports abdominal discomfort. d. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

d. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection (UTI). Which nursing action can the home health RN delegate to a home health aide (unlicensed assistive personnel [UAP])? a. Assisting the client in developing a schedule for when to take prescribed antibiotics b. Inserting a straight catheter as necessary if the client is unable to empty the bladder c. Teaching the client how to use the Credé maneuver to empty the bladder more fully d. Using a bladder scanner (with training) to check residual bladder volume after the client voids

d. Using a bladder scanner (with training) to check residual bladder volume after the client voids Use of a bladder scanner is noninvasive and can be accomplished by a home health aide (UAP) who has been trained and evaluated in this skill.

During discharge teaching for the client with kidney disease, what does the nurse teach the client to do? a. Drink 2 liters of fluid and urinate. b. Eat breakfast and go to bed. c. Check blood sugar and do a urine dipstick test. d. Weigh yourself and take your blood pressure.

d. Weigh yourself and take your blood pressure. Regular weight assessment monitors fluid restriction control. Blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction

*A client with cancer is receiving low-dose oral morphine but is reporting both "breakthrough" pain and constipation. What intervention does the nurse implement first?* A. Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) B. Decreases the morphine (morphine sulfate) dosage for the client C. Gives the client a Fleet's (sodium biphosphate) enema D. Records the client's bowel movements

*Answer: A* Rationale: Docusate is a stool softener, and gabapentin is an adjuvant for breakthrough pain. Constipation is a side effect of morphine, but decreasing the morphine dose will cause this client's pain to become even worse. Giving an enema is not the first intervention that should be tried by the nurse. Recording bowel movements is helpful for assessment, but does nothing to relieve the client's constipation.

*A postoperative client reports, "I have pain from a mild headache." Which PRN medication does the nurse administer?* A. Acetaminophen (Tylenol) B. Hydromorphone (Dilaudid) C. Midazolam (Versed) D. Oxycodone hydrochloride/acetaminophen (Tylox)

*Answer: A* Rationale: Non-opioid analgesics such as Tylenol are the first line of therapy for mild to moderate pain. Dilaudid is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Versed is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Although Tylox contains acetaminophen, it is also a narcotic; this level of pain control is not needed for a mild headache.

*A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor?* A. "Please allow the client to push the button when needed." B. "Please don't touch any equipment in the client's room." C. "Thank you. I am sure the client appreciated that." D. "The client is asleep and is not in pain."

*Answer: A* Rationale: The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. Telling the family member not to touch any equipment in the client's room is not only nonspecific, it is also disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

*A postoperative client is vomiting and states, "I am having a lot of pain—about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the client?* A. Intravenous B. Oral C. Rectal D. Transdermal

*Answer: A* Rationale: The intravenous route is the best choice for fast relief of nausea and pain. Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

*A client who had a laminectomy reports new onset of severe back pain. What responses by the nurse are most appropriate for the client at this time? Select all that apply.* A. "How is your pain on a 0-10 scale with 10 being the worst possible pain you've had?" B. "Could you describe the pain in your back?" C. "When you had visitors, you seemed to be laughing and not in any pain." D. "I'll get you some pain medication that the surgeon ordered." E. "Can you tell me what positions make the pain feel worse and better?"

*Answer: A, B, E* Rationale: Before the nurse intervenes to manage the patient's pain, he or she needs to do a complete pain assessment to collect more information. The statement "When you had visitors, you seemed to be laughing and not in any pain" is questioning the client's report of pain. Pain is subjective and is what the client says that it is. (pg.33)

*A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client?* A. Adding acetaminophen (Tylenol) B. Adding duloxetine (Cymbalta) as adjuvant therapy C. Increasing the opioid dose to control the pain D. Replacing the opioid with duloxetine (Cymbalta) for depression

*Answer: B* Rationale: Both tricyclic and other antidepressants such as duloxetine (Cymbalta) help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin. Adding acetaminophen would not address the client's depression. Increasing the opioid dose can cause respiratory depression. Discontinuing the opioid can cause relapse pain.

*A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond?* A. "I will cancel your medication order." B. "That sounds like a great plan; can you tell me more about it?" C. "That sounds like a wonderful idea; and I think it will definitely work!" D. "Your plan will not work; people with your type of pain need narcotics."

*Answer: B* Rationale: Complementary and alternative therapies should supplement, not replace, medication management. The nurse needs to obtain more data about the client's plan. Telling the client that his or her plan will not work is dismissive of the client. The client may not need to be prescribed narcotics for the pain.

