Physiological adaptation (elevate)

In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? Select all that apply 1. Dose rate. 2. Organs exposed. 3. Type of tumor being treated. 4. Presence of metastatic disease. 5. Type of radiation.

1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. Incorrect: The type of tumor being treated is important to know, but this will not affect the type of damage the client receives from the radiation. 4. Incorrect: The client may be receiving radiation therapy for palliative treatment. Damage to the client due to the radiation exposure will not increase or decrease due to the metastatic disease.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? Select all that apply 1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes 5. Kussmaul respirations

1., 2., 3. & 4. Correct: Hepatic encephalopathy results in changes in neurologic and mental responsiveness due to the accumulation of ammonia. All of the correct options are either mental or neurologic changes. 5. Incorrect: Kussmaul respirations are not a characteristic of hepatic encephalopathy. They are seen in diabetic ketoacidosis (DKA).

hich signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? Select all that apply 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. 6. Incorrect: Flank pain is seen when the urinary tract infection progresses to the kidneys.

A client is preparing to be discharged after a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. The nurse recognizes that education has been successful if the client makes which statement? 1. "Ulcerative colitis cannot be cured." 2. "I look forward to having the ileostomy closed." 3. "I am going to eat a hamburger and fries for dinner." 4. "Because of this surgery, I am at a higher risk of developing colon cancer."

2. Correct: Once the reservoir has healed, the ileostomy will be closed. 1. Incorrect: A total colectomy is removal of the entire colon. 3. Incorrect: It may take several days before solid food are tolerated. 4. Incorrect: The entire colon is removed so the client is not at risk for colon cancer.

What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? Select all that apply 1. Thick, white sputum 2. Crackles that clear with coughing 3. Wheezing 4. Orthopnea 5. Apical pulse 88/min 6. S3 gallop

3., 4., & 6. Correct: These S/S are commonly seen with ADHF because the heart is unable to keep up with the excess fluid in the vascular system. Wheezes indicate a narrowing of the bronchial lumen caused by engorged pulmonary vessels. Orthopnea is difficulty breathing when lying flat. The client will want to sit up rather than lie down. In older adults and the elderly with heart disease, an S3 often means heart failure. An S3 gallop is an early diastolic filling sound indicating an increase in left ventricular pressure. 1. Incorrect: The client with ADHF will have a frothy sputum with a pinkish color. 2. Incorrect: Crackles do not clear with coughing. 5. Incorrect: This is a normal pulse rate. Clients with ADHF will have tachycardia to keep blood moving in a forward direction.

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer? Select all that apply 1. Dark tea colored urine 2. Clay colored stools 3. Jaundice 4. Coffee ground emesis 5. Lower abdominal pain

1., 2., & 3. Correct: Diseases of the head of the pancreas such as pancreatic cancer can lead to darkening of the urine, clay colored stools, and jaundice. All are the result of bile duct blockage. 4. Incorrect: Coffee ground emesis is a symptom of an ulcer that is bleeding. 5. Incorrect: Pain in the upper abdomen that radiates to your back is seen with pancreatic cancer. Lower abdominal pain can be associated with diseases such as diverticulitis.

Which assessments will provide the nurse with the most information regarding a client's neurologic function? Select all that apply 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1 & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: This should be last resort.

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Correct: First, identify the client's symptoms.2. Incorrect: Not before proper identification of client's symptoms.3. Incorrect: Not before proper identification of client's symptoms.4. Incorrect: Not before proper identification of client's symptoms.

The nurse is monitoring a client in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? 1. pH 7.32 2. PaCO2 47 3. HCO3 25 4. PaO2 78

1. Correct: In DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. 2. Incorrect: Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 47 is high and not an expected finding. 3. Incorrect: Normal HCO3 is 22-26. For a client in DKA, the expected HCO3 would be less than 22. HCO3 is a base. In acidosis, the expected finding is low HCO3​. 4. Incorrect: Normal PaO2 is 80-100. An expected finding in DKA will be normal or increased PaO2, not decreased.

The nurse in the emergency department is caring for a client admitted in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 12 mm of Hg

1. Correct: Normal CVP is 2-6 mmHg. This is a CVP reading that would indicate fluid volume deficit. A client in DKA will have polyuria. A Hurst strategy is "with polyuria, think shock first". Less volume, less pressure! 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. 4. Incorrect: This CVP reading indicates fluid volume overload. The client in DKA will not be experiencing fluid volume excess.

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. Correct: Normal CVP is 2-6mmHg. This CVP reading indicates fluid volume deficit. A client with 52 percent of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues resulting in fluid volume deficit. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 4. Incorrect: An increased CVP reading indicates fluid volume excess. There is no indication in the stem that the client is experiencing a fluid volume excess.

A client returns to the clinic two days after receiving treatment for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and that the client is having difficulty walking steadily. Based on this data, what does the nurse suspect is wrong with the client? 1. Guillain-Barré Syndrome 2. Multiple Sclerosis 3. Myasthenia Gravis 4. Systemic Lupus Erythematosus

1. Correct: The clues in this stem are diarrhea from Campylobacter jejuni, tingling sensation that began in the toes, spread to the feet and legs today, muscle weakness in the legs, and difficulty walking steadily. These s/s point to Guillain-Barré Syndrome. 2. Incorrect: Multiple Sclerosis damages nerves but not in an ascending progression from toes to head. 3. Incorrect: Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles. Myasthenia gravis is characterized by weakness and rapid fatigue of any of the muscles under voluntary control. 4. Incorrect: Systemic lupus erythematosus, the most common form of lupus, is a chronic autoimmune disease that can cause severe fatigue and joint pain.

In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position

1. Correct: The goal after intracranial surgery is to keep the intracranial pressure (ICP) from rising while optimizing the cerebral perfusion pressure (CPP). The ideal position for this client is HOB elevated and the head in neutral position. 2. Incorrect: Placing the client in supine position may increase ICP. Supine position is achieved when the client is lying flat. 3. Incorrect: Dorsal recumbent position will increase ICP as this position will increase peripheral return. The client in dorsal recumbent position is lying flat with the knees flexed and separated. 4. Incorrect: The recovery position is side lying position with one knee flexed. This position can also increase ICP.

A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse's assessment reveals coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease

1. Correct: These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency and the extremities are cool to touch. Other s/s include: paleness of extremity when elevated or possible redness when lowered, loss of hair on affected extremity, and thick nails. 2. Incorrect: Venous insufficiency is not characterized by pain with walking. Pulses are generally normal and color is generally normal with the exception of the brown pigmentation that may be noted (especially around the ankles). 3. Incorrect: The description in the stem is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. No reports of chest pain were noted. 4. Incorrect: The description is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. The symptoms listed in the stem are indicative of a peripheral artery problem.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

1. Correct: Torsemide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmoL/L) is hypokalemia, and a common sign and symptom includes muscle cramps. 2. Incorrect: Normal calcium levels in the serum are 9.0-10.5 mg/dL (2.25-2.62 mmol/L). The level of 11 mg/dL (2.75 mmol/L) is hypercalcemia. Calcium acts like a sedative, so you would expect the client's muscle tone to be weak and flaccid rather than experiencing muscle cramping. 3. Incorrect: The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Therefore, a level of 140 mEq/L (140 mmol/L) is WNL and would not be a factor in the client's report of muscle cramping. 4. Incorrect: The pH level of 7.40 is also WNL and is not a lab finding that would be consistent with muscle cramping.

Which intervention would the nurse recommend to a client with rheumatoid arthritis to best help relieve joint stiffness? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

1. Correct: Warm water may provide muscle relaxation, increase blood flow, and reduce stiffness. 2. Incorrect: A mild analgesic may be taken before activity or exercise to decrease pain and inflammation. 3. Incorrect: Weight reduction may be recommended to relieve stress on joints but does not address joint stiffness. 4. Incorrect: Apply cold compresses for 15-20 minutes at a time. Longer than 20 minutes may cause tissue damage.

