Quiz 2

The nurse is developing a postoperative plan of care for Larry. Which concerns does the nurse have for Larry related to the assessment data noted in the nursing progress notes? Select all that apply.Nursing Progress Notes - Larry Moss Loneliness Constipation Inability to void Inability to cope Inability to clear airway

Inability to clear airway Constipation RATIONALE: Two complications of immobility are respiratory problems such as atelectasis or pneumonia and constipation. Larry's abdomen is slightly firm, with decreased bowel tones, and his last bowel movement was 2 days ago; this places him at risk for constipation. His lungs have crackles and his respiratory rate is increased, which supports the inability to clear airway concern. He does not have inability to void because he has an adequate output. There is no data to support loneliness or inability to cope.

A nurse checks the laboratory test results of a client who is undergoing chemotherapy and notes that the client's platelet count is 90,000 cells/mm. In light of this result, which action by the nurse is appropriate? Instituting bleeding precautions Instituting neutropenic precautions Informing the client that the test result is normal Educating the client about the importance of increasing iron in the diet

Instituting bleeding precautions

A nurse is providing information to a client who has just learned that he has type 1 diabetes mellitus. The nurse tells the client that the blood level of HbA1c will need to be checked periodically. How does the nurse explain the purpose of the test to the client? It is performed to determine how well the insulin is working. It is performed to determine whether a larger dose of insulin is required. It is used to measure the degree of glucose control in the preceding 3 months. It is used to measure the hemoglobin level to ensure that the prescribed diet is adequate for the client's needs.

It is used to measure the degree of glucose control in the preceding 3 months. RATIONALE: The HbA1c blood test is a measure of the degree of glucose control during the previous 3 months, the lifespan of the hemoglobin molecule. How well the client's insulin is working, determining whether a larger dose of insulin is required, and determining the adequacy of the prescribed diet are not the purposes of this blood test.

A nurse is gathering subjective data from a client with suspected bladder cancer. Which early manifestation of bladder cancer the nurse would expect the client to report? Flank pain Groin discomfort Lower back pain Painless hematuria

Painless hematuria RATIONALE: Painless hematuria is the first sign of a bladder tumor in most clients. It may be gross or microscopic and is usually intermittent. Dysuria and urinary frequency or urgency are the usual symptoms when infection or obstruction is present. Flank pain indicates renal involvement. Lower back pain and groin discomfort may occur later in the course of the disease.

A nurse is reviewing the laboratory results of a client with Addison's disease. Which finding is most closely correlated with this disorder? Calcium level of 8.6 mg/dL (2.15 mmol/L) Sodium level of 145 mEq/L (145 mmol/L) Potassium level of 5.5 mEq/L (5.5 mmol/L) Blood glucose level of 110 mg/dL (6.1 mmol/L)

Potassium level of 5.5 mEq/L (5.5 mmol/L) RATIONALE: Laboratory testing in Addison's disease reveals hypoglycemia, hyperkalemia, hyponatremia, and hypercalcemia. The normal blood glucose level ranges from 70 to 110 mg/dL. The normal potassium level ranges from 3.5 to 5.0 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal calcium level ranges from 8.6 to 10 mg/dL.

A client with hyperlipidemia has been prescribed a high-fiber diet. Which items should the nurse instruct the client to include in the diet? Select all that apply. Pasta Whole grain cereal White rice Apple juice

Whole wheat bread whole grain cereal RATIONALE: Whole-grain products (e.g., whole-wheat bread, cereal) are high in fiber. Refined grain products (e.g., white bread, white rice, pasta, cereals that are not whole-grain) are low in fiber. Vegetables and fruits without skins and seeds (e.g., canned fruit and fruit juice) are also low in fiber.

Rosanne is being started on intravenous trastuzumab, an antineoplastic medication. Which assessment finding indicates an adverse effect of the medication? Nausea Headache Tiredness Irregular heartbeat

Irregular heartbeat RATIONALE: Cardiomyopathy and ventricular dysfunction are adverse effects of trastuzumab. A baseline electrocardiogram (ECG) will be done. Signs of toxicity will show on the concurrent ECG and may be noted by an irregular heartbeat. Nausea, headache, and loss of strength and energy are side effects of the medication. TEST-TAKING STRATEGY: Note the strategic words "adverse effect." Use the ABCs, airway, breathing, and circulation to direct you to the correct option.