*An older client who has advanced Alzheimer's disease is admitted to the clinical unit after abdominal surgery and is guarding her abdomen and moaning. What action will the nurse take?* A. Ask the client's family to rate the intensity of the client's pain using the 0-to-10 scale. B. Use a behavioral pain assessment tool to determine the presence of pain. C. Ask the client to rate the intensity of her pain using the 0-to-10 scale. D. Contact the primary health care provider to request an order for an antianxiety drug.

*Answer: B* Rationale: The client is unable to verbally rate her pain because of advanced dementia. Therefore, the nurse will observe the client's behaviors using an evidence-based screening tool to assess the level of the client's pain. Family members do not know how much pain the client has. (Pg. 34)

*A nursing technician reports that a postoperative client who is receiving IV PCA morphine is very drowsy, unable to complete a sentence without falling asleep, and has a respiratory rate of 12 breaths per minute. What is the nurse's first action at this time?* A. Arouse the client and raise the head of the bed to a 90-degree angle. B. Promptly call the primary health care provider to request an order to reduce the opioid dose. C. Take away the client's PCA button and tell the family to notify staff when pain returns. D. Reduce environmental stimuli by darkening the room so that the client can sleep.

*Answer: B* Rationale: The client's assessment findings are consistent with PCA morphine administration. The nurse continues to monitor the client's level of consciousness and assesses the respiratory rate frequently to determine if opioid overdose occurs. (Pg. 44)

*The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond?* A. "I will ask his oncologist about your question." B. "Let's ask your father about your request." C. "No, his pain relief is more important than your concerns." D. "Yes, this is a valuable way for all of you to make needed adjustments."

*Answer: B* Rationale: The client's desires about analgesia are the most important consideration in this scenario. He should be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker. Although the physician might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

*A client reports increasing pain during dressing changes. Which interventions are recommended for the client? (Select all that apply.)* A. Assistance by the client with the dressing change B. Distraction C. Epidural analgesic D. Music therapy E. Premedication F. Transcutaneous electrical nerve stimulation (TENS)

*Answer: B, D, & E* Rationale: Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment. Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain; its use during a dressing change would not be feasible.

*The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing?* A. 3:30 p.m. B. 4:00 p.m. C. 4:30 p.m. D. 7:00 p.m.

*Answer: C* Rationale: About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client. It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

*A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication?* A. "Are you bleeding?" B. "Are you really hurting every 4 hours?" C. "Is your pain controlled between doses?" D. "What do you do for pain when you're at home?"

*Answer: C* Rationale: Asking the client about the frequency of pain and how the pain is being controlled helps in formulating an effective pain management plan. Asking the client about the occurrence of bleeding does not address the pain issue; it is a separate problem. Indicating that the client isn't really hurting sounds judgmental and places the client on defense. Asking what the client does for pain at home is helpful in assessing chronic pain, but not for assessing postoperative pain; it is not relevant in this scenario.

*Which client does the RN arriving for duty assess first?* A. A 27-year-old who has chronic severe back pain with movement B. A 51-year-old with lung cancer who reports pain "whenever I cough" C. A 56-year-old with acute pancreatitis who reports increasing abdominal pain D. A 63-year-old who reports ongoing pain associated with rheumatoid arthritis

*Answer: C* Rationale: Because acute pain is a biological warning signal, the nurse should assess the client with pancreatitis for complications such as bleeding or perforation that may be causing the client's increasing pain. The clients with back pain, lung cancer pain, and rheumatoid arthritis have chronic pain; they should be assessed and treated as rapidly as possible, but the client with acute pain takes priority.

*A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next?* A. Decreases the client's standard pain medication dose B. Gives the client a placebo and monitors the outcome C. Gives the pain medication as requested D. Withholds the pain medication

*Answer: C* Rationale: Both types of chronic pain (chronic cancer pain and chronic non-cancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's responses when it is chronic cancer pain. The nurse should never decrease pain medication under the assumption that, because the client does not exhibit pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication.

*A hospitalized client anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure?* A. Animal-assisted therapy B. Hydrotherapy C. Imagery D. Acupuncture

*Answer: C* Rationale: Changing dressings or performing other procedures may produce pain for the client. Imagery can be used to calm and distract the client from pain. Animal-assisted therapy would be difficult because the nurse will be performing a dressing change, and the animal could get in the way, contaminate the wound, or cause the client to move around too much. Hydrotherapy may be contraindicated for this client. Acupuncture is not something that the nurse can easily offer during a dressing change.