What assessment data is the priority nursing concern in a client receiving prednisolone for the treatment of nephrotic syndrome? 1. Weight gain of 2 lbs (0.907 kg) in 24 hours 2. Temperature 99.6°F (37.5° C) 3. Blood glucose 116 mg/dL 4. Blood pressure 138/88

1. Correct: Well, if my weight is going up rapidly, it is from fluid not fat. Edema is getting worse, then my kidneys are getting worse. Edema is more significant than an "expected" increase in glucose. I expect the glucose to be elevated. Remember, steroids inhibit insulin, so I expect the glucose to go up with prednisolone. Also, 116 mg/dL (6.44 mmol/L) is not that far from the top of the normal range. 2. Incorrect: Is this an abnormal temp? Not really. 3. Incorrect: The glucose is elevated. What's normal: 70-110 mg/dL (3.9-6.2 mmol/L). Edema is more significant than an "expected" increase in glucose. 4. Incorrect: Hypertension can be a sign of nephrotic syndrome. Remember, the client is retaining fluid. More volume, more pressure. But is this a BP that is worrisome? No

The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease

2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes. 1. Incorrect: No, not associated with chronic pancreatitis. 3. Incorrect: No, not associated with chronic pancreatitis. 4. Incorrect: No, not associated with chronic pancreatitis.

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? Select all that apply 1. Orthopnea. 2. Paroxysmal nocturnal dyspnea. 3. Petechiae on the trunk. 4. Increasing CVP with decreasing BP. 5. Pericardial friction rub. 6. Widening pulse pressure.

1., & 2. Correct: These are signs seen with valvular heart disease. Orthopnea is a condition where the client must sit or stand to breathe comfortably. Paroxysmal nocturnal dyspnea occurs when the client is reclining. It is sudden respiratory distress. 3. Incorrect: This is a sign of endocarditis. 4. Incorrect: This is the hallmark sign for cardiac tamponade. 5. Incorrect: This is a sign of pericarditis. 6. Incorrect: This is a sign of increased intracranial pressure.

The nurse is caring for a client being treated for hypertensive crisis and suspects that the client may be developing an abdominal aortic aneurysm (AAA). Which assessment findings by the nurse suggest that the client is developing this complication? Select all that apply 1. Abdominal bruit 2. Upper back pain 3. Hoarseness 4. Pulsations around umbilicus 5. Shortness of breath

1., & 4. Correct. A bruit heard over the abdomen is an indicator of an abdominal aortic aneurysm and warrants further investigation. An abdominal aortic aneurysm usually causes a balloon-like swelling. The wall of the aorta bulges out which results in a pulsating mass in the abdomen. 2. Incorrect. Upper back pain is not associated with AAA but rather with a thoracic aneurysm. 3. Incorrect. Hoarseness can be caused by any number of disorders, but not AAA. It can be seen with a thoracic aneurysm. 5. Incorrect. Shortness of breath is indicative of a respiratory problem but can be seen with a thoracic aneurysm. It is not a symptom of AAA.

A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? Select all that apply 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.

1., & 5. Correct: With a left-sided stroke, the right side of the body is affected. Applying a splint at night to the affected extremity will prevent flexion of that extremity. Prolonged flexion leads to contractures. Prevent adduction of the affected shoulder with a pillow placed in the axilla. 2. Incorrect: Vision is controlled by the left side of the brain. Vision on the right side of both eyes may have decreased (hemianopia) due to this left-sided stroke, so approach the client from the left side. 3. Provide full range of motion four or five times a day to maintain joint mobility. 4. Incorrect: Remember, left-sided cerebrovascular accident = right sided paralysis. The right extremities, which are affected by the left-sided stroke should be elevate on a pillow to prevent dependent edema. 6. Incorrect: The fingers should be positioned so that they are minimally flexed. This will prevent a contracture of the hand. Flexing the fingers into a fist will cause them to contract.

The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? Select all that apply 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia

1., 2 & 4. Correct: Parkinson's disease is a debilitating, progressive neurological disorder of unknown cause. The most classic symptoms include unsteady gait secondary to increasing muscle rigidity and bradykinesia, plus difficulty with purposeful movement. These symptoms worsen over time and are often accompanied by tremors in the extremities at rest. 3. Incorrect: Reflexes in clients with Parkinson's disease become progressively slowed, not hyperactive. Because this disorder affects the midbrain, and ultimately the connection of the basal ganglia, deep tendon reflexes decrease over the course of the disease. Hyperactive reflexes are associated with other neurologic disorders such as multiple sclerosis. 5. Incorrect: Expressive aphasia is associated with brain trauma or cerebral vascular accident (CVA) and prevents the client from verbalizing appropriate or desired terminology. In Parkinson's disease, the client's speech volume becomes too low and very monotone. Also, because of facial muscle rigidity, there is great difficulty articulating words enough to be clearly understood.

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1., 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. 4. Incorrect: Never place an object in a client's mouth who is experiencing a seizure. 5. Incorrect: Magnesium sulfate is administered to control BP and decrease seizures. Magnesium sulfate leads to fewer maternal deaths and fewer future seizures when given for eclamptic seizures. Diazepam is contraindicated for use in pregnancy.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? Select all that apply 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status. 3. Incorrect: The CVP reading reflects the client's fluid volume status. The client's temperature would not reflect the client's fluid volume status. 4. Incorrect: The CVP reading reflects the client's fluid volume status. The nail bed color would not reflect the client's fluid volume status. 5. Incorrect: The CVP reading reflects the client's fluid volume status. The EKG rhythm would not reflect the client's fluid volume status.

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? Select all that apply 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1., 2. Correct: Symptoms of tabes dorsalis are caused by damage to the nervous system. Problems walking occur such as an abnormal gait or inability to walk at all. Vision changes can occur. Blindness is a complication of tabes dorsalis. 3. Incorrect: Loss of coordination and diminished reflexes occur rather than hyperreflexia. 4. Incorrect: Stiff neck is seen with meningitis, but also with meningovascular neurosyphilis. Meningeal neurosyphilis usually manifests with the clinical features of acute meningitis. 5. Incorrect: Hearing is not affected by neurosyphilis. However, vision changes, including blindness can occur.

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1., 2., & 3. Correct: Wet clothing is removed to eliminate continued exposure to the cold and allow the warming process to begin. Swelling is common so anything, such as clothing or jewelry that could cause constriction to blood flow should be removed. A controlled and rapid re-warming process is accomplished using a continuous flow of warm water until flushing is noted in the affected areas. Antiseptics or antibiotics are often used, and each digit is wrapped individually with sterile gauze (not constricting) to minimize the risk of infection and assist in the warming process. The core should be re-warmed first to prevent "afterdrop" which is a further drop in core temperature caused by cold peripheral blood returning to the central circulation. 4. Incorrect: Movement of frostbitten areas can cause ice crystals to form in the tissue and cause further damage. In addition, lack of sensation places the client at risk for falls or other injury. 5. Incorrect: External heat such as heating pads, fireplaces, etc. should not be used because burns are more likely to result due to the presence of decreased sensation in the affected areas. 6. Incorrect: Initial rubbing or massage of the frostbitten digits is an absolute contraindication as it can cause further tissue damage. Gentle handling is required to prevent stimulation of the cold myocardium.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? Select all that apply 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.5. Incorrect: These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure.

Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? Select all that apply 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen

1., 2., 3. & 5. Correct: Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Epigastric pain may also be present as well as fever, chills, and anorexia. A physical examination often reveals rigidity of the upper right abdomen that may radiate to midsternal area or right shoulder. Rebound and guarding are present in some cases. 4. Incorrect: The client with cholecystitis will have nausea and vomiting which usually results in a decreased appetite.

The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly? Select all that apply 1. Elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar. 2. Suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes. 3. Symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules. 4. Stress the importance of proper foot care and regular eye exams. 5. Check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous.