*The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager?* A. Asking a client with chest pain if the pain is sharp and stabbing B. Instructing a confused postoperative client about how to use patient-controlled analgesia C. Preparing to administer a placebo to a client with chronic back pain D. Requesting that a client with chronic pain describe the specific location of the pain

*Answer: C* Rationale: Current national guidelines from regulatory agencies and nursing organizations indicate that placebos should never be used for clients who are experiencing pain. Asking the client a closed-ended question about his or her pain, attempting to instruct a confused client, and asking the client with chronic pain to specify its location all indicate a need for further education in assessment and management of pain, but would not be as great a concern as the possible use of placebos.

*The nurse is preparing a client for home care pain management following discharge. Which intervention does the nurse implement?* A. Discuss pain-relieving strategies on the day of discharge. B. Discuss home care with only the client's family, not with the client. C. Offer flexibility in home management of the client's current regimen. D. Offer information about end-of-life pain control management.

*Answer: C* Rationale: Flexibility will be necessary to adapt to the client's needs and allow for uninterrupted control of the client's pain issues. Discussion of pain relief strategies should begin when the client is admitted, not at the time of discharge. The client and other necessary health care agencies should be included in the discussion about home care. End-of-life pain control management will not be needed for most clients.

*The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially?* A. Calls the care provider for a change in the medication order B. Changes the order to every 6 hours rather than every 4 hours C. Gives the client a dose of naloxone (Narcan) 0.4 mg IV D. Performs a cognitive assessment on the client

*Answer: C* Rationale: For an unresponsive client, the nurse should administer naloxone (Narcan) 0.4 mg (diluted in 10 mL) over a 2-minute time period to reverse the action of the opioid analgesic. The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse should take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

*A hospitalized client expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the client most likely use?* A. Herbs B. Homeopathy C. Imagery D. Tai chi

*Answer: C* Rationale: Imagery is often used for reducing pain, nausea and vomiting, and anxiety. The remaining CAM therapies are not typically used for pain control. Herbs are typically used as a means to promote health, prevent disease, or cure a variety of ailments. Homeopathic medicine uses small doses of specially prepared plant extracts and minerals to promote healing. Tai chi integrates body movements, mind concentration, muscle relaxation, and breathing to achieve a desired outcome.

*Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN?* A. Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable B. Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain C. Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care D. Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief

*Answer: C* Rationale: LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes. Assessment and education are not within the LPN/LVN scope of practice.

*An older client takes acetaminophen (Tylenol) 2000 mg daily for osteoarthritis. What health teaching will the nurse provide for the client related to this medication?* A. "Be sure and take your medication with food to prevent stomach ulcers." B. "Take your medication only when you need it for chronic pain." C. "Avoid any over-the-counter medications that may contain acetaminophen." D. "Take your blood pressure often because acetaminophen can cause it to go up."

*Answer: C* Rationale: Many over-the-counter drugs contain acetaminophen, which when combined with the maximum prescribed dose of 3000 mg can cause liver toxicity. Acetaminophen does not cause stomach ulcers or increased blood pressure like other nonsteroidal antiinflammatory drugs can. Drugs for chronic pain should be taken on a regular regimen, not "as needed." (Pg. 37)

*Which statement is true about assessing pain in an older adult client?* A. The nurse should assess for present and past pain. B. Older adults typically believe that expressing pain is acceptable. C. Older adults are at great risk for undertreated pain. D. Older adults usually believe that pain signifies a minor illness.

*Answer: C* Rationale: Older adults are at great risk for undertreated pain because of outdated beliefs by some health care providers about older adults' pain sensitivity, tolerance, and ability to take opioids. The nurse should assess only for present pain. Older adults often believe that expressing pain is unacceptable. Older adults often believe that pain signifies a major illness.

*A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have?* A. Addiction B. Equianalgesia C. Physical dependence D. Pseudoaddiction

*Answer: C* Rationale: Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms. Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Equianalgesia refers to the dose and route of administration of one drug that produces about the same degree of analgesia as the given dose and route of another drug; this term is used when switching opioids or routes of opioids. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

*A newly admitted client who was in an automobile accident has a concussion and is reporting pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client?* A. An experienced RN travel nurse who arrived on the unit this morning B. An LPN/LVN who has worked on the orthopedic unit for 6 years C. The neurology unit RN who has floated to the orthopedic unit D. The RN orthopedic case manager who is responsible for discharge planning

*Answer: C* Rationale: The RN from the neurology unit will have the skills and experience needed to assess the neurologic and orthopedic status of this client, as well as the client's pain status. The travel RN may have the expertise to care for the client, but will not be familiar with hospital policies or equipment. The LPN/LVN does not have the education or scope of practice to be assigned the care of this complex client, although the RN may delegate some aspects of the client's care to the LPN/LVN. The case manager's expertise involves coordinating discharge for the client rather than caring for the client during the acute hospitalization.