1., 2., 3. & 5. Correct: Older clients are at risk for hypoglycemia unawareness. Blood sugar levels should be checked frequently. Some oral medications are more likely to cause hypoglycemia episodes. If the client has frequent episodes, perhaps a medication change is warranted. The elderly must maintain regular meal schedules and adequate food intake. This may present challenges for the elder who lives alone. If an elder develops unsteady gait, loss of concentration, and/or lightheadedness, the blood glucose levels should be checked. These symptoms are typical in a hypoglycemic episode.4. Incorrect: Proper foot care and regular eye exams should be done to avoid complications caused by hyperglycemia, not hypoglycemia.

What assessment data would a nurse expect to find in a client diagnosed with acute inflammatory bowel disease? Select all that apply 1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr 5. Increased serum prealbumin

1., 2., 3., & 4. Correct: Stools are bloody and contain mucus. The client will be malnourished, thus will be pale due to anemia. Anemia is related to folate deficiency. Anorectal excoriation and pain can occur. Hypotension and low urine output indicate possible fluid volume deficit. 5. Incorrect: Serum prealbumin, albumin, and protein levels are decreased in malnourished individuals.

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? Select all that apply 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1., 2., 3., & 4. Correct: These are signs of cannula displacement. Observe for signs of cannula displacement into the tissues which will be swelling, bleeding, lack of a normal arterial waveform, fluid leakage, blanching, and pain or discomfort. 5. Incorrect. This is a sign of infection rather than cannula displacement. Signs of infection include pain, redness, purulent drainage, and fever. 6. Incorrect. This is a sign of infection rather than cannula displacement.Signs of infection include pain, redness, purulent drainage, and fever.

A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? Select all that apply 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia

1., 2., 3., & 6. Correct: The earliest signs of alcohol withdrawal are anxiety, agitation, insomnia, and tremors. Tachycardia of 120-140 /min persists throughout withdrawal. 4. Incorrect: The onset of hallucinations indicates alcohol withdrawal delirium, a potentially fatal complication of alcohol withdrawal that occurs when the withdrawal process has not been medically managed. It begins the 2nd or third day after the client's last drink and lasts 48-72 hours. 5. Incorrect: Confabulation is a symptom of alcohol amnestic disorder or Korsakoff syndrome. Thiamine deficiency is thought to cause this syndrome.

A client who is 36 weeks gestation has been admitted to the labor and delivery area for evaluation due to worsening signs of pregnancy induced hypertension (PIH). The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a fetal heart rate of 90/min on the fetal monitor. What nursing actions would be appropriate for this client? Select all that apply 1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I & O. 5. Prepare for emergency vaginal delivery. 6. Monitor for restlessness and decreased level of consciousness (LOC).

1., 2., 3., 4., and 6. Correct: The nurse recognizes that the client is demonstrating signs of placental abruption (abruptio placentae), most likely due to the presence of PIH. Due to the risk of shock, the maternal vital signs are checked immediately and continuously monitored. The mother will be aware of the emergent nature of her situation. She will need to be informed of what is occurring and kept informed of the status of the fetus. Accurate measurement of I&O, in addition to assessing the amount of vaginal blood loss, will be crucial in determining fluid volume status. Restlessness and decreasing level of consciousness would indicate poor cerebral perfusion as a result of decreased vascular volume and decreased cardiac output. Fluid and blood replacement would be indicated. 5. Incorrect: The infant is already demonstrating signs of distress (bradycardia), and the mother is considered unstable. The nurse would need to prepare her for an emergency delivery by cesarean, not a vaginal delivery.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? Select all that apply 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Increase protein rich foods in the diet. 4. Cut fingernails short 5. Provide mouth care prior to meals

1., 2., 4. & 5. Correct: The build up of uremic frost associated with end stage renal disease causes pruritus. Gloves reduce the risk of dermal injury. Emollients and lotion will aid dry, itchy skin. Apply after bathing. Cutting nails short will decrease risk of skin breakdown when scratching. Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste. 3. Incorrect: A client in end stage renal disease needs to decrease the amount of protein in the diet. Dietary restrictions include protein, sodium, potassium, and phosphate.

What discharge teaching should the nurse include to the parent of an adolescent who has a mild concussion? Select all that apply 1. Concussion symptoms may last anywhere from hours and days to weeks and months. 2. Return to the emergency department for worsening headache. 3. Monitor for increased intracranial pressure. 4. Avoid physical activities until released from care. 5. Awaken the client every two hours.

1., 2., 4., & 5. Correct. This injury will result in symptoms that may last anywhere from hours and days to potentially weeks and months. Contact the primary healthcare provider or the Emergency Department if the client has repeated vomiting, severe or worsening headache, severe or worsening dizziness, or any worsening symptom that alarms client or family. Avoid physical activities (sports, gym, and exercise) and reduce cognitive demands (reading, texting, computer use, video games, etc). The brain is responsible for managing physical and cognitive functions of the body; therefore, it is important to decrease any activity that increases symptoms. Awaken every two hours to check level of consciousness. 3. Incorrect. A lay person would not know the signs/symptoms of increased ICP.

The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? Select all that apply 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.

1., 2., 4., 5., & 6. Correct: Music therapy may produce relaxation by quieting the mind and promoting a restful state. Aromatherapy with chamomile may also help overcome anxiety, anger, tension, stress, and insomnia in dying clients. When the lights go down and the room darkens, this signals to the brain that it's time for rest. Keeping conversations quiet will help to decrease stimuli. Simple techniques such as repositioning pillows or bed clothes and gentle massage (if tolerated) can also provide relief from pain. 3. Incorrect: Restraints will only agitate the client more. Remember, use restraints as a last resort.

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? Select all that apply 1. Blank affect. 2. Decreased ability to swing arms. 3. Waddling gait. 4. Walking on toes. 5. Pill-rolling tremor. 6. Stiff muscles.

1., 2., 5., & 6. Correct: Classic characteristics of Parkinson's disease include a blank facial expression, forward tilt in the posture, slow/slurred speech, tremor, and a short shuffling gait. These symptoms also are manifested by a decreased ability to swing the arms and stiff muscles. 3. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait. 4. Incorrect: This is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? Select all that apply 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1., 3. & 5. Correct: Effects of radiation therapy include, but are not limited to pancytopenia (marked decrease in the number of RBCs, WBCs and platelets), erythema (redness of the skin), and fatigue.2. Incorrect: Leukocytosis is an increase in WBCs. External radiation causes pancytopenia which is a decrease in the number of blood cells including WBCs. 4. Incorrect: Fever is not typically seen with external radiation.

A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? Select all that apply 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.

1., 3., & 4. Correct: Pertussis is a very contagious disease that spreads from person to person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. The nurse should place the child on droplet precautions in addition to standard precautions. For infants older than 1 month of age, macrolides drugs such as erythromycin are the drugs of choice. With droplet precautions you should use client dedicated or disposable equipment to prevent the spread of infection. If this is not possible, you must clean and disinfect shared/reusable equipment between use. This includes IV pumps, cell phones, pagers, other electronics, supplies, equipment. Clean prior to removing from the room. 2. Incorrect: A mist tent with high humidity may be used. The purpose is to improve a child's respiratory status by liquefying pulmonary secretions. 5. Incorrect: This child needs fluids, either by mouth or IV to keep from getting dehydrated, and to liquify secretions.

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? Select all that apply 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

1., 3., 4., & 5. Correct: As rheumatoid arthritis worsens, the joints become progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows. 2. Incorrect: A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia.

A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse? Select all that apply 1. Anxiety 2. BP 136/80 3. CVP 5 mmHg 4. Crackles noted right posterior lung field 5. S3 heart sound

1., 4. & 5. Correct: Volume overload is an adverse effect of IV therapy in the elderly. Anxiety is an early sign of hypoxia due to FVE. Crackles to the bases are an early sign of fluid volume excess (FVE). S3 heart sounds are also an indication of FVE. 2. Incorrect: This blood pressure is not considered hypertension in this age group. Blood pressure of >140/90 is cause for concern in this age group. Also, one BP is not cause for concern. In assessing for FVE, it is important to compare to the client's baseline. 3. Incorrect: Normal CVP is 2-6 mmHg. A CVP reading of 5mmHg does not indicate FVE.

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? Select all that apply 1. Hypotension 2. Hypoglycemia 3. Hyperreflexia 4. Flaccid muscle tone 5. Respiratory depression

1., 4. & 5. Correct: When magnesium sulfate is administered to the mother for preeclampsia, the intent is to prevent seizures and decrease blood pressure by suppressing the central nervous system, thus preventing premature labor. The dose of this drug and the length of time administered will determine what side effects might be seen in the newborn, since magnesium crosses the placental barrier. The nurse will most likely note hypotension and some degree of respiratory depression in the newborn. Additionally, the newborn may have flaccid or weak muscles along with poor, or even absent reflexes. Treatment of the newborn will be based on the degree of depression. 2. Incorrect: The use of magnesium sulfate in the mother prior to delivery does not affect the blood glucose level of the fetus/newborn. Magnesium sulfate affects the central nervous system, not the pancreas, so blood sugar should be within normal limits. 3. Incorrect: Magnesium is a central nervous system depressant that crosses the placental barrier. Side effects to the newborn would be similar to those noted in the mother, including depressed or absent reflexes. The nurse would not find hyperreflexia.

The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? Select all that apply 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness

1., 4., & 5. Correct: A set of vital signs and assessment for hypovolemic shock take priority for this client. S/S of shock include thready, rapid pulse, decreased LOC, shortness of breath, cold and clammy skin, and decreased urinary output.2. Incorrect: History of prior bleeding episodes is important but does not address the immediate problem.3. Incorrect: Medication history is important, but the nurse must first determine whether or not the client is in shock.

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? Select all that apply 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2, 4, 5 and 6. CORRECT: The Bratt diet is useful for children following any type of gastroenteritis which included nausea, diarrhea or severe vomiting. This bland diet is used in the first 24 hours to allow the gut to rest and readjust slowly to foods that are low protein, low fat and low fiber. The BRATT diet is for short term use only and consists of bananas, rice, apple sauce, toast and tea. 1. INCORRECT: Although raisins are normally a natural source of healthy fruit, they have too much fiber for an irritated gastric tract. They are not part of the BRAT diet. 3. INCORRECT: Apples are high in fiber and natural sucrose, which is not appropriate for a child with severe gastroenteritis. However, apple sauce is part of the BRAT diet and is an excellent source of nutrition without stressing a weakened gastrointestinal system.

What instructions should the nurse include when teaching a mother, whose newborn has hyperbilirubinemia, regarding phototherapy and its effects? Select all that apply 1. Breastfeeding should be discontinued until phototherapy is completed. 2. Feed newborn at least every 2-4 hours. 3. Make sure the newborn's eyes are closed when applying eye patches. 4. Keep the baby quiet and swaddled. 5. Report immediately if the urine becomes dark in color.

2. & 3. Correct: Providing adequate breast milk or formula by feeding at least every 2-4 hours is key in preventing and treating jaundice because it promotes elimination of the bilirubin in the stools and urine. The infant should be monitored for signs of dehydration, including decreased skin turgor and decreased urinary output. Dehydration often results from decreased intake, phototherapy, and diarrhea. When applying the eye patches, the newborn's eyes should be closed to avoid causing a corneal abrasion. 1. Incorrect: Breast feeding is encouraged and is an important part of meeting both the nutritional and emotional needs of the newborn. 4. Incorrect: The infant's clothing is removed to allow maximum exposure of the skin to the phototherapy. The genitalia should be covered. 5. Incorrect: The caregiver should be taught to expect the infant's stools to be green and the urine dark because of photo degradation products (breakdown of bilirubin for excretion).

What should the nurse who is educating about the most common initial visual changes associated with glaucoma inform the client? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes. 4. Eye floaters begin to be noticed.

2. Correct: If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses. 1. Incorrect: Central vision loss is the classic visual disturbance for macular degeneration but peripheral vision is usually maintained. 3. Incorrect: Individuals experiencing retinal detachment may have sudden flashes of light in the affected eye, but this is not an initial visual change related to glaucoma. 4. Incorrect: Eye floaters are more common in eye disorders such as retinal detachment or may occur associated with the aging process.

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes to curl fan out when the soles of the feet are stroked. 1. Incorrect: This is a normal response seen in the neonate. 3. Incorrect: This is a normal response seen in the neonate. 4. Incorrect: This is a normal response seen in the neonate.

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

2. Correct: The body cools itself by sweating and allowing that sweat to evaporate. This requires enough fluid in the body to make sweat, air circulating across the skin, and low enough air humidity to allow that sweat to evaporate. 1. Incorrect: With heat stroke the body's temperature reaches more than 104 degrees F (40 degrees C). 3. Incorrect: Sweating is seen in heat exhaustion. Sweating stops with heat stroke. 4. Incorrect: Clients with heart exhaustion usually have flu like symptoms with headache, weakness, nausea and/or vomiting.

preeclampsia client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. What is the nurse's priority action? 1. Place client in Trendelenburg position and apply oxygen. 2. Stop magnesium and prepare to give calcium gluconate. 3. Ask another nurse to verify the deep tendon reflexes. 4. Prepare client for an emergency cesarean section.

2. Correct: The nurse's findings indicate the client's central nervous system has been overly depressed, with a respiratory rate of 10 and absent deep tendon reflexes. The nurse's priority intervention is to stop the magnesium, which is the cause of the problem, and prepare to reverse the situation with calcium gluconate. 1. Incorrect: Placing a client head down, in Trendelenburg position, is used for treating shock. No information is presented that indicates shock. Also, there is no information about oxygen saturation levels that would indicate the need for oxygen. 3. Incorrect: It is not unusual for one nurse to ask another nurse to confirm abnormal findings; however, in this situation, it would be considered a delay of treatment and transfers care of the client to someone else. The nurse's priority action must focus directly on the client. 4. Incorrect: The purpose of administering magnesium sulfate is to prevent seizures and decrease the blood pressure in a preeclampsia client. There is no information in the question that indicates that either the client or the fetus is in distress, requiring an emergency section.

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. Reports shortness of breath 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

2. Correct: The onset of shortness of breath could be an indicator that the client should not advance to the next level. The client should be instructed to stop and rest if chest pain or shortness of breath occurs. While in a rehabilitation program, it is imperative to give the client very specific guidelines for physical activity so overexertion will not occur. 1. Incorrect: Facial flushing is not life-threatening. The client can advance to the next level. 3. Incorrect: An increase in heart rate of 10 beats a minute is an expected finding with physical activity. This would not prevent the client from advancing to the next level. 4. Incorrect: An increase in systolic BP is an expected finding with physical activity.

The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.

2. Correct: The worst complication of a DVT is the potential for a pulmonary embolism, resulting when part of the blood clot breaks free and travels to the lungs. This life-threatening complication presents with symptoms of hypoxia, including restlessness, agitation, or dizziness. The client may also develop chest pain, depending on the size of the clot. 1. Incorrect: While these symptoms may require further assessment, the question does not provide any parameters for vital signs. Individually, tachycardia and tachypnea could be attributed to pain, anxiety, or even hospitalization. There is not enough information provided to necessitate an immediate call to the Primary healthcare provider. 3. Incorrect: Pain in the affected extremity is not an unexpected finding with this diagnosis, although the nurse would need to further assess and evaluate the level and location of the pain in relation to the blood clot. This symptom is not surprising and would not require immediately alerting the primary healthcare provider. 4. Incorrect: The Homan's sign was a method formerly used to assess for the presence of a DVT and was performed by dorsiflexing the foot of the affected leg in an effort to elicit pain. However, this technique has proven to be unreliable and is no longer part of the assessment process.