*During change-of-shift report, the day shift staff learns that a client who had back surgery has been reporting increasing lower back pain during the night. It is most appropriate for which day staff member to assess the client's pain?* A. LPN/LVN who is responsible for administering medications to the client B. RN nurse manager who is in charge of coordinating care for several units C. RN team leader who is responsible for updating the care plan for the client D. RN who has floated to the unit from the emergency department

*Answer: C* Rationale: The RN team leader should assess this client's level of pain and the need for a change in the plan of care. The LPN/LVN will assist with management of the client's pain, but assessment should be done by the RN. The RN nurse manager has the education and scope of practice to assess the client's pain, but providing direct client care is not the designated role for this nurse. The RN from the emergency department will not be familiar with assessments and interventions for postoperative back pain.

*In the role of client advocate, what does the nurse do first for a client who reports pain?* A. Administers pain medication B. Assesses the level of pain C. Believes the client's report of pain D. Calls the provider for a medication order

*Answer: C* Rationale: The nurse's primary role in pain management is to advocate for the client by believing reports of pain. Administering pain medication, assessing the pain level, and calling the provider are not the first step to take

*When assessing a client for pain, acute or chronic, what question does the nurse ask the client to obtain the most data?* A. "Did someone do this to you?" B. "Does it hurt badly?" C. "Is the pain really that bad?" D. "When does it hurt?"

*Answer: D* Rationale: Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response. Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it hurt badly?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.

*A client with osteoarthritis pain tells the nurse, "I take two arthritis-strength Tylenol (650 mg) every 8 hours." How does the nurse respond?* A. "Aspirin would be a better, more effective choice for your pain relief." B. "More Tylenol is needed to provide effective pain relief for you." C. "That is the appropriate dose of Tylenol for your pain." D. "You will need to have routine liver and kidney function laboratory tests."

*Answer: D* Rationale: Clients taking Tylenol, especially high doses of it, should be reminded to have routine liver and kidney function laboratory testing done, because hepatotoxicity and nephrotoxicity are adverse effects associated with long-term use. Acetaminophen (Tylenol) is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding. The client is actually taking more than the recommended upper limit of Tylenol; no more than 3600 mg daily should be used, and no more than 2400 mg for older adults.

*The nurse is establishing a plan of care for a hospitalized client with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant?* A. Application of a transcutaneous electrical nerve stimulation (TENS) device B. Education about nonpharmacologic interventions for pain control C. Referral to available community resources for pain management D. Engagement in conversation about the client's family to distract the client

*Answer: D* Rationale: Distraction techniques such as conversation, music, and television may be implemented by unlicensed nursing staff members. Application of a TENS unit, education about nonpharmacologic pain interventions, and community resource referrals require specialized nursing education and scope of practice and should be performed by licensed nursing staff.

The client with type 1 diabetes mellitus received regular insulin at 7 AM. The client should be monitored for hypoglycemia at which time? 7:30 AM 11 AM 2 PM 7:30 PM

11 AM

A client with syndrome of inappropriate antidiuretic hormone is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider does the nurse address first? Administer infusion of 150 mL of 3% NaCl over 3 hours. Draw blood for hemoglobin and hematocrit. Insert retention catheter and monitor urine output. Weigh the client on admission and daily thereafter.

The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing Client with Graves' disease who is experiencing increasing anxiety and diaphoresis Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy

1. 6. The dietitian is developing a specialized therapeutic diet plan for the client who is about to be discharged. Which domain of complementary and alternative medicine is the dietitian using? A. Biologically based B. Energy C. Mind-body D. Systems of health care

A Correct: Biologically based therapies use natural substances for healing, including herbs, foods, vitamins, and minerals.

1. 2. The nurse is assessing the preoperative client for the use of herbal preparations. Which client statement causes the nurse concern? A. "I've been taking garlic supplements to help lower my cholesterol." B. "I sometimes take Echinacea to help with wound healing." C. "I take ginseng as an anti-aging remedy." D. "I've been taking St. John's wort to ease mild depression."

A Correct: Garlic supplements can cause bleeding and must be discontinued before any surgical procedure.