What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee? Select all that apply 1. Sjogren's syndrome 2. Clicking sound when knee bends 3. Fever 4. Pain that is worse after activity 5. Severe fatigue

2., & 4. Correct: Loss of cartilage between bone joints produces the clinking or cracking sound heard when the joint bends. Pain is worse after an activity involving the affected joint or toward the end of the day. 1. Incorrect: Sjogren's (SHOW-grins) syndrome is a disorder of the immune system identified by its two most common symptoms — dry eyes and a dry mouth. It is not seen in osteoarthritis. 3. Incorrect: Fever is not associated with Osteoarthritis but is associated with rheumatoid arthritis (RA). 5. Incorrect: Severe fatigue is seen with rheumatoid rather than osteoarthritis.

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

2., 3. & 6. Correct: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. Weight loss indicates that fluid is being removed and a urine output of 50mL/hour indicates that renal perfusion is adequate. All three assessents indicate improvement. 1. Incorrect: 3+ pedal edema would indicate that the client is not better. 4. Incorrect: Purse-lip breathing is seen when client is still short of breath. 5. Incorrect: Pale conjuctiva, nail beds, buccal mucosa are signs of impaired gas exchange.

A client is admitted with abdominal pain, distention, fever, dehydration, (+) Cullen's sign and a rigid boardlike abdomen. Which interventions would help control the client's pain in the acute period? Select all that apply 1. Small frequent feedings 2. NG tube to low suction 3. Side-lying position with head elevated 4. Hydromorphone by PCA pump 5. IV isotonic solutions

2., 3., & 4. Correct: The pain is caused by inflammation of the pancreas and the autodigestive process. How do we fix the pain? Rest the pancreas and decrease the secretion of digestive enzymes or better known as...empty and dry. The NG tube will keep the stomach empty and dry. Side-lying with head elevated decreases tension on the abdomen and may ease pain. The hydromorphone is an analgesic and will help with the pain. 1. Incorrect: We want them NPO. If you selected this option, then you are telling the NCLEX Lady that you are going to constantly stimulate the release of digestive enzymes with frequent feedings and keep the pancreas inflamed, inflamed, inflamed! Pain! 5. Incorrect: IV solutions will keep them hydrated and correct electrolyte disturbances but not relieve pain.

Which finding would the nurse expect to see in a client diagnosed with pneumocystis carinii pneumonia (PCP)? Select all that apply 1. Hemoptysis 2. Fever 3. Dyspnea 4. CD4 count of 500 cells/cubic millimeter 5. Wheezing

2., 3., & 5. At first, PCP may cause only mild symptoms or none. Common signs/symptoms include fever (usually low-grade if with HIV), dry cough or wheezing, shortness of breath or dyspnea on exertion, fatigue, and pleuritic pain on inspiration. 1. Incorrect: Clients with pneumocystis pneumonia have a nonproductive cough. Hemoptysis is a late sign of lung cancer or tuberculosis. 4. Incorrect: The CD4 count is a test that measures how many CD4 cells are in the blood. These are a type of white blood cells, called T-cells, that move throughout the body to find and destroy bacteria, viruses, and other invading germs. A normal CD4 count is from 500 to 1,400 cells per cubic millimeter of blood. CD4 counts decrease over time in persons who are not receiving antiretroviral therapy. At levels below 200 cells per cubic millimeter, clients become susceptible to a wide variety of opportunistic infections, many of which can be fatal.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? Select all that apply 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome.

An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? Select all that apply 1. Purposeful movement. 2. Sudden emotional outbursts. 3. Client report of blurred vision. 4. Pupils equal, react to light, and accommodation. 5. Bright red blood oozing from the wound. 6. Headache unrelieved by acetaminophen.

2., 3., & 6. Correct: Signs/symptoms of increased ICP include: excessive sleepiness, inattention, difficulty concentrating, impaired memory, faulty judgment, depression, irritability, emotional outbursts, disturbed sleep, diminished libido, difficulty switching between two tasks, and slowed thinking. Abnormalities in vision and extraocular movements occur in the early stages of increased ICP. A headache that is unrelieved by acetaminophen would warrant further investigation. 1. Incorrect: This is a normal response and does not warrant further investigation. 4. Incorrect: This is a normal response and does not warrant further investigation. 5. Incorrect: The scalp is very vascular and oozing would be expected. Apply pressure to stop bleeding.

The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose? Select all that apply 1. Hypoventilation 2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration 6. Hypothermia

2., 3., 4., & 5. Correct: Nausea and vomiting are the most common toxic effects. This can be caused by CNS toxicity or by direct damage to the gastric mucosa. Salicylates can be neurotoxic, and this is manifested by ringing in the ears. Ototoxicity can also lead to hearing loss. Diaphoresis results in the early phase of toxicity. Serious dehydration can result from insensible losses due to hyperventilation and fever, as well as active losses due to vomiting. 1. Incorrect: The first phase of salicylate toxicity is characterized by hyperventilation due to stimulation of the respiratory center in the brain. This is a key feature of salicylate toxicity. 6. Incorrect: Hyperpyrexia is an indication of severe toxicity, especially in younger children.

hat electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? Select all that apply 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2., 3., 4., & 5. Correct: The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? Select all that apply 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion

2., 3., 4., & 5. Pernicious anemia symptoms could include a smooth tongue that is red in color rather than a healthy pink. And neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. Light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report. 1. Incorrect. Pain is a symptom seen in sickle cell anemia.

A client reporting right thigh pain is admitted to a local hospital with a diagnosis of deep vein thrombosis (DVT). During the admission assessment, the client develops new signs/symptoms. The nurse would be most concerned about what sign/symptom? 1. Swelling along vein of leg 2. Right foot begins to tingle 3. Restlessness 4. Warmth over affected area

3. CORRECT. A change in client's behavior or level of consciousness indicates possible decreased oxygenation to the brain. When there is a known DVT, the nurse would be concerned about a potential stroke from a clot that has broken off from the main thrombus. 1. INCORRECT. The client has just been diagnosed with a right thigh DVT; therefore, symptoms are still evolving. It is not unusual for edema to continue to increase, though the nurse should observe carefully for additional issues. 2. INCORRECT. Tingling of the foot on the affected side is expected since the affected thigh edema and the clot are compressing the circulation and nerves that extend into the foot. The nurse must monitor the situation carefully to prevent further complications. 4. INCORRECT. Pain and warmth are typical early signs of a DVT. Additionally, the tissue becomes red and inflamed from the internal edema. The nurse is aware some of the client's symptoms are still evolving, so this sign is not the most alarming at this time.

A client had an open cholecystectomy several days ago. What finding by the nurse should be reported to the primary healthcare provider immediately? 1. Respiratory rate of 30 2. Blood pressure reading of 104/50 3. Incisional pain with foul, green drainage 4. Urinary output of 75 mL straw colored urine

3. CORRECT: The client is having incisional pain, which by itself could be expected following an open cholecystectomy. However, there should never be any foul, green drainage from an incision, as this indicates a post-operative infection. The nurse should report this immediately to the primary healthcare provider. 1. INCORRECT: Although this respiratory rate seems slightly on the elevated side, this client has had recent surgery and is now having some complications. Combined with the pain, this rapid respiratory rate would be expected. 2. INCORRECT: There is no baseline data provided regarding this blood pressure data. Without a reference to a client's previous blood pressure, it is impossible to form any opinion about this reading. We worry about a systolic BP of 90. 4. INCORRECT: The information provided in the question does not give any parameters by which to evaluate the urine. Straw colored urine is a normal finding; however, there is no indication regarding the length of time it took to accumulate 75 mL of urine. Therefore, no decision can be formed about this finding.

The nurse is teaching a client diagnosed with asthma about using a peak expiratory flow meter. The nurse asks the client what action should be taken if the reading is 65% of the client's personal best value. What statement by the client indicates to the nurse that education was successful? 1. "This is a good reading for me, so I can go about my usual activities." 2. "I will administer my long-term inhaler medication." 3. "My as needed inhaler medication needs to be administered." 4. "I need to immediately call 911."

3. Correct: Between 50% and 79% of the client's personal best value indicates asthma is getting worse and the client should immediately take the "as needed" medication which should be a short-acting bronchodilator. 1. Incorrect: 80% to 100% of a client's personal best value is considered "doing well" and is the range recommended that the client can do usual activities. However, a reading of 65% falls below this recommended level, so the client may not be able to perform usual activities. 2. Incorrect: 80% to 100% of a client's personal best value indicates continuation of long term inhaler medication each day. The level of 65% of the client's personal best value confirms the need for a rescue medication. 4. Incorrect: If the client is unresponsive to immediate therapy, emergency care may be required.

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

3. Correct: Fine tremors are the first symptom reported in 70% of client's diagnosed with Parkinson's Disease. 1. Incorrect: Tremors are not a normal age change. 2. Incorrect: Tremors may indicate a problem. 4. Incorrect: Tremors may indicate early onset Parkinson's Disease.

The emergency department nurse is assuming care of a client with full thickness burns to both legs. Which primary healthcare provider prescription should be implemented first? 1. Administer IV morphine 2. Insert oropharyngeal airway 3. Start two large bore IVs 4. Apply silver sulfadiazine to burn area

3. Correct: Full thickness burns of both legs would result in a severe fluid volume deficit. A priority treatment for burns include fluid replacement; therefore, insertion of 2 large bore IVs is a priority. 1. Incorrect: Pain is important but not priority over fluid volume status. Remember, pain never killed anybody.2. Incorrect: This client does not have airway involvement. These burns are on the legs; there is no indication in the stem that the airway is involved. 4. Incorrect: Application of silver sulfadiazine does not take priority over fluid replacement.

While suctioning a client's endotracheal (ET) tube, the nurse notes that the client's heart rate has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action? 1. Deflate the ET tube cuff. 2. Have the client cough several times in a row. 3. Oxygenate the client with 100% oxygen. 4. Notify the primary healthcare provider.

3. Correct: The drop in pulse rate indicates acute hypoxia, which can be caused by suctioning. The nurse should stop suctioning and oxygenate with 100% oxygen. 1. Incorrect: There is no indication to deflate the ET cuff. Routine ET cuff deflation is not recommended. 2. Incorrect: This is a vagal maneuver that can be done to increase parasympathetic tone and decrease the conduction of the electrical impulses to the heart, usually done for treatment of supraventricular tachycardias. 4. Incorrect: The primary healthcare provider does not have to be called unless the client does not respond to oxygen.

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

3. Correct: Hemorrhagic strokes are the result of ruptured vessel bleeding in the cranial cavity. This action will result in increased intracranial pressure (ICP). ICP can cause a decrease in the brain's metabolism and hypoxia of the brain tissue. The head of the bed should be elevated to decrease the increased intracranial pressure which can reduce damage to the brain. The intervention of raising the head of the bed to 25 -30 degrees is directly related to a decrease in ICP. 1. Incorrect: An osmotic diuretic is administered to increase the osmotic effect on the kidneys which will decrease ICP. An osmotic diuretic is initiated during the acute care protocol for a stroke. 2. Incorrect: A neurological assessment would be done upon admission to the medical unit. But maintaining the head of the bed at 30 degrees is the initial action. 4. Incorrect: The readiness of the client to learn should be evaluated prior to initiating teaching. Due the client's immediate transfer from ICU, this is not the apparent time to begin to the initiate client teaching. Ways to avoid straining during a bowel movement instruction is not the priority nursing intervention.

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Correct: Metabolic acidosis. Look at the hints you have been given. Diabetes, blood sugar of 400 mg/dL (22.2 mmol/L), muscle twitching, and increased respirations. This client is going into diabetic ketoacidosis (DKA), which leads to metabolic acidosis. 1. Incorrect: The problem is not a respiratory problem, so respiratory acidosis in not correct. 2. Incorrect: The problem is not a respiratory problem, so respiratory alkalosis in not correct. 4. Incorrect: This client would be breaking down body fat, which produces ketones. Ketones are an acid, so the client would be in metabolic acidosis, not metabolic alkalosis.

A client is admitted to the hospital reporting chills, fatigue and left lower leg pain for nearly a week. During initial assessment, the nurse notes wide-spread swelling and redness of left ankle in addition to a fever of 103.5° F (39.72° C). Which admission order should the nurse implement first? 1. Perform sterile wound care to lower leg. 2. Start I.V. for administration of antibiotics. 3. Place client on bedrest with left leg elevated. 4. Draw blood for serial cultures and lab work.

3. Correct: Osteomyelitis is a serious inflammation of bone tissue caused when bacteria or fungus has entered the body through an open wound, an infected prosthetic, or even animal bite. Symptoms include fever, chills, nausea, and fatigue with decreased mobility in the affected extremity. The client can quickly become septic as the illness spreads through the system. Bedrest along with massive doses of antibiotics are necessary to prevent the spread of the infection, resulting in possible bone death or even amputation. 1. Incorrect: Since the nurse is in the process of admitting this client, wound care is not a priority action. There are more urgent orders to be implemented in order to stabilize the client. 2. Incorrect: Intravenous antibiotics are generally prescribed for up to six weeks, and the client may need a PICC line to continue antibiotic therapy in the home setting. While starting an I.V. line for antibiotic administration is important, this is not the most crucial first action. 4. Incorrect: Lab tests can provide valuable diagnostic information about clients with osteomyelitis. The Healthcare provider would most likely order a complete blood count (CBC) and sediment rate, expecting elevations in both. Blood cultures would also confirm whether the infection has become systemic. However, a venipuncture can wait until a more important action has been completed.

The nurse is caring for a female client who is at risk for renal failure. The nurse has completed the initial assessment of the most recent lab results so that any concerns can be reported to the primary healthcare provider. Which assessment finding warrants further action? 1. Hemoglobin of 12 g/dl (120 g/L) 2. Hematocrit of 38% (0.38) 3. Potassium levels of 5.2mEq/L (5.2 mmol/L) 4. BUN of 15 mg/dl. (5.35 mmol/L)

3. Correct: Potassium is excreted primarily through the kidneys. When the kidneys are not working, potassium is being held. The normal value is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). This potassium level is high and warrants further action. 1. Incorrect: This hemoglobin level is within normal limits for the female client. Normal hemoglobin values are 11.7-15.5g/dL (117-155g/L). 2. Incorrect: This hematocrit value is within the normal range for a female client. Normal hematocrit values are 35-45% (0.35-0.47).4. Incorrect: This BUN level is within normal limits. Normal BUN levels are 10-20mg/dL (3.6-7.1mmol/L). Just because this client is in renal failure would not indicate a need to select this option.

A client arrives at the emergency department (ED) in obvious emotional distress, reporting perioral numbness and tingling of the fingers and toes. The nurse notes a respiratory rate is 56/min. What should be the initial intervention performed by the nurse? 1. Send the client for a CT of the head. 2. Place on 100% O2 per non-rebreathing face mask. 3. Have the client breathe into a paper bag. 4. Administer diazepam 2 mg IV push.

3. Correct: Recognize the respiratory rate is too fast. This client is hyperventilating and blowing off too much CO2 which has resulted in symptoms of respiratory alkalosis, perioral numbness, and tingling of the fingers and toes. The nurse should try to help calm the client and encourage the client to slow the rate of breathing. This will help hold onto CO2. By breathing into a paper bag, the client will re-breathe CO2 therefore increasing the CO2 level. 1. Incorrect: The client is not demonstrating signs of a stroke. A CT is not warranted based on the information provided. 2. Incorrect: Administration of O2 is not warranted at this time. The client is blowing off too much CO2 and needs to re-breathe CO2 using a paper bag. Increasing O2 will not fix the problem of emotional distress. 4. Incorrect: Diazepam has sedative effects. Although hysterical clients may have to be sedated to decrease the respiratory rate, the less invasive means of using the paper bag should be attempted first.