Which of these clients with diabetes should the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A 58-year-old with sensory neuropathy who needs teaching about foot care A 68-year-old with diabetic ketoacidosis who has an IV running at 250 mL/hr A 70-year-old who needs blood glucose monitoring and insulin before each meal A 76-year-old who was admitted with fatigue and shortness of breath

A 70-year-old who needs blood glucose monitoring and insulin before each meal

Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? "How does that make you feel?" "The mood swings should diminish with treatment." "The medications will make the mood swings disappear completely." "Your family member is sick. You must be patient."

A client diagnosed with hyperpituitarism resulting from a prolactin-secreting tumor has been prescribed bromocriptine mesylate (Parlodel). As a dopamine agonist, what effect does this drug have by stimulating dopamine receptors in the brain? Decreases the risk for cerebrovascular disease Increases the risk for depression Inhibits the release of some pituitary hormones Stimulates the release of some pituitary hormones

A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? The client eating a morning meal of cereal and fruit The physical therapist walking with the client in the hallway Unlicensed assistive personnel pulling the client up in bed by the shoulders Visitors talking with the client about going home

An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? Client with Graves' disease who needs discharge teaching after a total thyroidectomy Client with hyperparathyroidism who is just being admitted for a parathyroidectomy Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements

An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? Ask the client about any numbness or tingling. Check for bone deformities in the client's back. Measure the client's intake and output hourly. Monitor the client for shortness of breath.

The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? "I should have more energy with this medication." "I should take it every morning." "If I continue to lose weight, I may need an increased dose." "If I gain weight and feel tired, I may need an increased dose."

These data are obtained by the RN who is assessing a client who had a transsphenoidal hypophysectomy yesterday. What information has the most immediate implications for the client's care? Dry lips and oral mucosa on examination Nasal drainage that tests negative for glucose Client report of a headache and stiff neck Urine specific gravity of 1.016

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? Assess the wound dressing for bleeding. Give morphine sulfate 4 to 8 mg IV for pain. Monitor oxygen saturation using pulse oximetry. Support the head and neck with sandbags.

Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II? Anaplastic Follicular Medullary Papillary

1. 8. The hospitalized client anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure? A. Animal-assisted therapy B. Hydrotherapy C. Imagery D. Acupuncture

C Correct: Changing dressings or performing other procedures may produce pain for the client. Imagery can be used to calm and distract the client from pain.

1. 3. During an admission assessment, the client confirms the use of herbal remedies. Which question does the nurse ask to determine whether additional education is needed for the client? A. "Have you told your doctor?" B. "Do you know that herbal preparations are not regulated?" C. "What do you take, and how often?" D. "What side effects have you noticed?"

C Correct: Clients should be questioned about their use of herbals, the purpose for taking them, and the frequency and doses taken.

1. 10. The hospitalized client expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the client most likely use? A. Herbs B. Homeopathy C. Imagery D. Tai chi

C Correct: Imagery is often used for reducing pain, nausea and vomiting, and anxiety.

The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? Client in Addisonian crisis who is receiving IV hydrocortisone Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer Client being discharged after a unilateral adrenalectomy to remove an adrenal tumor Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin

1. 5. The nurse is providing care to a American Indian client. Which domain of complementary and alternative medicine therapies does the nurse expect to implement? A. Biologically based B. Energy C. Mind-body D. Systems of health care

D Correct: Each system of health care is based on a philosophy that guides practitioners in their assessments and selection of therapies. This domain is guided by the client's ethnicity and cultural background.

1. 7. The client's family asks the nurse whether they can do anything to help their unconscious family member who has suffered a severe head injury after a motor vehicle accident. Which complementary and alternative medicine therapies may the nurse offer? A. Herbs B. Guided imagery C. Journaling D. Prayer

D Correct: Prayer is the most common mind-body therapy used by health care professionals, clients, and clients' families.

1. 1. A 20-year-old client tells the nurse about experiencing extreme anxiety caused by current problems at work. The client states that having to sit at a desk all day while working increases his anxiety level. Which alternative therapy is most appropriate to suggest for this client? A. Journaling B. Acupressure C. St. John's wort D. Walking meditation

D Correct: The client is physically inactive and this increases anxiety; walking meditation is an appropriate intervention for the client.

1. 4. The nurse would like to perform a study examining the effectiveness of various complementary therapies. What is the best federal funding source for this study? A. Department of Health and Human Services (DHHS) B. Education system in which the nurse received education C. Hospital system in which the nurse is employed D. National Center for Complementary and Alternative Medicine (NCCAM)

D Correct: The purposes of the NCCAM are to fund studies examining the effectiveness of various complementary therapies, advance knowledge about complementary therapies for health care professionals, and serve as a clearinghouse for information about these therapies.

part 12

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