The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

3. Correct: The most serious complications of hypokalemia are cardiac changes. Hypokalemia impairs myocardial conduction and prolongs ventricular repolarization. This can be seen by a prominent U-wave (a positive deflection following the T-wave on the EKG). The U-wave is not totally unique to hypokalemia, but its presence is a signal for the clinician to check the serum potassium level. 1.Incorrect: Remember hypermagnesemia results in the client having a sedated appearance, decreased deep tendon reflexes, decreased level of consciousness, decreased respiratory rate, and ultimately cardiac arrest. 2. Incorrect: In hypocalcemia, this client is not sedated and will have an increased nerve excitability, tetany, appearance of Trousseau's, and Chvostek's sign. Cardiac manifestations include Vtach. 4. Incorrect: Hyponatremia results in neurological symptoms: confusion, irritability, and ultimately coma.

The ICU nurse is caring for a client with massive head injuries. The nurse notices that the client's respirations have a rhythmic increase and decrease of rate and depth and include brief periods of apnea. How would the nurse document this respiratory pattern? 1. Apneusis 2. Ataxic 3. Cheyne-Stokes 4. Cluster

3. Correct: The respiratory pattern described is Cheyne-Stokes. A client with massive head injuries is at risk for this breathing pattern due to an injury with the cerebal hemispheres. 1. Incorrect: Apneusis is characterized by a sustained inspiratory effort. It does not typically have a period of apnea. 2. Incorrect: Ataxic respirations have an irregular, random pattern of deep and shallow respirations with irregular apneic periods. The irregularity of it differentiates ataxic respirations from Cheyne-Stokes respirations. 4. Incorrect: Cluster breathing is characterized by a closely grouped series of gasps followed by a period of apnea. There is no rhythmic increase and decrease as in Cheyne-Stokes respirations.

Which initial arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)? 1. pH 7.54, PaCO2 41, PaO2 63, SaO2 91, HCO3 36 2. pH 7.24, PaCO2 37, PaO2 83, SaO2 95, HCO3 18 3. pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25 4. pH 7.12, PaCO2 28, PaO2 72, SaO2 93, HCO3 10

3. Correct: This ABG result indicates respiratory alkalosis. Aspirin stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO​2 and normal HCO​3. 1. Incorrect: This ABG result indicates metabolic alkalosis. The pH is high, PaCO​2 is normal and HCO​3 is high. Normal pH is 7.35-7.45, normal PaCO​2 is 35-45, normal HCO​3 is 22-26. 2. Incorrect: The client with an initial aspirin overdose will have a respiratory alkalosis. 4. Incorrect: This ABG also indicates metabolic acidosis. The problem in the stem would result in a respiratory problem.

hich clients would the nurse monitor for the development of hypovolemic shock? Select all that apply 1. Having an allergic reaction form multiple wasp stings 2. Post-operative cervical spinal cord surgery 3. Addisonian crisis 4. Partial thickness burns over 50% total body surface area (TBSA) 5. Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma (HHNK)

3., 4. & 5. Correct: A client in Addisonian crisis loses sodium and water and can have hypovolemic shock. A 10 year old child with 40% burns is shifting fluid to the tissues because of the tissue damage of the burns, increasing permeability. An adult with type 2 diabetes and an infection can develop HHNK. This massive polyuria can cause shock. With polyuria, think shock first. 1. Incorrect: I would worry about anaphylactic shock with this client. 2. Incorrect: I would worry about neurogenic shock with this client.

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

3., 5., & 6. Correct: Guillain-Barre' Syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It is characterized by ascending, symmetric paralysis affecting the cranial and peripheral nerves. Signs and symptoms include paresthesia, hypotonia, areflexia, muscle aches, cramps, orthostatic hypotension, hypertension, bradycardia, facial flushing, facial weakness, dysphagia, and respiratory distress. 1. Incorrect: Opisthotonos is extreme arching of the back and retraction of the neck. This is seen with tetanus, not with Guillain-Barre' Syndrome. 2. Incorrect: Seizures can be associated with many neuromuscular problems but are not typical with Guillain-Barre' syndrome. Look for seizures with such problems as increasing ICP, infections of the brain, high fever, epilepsy. 4. Incorrect: Hemiplegia, paralysis on one side of the body, is not seen. There is a symmetric paralysis starting in the lower extremities and ascending through the body. In other words, weakness begins in the feet and progresses upward. The client gets better in reverse order.

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

4. Correct: Histoplasmosis is a fungal infection transmitted through ingestion of soil contaminated by bird manure. 1. Incorrect: The classic symptom of Lyme disease is usually an expanding target-shaped or "bull's-eye" rash which starts at the site of the tick bite. Fever, headache, muscle aches, and joint pain may also occur. 2. Incorrect: Toxoplasmosis occurs from contact with cat feces. Symptoms may be influenza-like: swollen lymph nodes, headaches, fever, and fatigue, or muscle aches and pains. 3. Incorrect: TB is often suspected; however, the primary difference is exposure to bird feces.

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

4. CORRECT: In any emergency situation, the nurse must still adhere to Maslow hierarchy and follow current American Heart Association guidelines when assessing a client. Once the client has been pulled from the water, the first action is to open the airway and check for the presence of spontaneous respirations. 1. INCORRECT: While this client will most likely require cardiopulmonary resuscitation, the nursing process requires assessment prior to initiating any action. Additionally, checking for any respirations must be done before starting chest compressions. 2. INCORRECT: There is no information on whether the client fell into the pool or was already in the pool; therefore, the client will need to be assessed for injuries at some point. However, that particular assessment is not the initial priority action. 3. INCORRECT: The client's core body temperature may be decreased. However, hypothermia is not an initial concern with this client, and in fact, hypothermia can sometimes be beneficial in a drowning situation.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" appearance of the eye 4. Extreme pain in the eye

4. Correct. The postoperative cataract client usually experiences little to no pain, and it can be managed with mild analgesics. If the pain is severe, there may be an increase in intraocular pressure, hemorrhage, or infection, and the surgeon should be notified. 1. Incorrect. Slight swelling of the eyelid is considered a normal finding following cataract surgery. 2. Incorrect. The postoperative cataract client usually experiences little to no discomfort following surgery. This is a normal finding.3. Incorrect. Slight redness is an expected finding. Pay attention to the word "slight". Increased redness is cause for concern. Compare it to the non-operative eye.

A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? 1. Ambulate client around room every 2 hours. 2. Assess Homans' sign every 8 hours. 3. Place sequential compression device on both legs. 4. Apply intermittent warm, moist soaks to affected area.

4. Correct. Warm, moist soaks help to decrease edema and ease the discomfort. 1. Incorrect. The client is placed on bedrest with a gradual increase in ambulation over several days to allow time for the clot to adhere to the vessel wall which will prevent embolization. 2. Incorrect. Manipulating the leg to determine Homans' sign can dislodge the clot. 3. Incorrect. Do not use sequential compression devices to treat a DVT. It could cause the clot to break loose or dislodge.

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.

4. Correct: A ventriculostomy is a temporary drain placed in the brain to remove excess cerebral spinal fluid in order to decrease intracranial pressure. Because the client's ICP readings are increasing, the nurse's initial action is to try to reduce that pressure by hyperventilating the client with a bag valve mask, also called an Ambu bag or manual resuscitator. This lowers cerebral CO2 levels, causing vasoconstriction which temporarily decreasing blood flow and reducing pressure within the brain. 1. Incorrect: Clients experiencing increased intracranial pressure must be positioned in a neutral position, head midline and slightly elevated, generally with sandbags or immobilizers on either side of the skull to maintain that position. This allows for optimal drainage of cerebral spinal fluid (CSF) from the ventriculostomy. 2. Incorrect: The primary healthcare provider or surgeon will indeed need to be notified. However, the nurse's initial action is always focused on stabilizing the client if possible. In this case, the nurse can intervene prior to calling the primary healthcare provider. 3. Incorrect: Lowering the head of the bed is contraindicated following brain surgery since it increases blood flow to the brain, thus increasing intracranial pressure. The ideal position is head slightly elevated at 30 to 45 degrees with head immobilized in the midline position to improve drainage of CSF.

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? 1. Alopecia 2. Arthritis of hands 3. Weight gain 4. Fever

4. Correct: Fever is the classic sign of a flare, or exacerbation of SLE. 1. Incorrect: Lupus can cause the hair on your scalp to gradually thin out, although a few people lose clumps of hair. 2. Incorrect: Most SLE clients will develop arthritis with their illness. Arthritis from SLE commonly involves swelling, pain, stiffness, and even deformity of the small joints of the hands, wrists, and feet. Sometimes, the arthritis of SLE can mimic that of rheumatoid arthritis, another autoimmune disease. 3. Incorrect: Weight gain is not a sign of exacerbation but is a side effect of long-term corticosteroid use.

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

4. Correct: Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition. 1. Incorrect: Tenesmus is the urge to move your bowels even if you've just emptied your colon. This is a common symptom of an ulcerative colitis flair and would not be of immediate concern to the nurse. 2. Incorrect: Hyperactive bowel sounds can mean there is an increase in intestinal activity. This may happen with diarrhea or after eating. This client has ulcerative colitis so hyperactive bowel sounds during a flare is expected. 3. Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse.

The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia

4. Correct: Hyperemesis gravidarum is characterized by persistent severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH. 2. Incorrect: The lower GI tract has a lot of magnesium; this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up i.e. sodium, hematocrit and specific gravity.

A client asks the nurse, "What causes hypermagnesemia?" The nurse should explain to the client that hypermagnesemia can occur secondary to what health problem? 1. Peripheral vascular disease 2. Dehydration 3. Liver failure 4. Renal insufficiency

4. Correct: Magnesium is excreted primarily through the kidneys. When the client experiences renal insufficiency, magnesium is held. The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency. 1. Incorrect: Peripheral vascular disease does not lead to hypermagnesemia 2. Incorrect: Dehydration leads to the electrolyte imbalance of hypernatremia, it does not cause hypermagnesemia. A client who has become dehydrated due to excessive urination may experience hypomagnesemia. 3. Incorrect: Liver failure does not lead to hypermagnesemia. Magnesium is regulated by GI absorption and renal excretion.

A client has received 850 mL of an isotonic solution intravenously in less than 60 minutes. Which central venous pressure (CVP) reading noted by the nurse indicates a problem related to the amount of intravenous fluids infused? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

4. Correct: Normal CVP is 2-6 mmHg. This client has received an isotonic solution amount of time. Remember that isotonic fluids stay "where I put them". The vascular space will increase in volume. More volume, more pressure! 1. Incorrect: This CVP reading indicates fluid volume deficit. There is no indication in the stem that the client is losing fluid. 2. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg. 3. Incorrect: This is a normal CVP reading. Normal CVP is 2 to 6 mm of Hg.

A client, who arrives at the emergency department, reports flashes of light. What problem does the nurse suspect? 1. Cataract 2. Open angle glaucoma 3. Macular degeneration 4. Retinal detachment

4. Correct: Seeing flashes of light is one indication of retinal detachment. The client may also report floating spots or blurred, "sooty" vision. If detachment progresses rapidly, the client may report a veil-like curtain obscuring parts of the visual field. Early on, straight-ahead vision may be intact but, as detachment evolves, there is a loss of central and peripheral vision. 1. Incorrect: A cataract is a clouding that occurs over the eye lens. The client states it is like looking through a fogged-up window. 2. Incorrect: Glaucoma is a group of eye conditions that damage the optic nerve, often caused by an abnormally high pressure in the eye. Open-angle glaucoma results in patchy blind spots in the peripheral or central vision, frequently in both eyes. Tunnel vision occurs in the late stages. 3. Incorrect: Macular degeneration is the leading cause of irreversible vision loss in people over the age of 60. It occurs when the small central portion of the retina deteriorates. Although macular degeneration is almost never a totally blinding condition, it can be a source of significant visual disability. The first sign a person will notice is a gradual or sudden change in the quality of vision or that straight lines appear distorted. Other symptoms include dark, blurry areas or whiteout that appears in the center of vision. In rare cases, a change in color perception can occur.

What should the summer camp nurse include when teaching a group of adolescents about West Nile Virus? 1. Antiviral medications are used to treat West Nile Virus. 2. Using insect repellent containing diethyltoluamide (DEET) will kill the virus when a mosquito makes skin contact. 3. Nothing can be done to prevent West Nile Virus. 4. Symptoms of West Nile Virus include headache, fever, and fatigue

4. Correct: The West Nile Virus begins with flu-like symptoms such as headache, fatigue, and fever. These symptoms, however, may continue for several months. 1. Incorrect: There is no medication to treat West Nile Virus infection. 2. Incorrect: Insect repellent repels the mosquito but has no effect on the virus the mosquito is carrying 3. Incorrect: There are prevention methods that can be initiated to attempt to prevent West Nile Virus, such as using insect repellant with DEET as instructed; dress in clothing that covers arms and legs; cover crib, stroller, and baby carrier with mosquito netting; use screens on windows and doors; repair holes in screens to keep mosquitoes outside; use air conditioning when available; sleep under mosquito net if sleeping outdoors; and check inside and outside home for standing water (where mosquitoes lay eggs).

uring evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.

4. Correct: The chest compressions, airway, and breathing (CAB) sequence is always of primary concern. The first nurse correctly activated a code and then began chest compressions. The second nurse will assist by oxygenating the client, using a bag valve mask. 1. Incorrect: Although it will be necessary to bring the crash cart into the room, the initial priority should focus on the client's needs. In the case of a client in cardiac arrest, the first personnel to respond must focus on CPR protocols, including compressions and oxygenation. Other personnel can bring the crash cart into the room. 2. Incorrect: Documenting all the events that occur during a code is vital for both legal and quality assurance purposes; however, the initial priority must focus on stabilizing the client. 3. Incorrect: The Healthcare Provider does need to be notified, but it is not an immediate priority for either nurse. Ancillary personnel, such as the unit secretary, can complete this task. Professional personnel must focus on the client's immediate needs at this critical point.

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Correct: This is your priority. This position will facilitate maximum lung expansion. It will also decrease venous return to the right side of the heart so that pressure decreases in the pulmonary vascular system. 1. Incorrect: Oxygen is needed, but the first thing the nurse should do is raise the head of the bed, so the client can breathe easier. Then get the oxygen set up. 2. Incorrect: Obtaining a blood pressure reading at this point is delaying treatment. The problem is a breathing problem. Do something to fix the breathing problem first. Then, you can continue your assessment by checking circulation status. 3. Incorrect: Connecting the client to a cardiac monitor is an appropriate intervention, but facilitating breathing takes priority and should be done first.

What would be the best way for the nurse to evaluate the effectiveness of fluid resuscitation during the emergent phase of burn management? 1. Weight increases by 2 pounds in 24 hours 2. Urinary output is greater than fluid intake 3. Blood pressure is 90/60 mmHg 4. Urine output greater than 35mL/hour

4. Correct: Urine output of 30 to 50 mL/hour indicates adequate fluid replacement. 1. Incorrect: May indicate fluid retention. 2. Incorrect: Does not indicate fluid balance. 3. Incorrect: Blood pressure alone does not indicate adequate fluid balance.

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level

Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. 2. Incorrect: You may do this; however, seizure precautions will take priority. 3. Incorrect: The priority here is seizure precautions. 4. Incorrect: This data should lead to the suspicion of dehydration and hypernatremia, not suspected MI, which would be the reason a troponin level would be obtained.