The school nurse receives a telephone call from a physical education teacher, who says that a student with diabetes mellitus is feeling shaky and weak. Which action should the nurse tell the teacher to take immediately? Laying the student on the floor Staying with the student until the nurse arrives Giving the student a glass of orange juice or non-diet soda Calling for an ambulance to bring the student to the emergency department

Giving the student a glass of orange juice or non-diet soda RATIONALE: Exercise can cause the blood glucose level to drop. Shakiness and weakness are signs of a hypoglycemic reaction in a diabetic client. A hypoglycemic reaction is treated promptly with a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (non-diet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. If the symptoms are not relieved in 15 minutes, the treatment is repeated. Laying the student on the floor, staying with the student until the nurse arrives, and calling for an ambulance would each delay necessary interventions. There is no need to call an ambulance at this time.

The nurse should include which information in the preoperative plan of care for a client with appendicitis? Select all that apply. Administer a Fleet enema Allow sips of clear fluids only Apply an ice bag to the abdomen Administer 15 mL milk of magnesia orally Insert an intravenous (IV) line and infuse IV fluids as prescribed

Insert an intravenous (IV) line and infuse IV fluids as prescribed Apply an ice bag to the abdomen RATIONALE: A concern for the client with appendicitis is rupture and resultant peritonitis. Surgery, generally performed laparoscopically, is performed as soon as the diagnosis is made. To ensure that the stomach is empty in the event that surgery is needed, the client is kept on nothing-by-mouth (NPO) status. Antibiotics and fluid resuscitation are administered before surgery. Laxatives and enemas are especially dangerous because the resulting increased peristalsis may cause perforation of the appendix. An ice bag may be applied to the right lower quadrant to decrease inflammation. Heat can cause the appendix to rupture.

A nurse provides information to a client who has undergone a Billroth II procedure about dietary measures to prevent dumping syndrome. Which menu choices by the client indicates an understanding of the teaching? Select all that apply. Milk Rice Eggs Beef Apple pie

Rice Eggs Beef RATIONALE: Dumping syndrome, a complication of gastric resection, is the rapid emptying of gastric contents into the small intestine. To prevent or minimize dumping syndrome, the client is instructed to eat a high-protein, high-fat, low-carbohydrate diet; to eat small, frequent meals; to avoid drinking fluids with meals; avoid milk, sweets, and other foods containing sugars; and to lie down after meals. Rice, eggs, and beef are all acceptable foods.

A nurse is reading the medical record of a client admitted to the hospital with a diagnosis of diabetes insipidus. Which of these signs/symptoms should the nurse expect to see documented in the client's record? Select all that apply. Anuria Tachycardia Complaints of thirst Moist mucous membranes Complaints of muscle weakness

Tachycardia Complaints of thirst Complaints of muscle weakness RATIONALE: Diabetes insipidus is a disorder of water metabolism caused by hyposecretion of ADH and a deficiency of vasopressin. Signs/symptoms include polyuria (5 to 20 L/day), polydipsia, signs of dehydration, inability to concentrate urine and a low urinary specific gravity of 1.006 or less, fatigue, muscle pain and weakness, postural hypotension and tachycardia.

A client with chronic kidney disease (CKD) has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which finding in the electrocardiographic (ECG) reading should the nurse expect to note? U waves Elevated P waves Tall, peaked T waves Shortened PR interval

Tall, peaked T waves RATIONALE: In CKD, hyperkalemia results from decreased renal excretion of potassium. The nurse should monitor the client's vital signs for hypertension or hypotension and the apical heart rate for irregularities. The nurse must also monitor the serum potassium level; a serum potassium level above 6 mEq/L can produce tall, peaked T waves; flat P waves; a widened QRS complex; and a prolonged PR interval on ECG in addition to decreased cardiac output; heart blocks, fibrillation, and asystole.

A nurse provides home care instructions to a client with acute hepatitis. Which statement by the client indicates a need for further teaching? "I need to eat frequent small meals." "I need to eat foods high in carbohydrates and low in fat." "I need to maintain my normal physical activity and daily routine." "I need to avoid close physical contact with other people until my test results are negative."

"I need to maintain my normal physical activity and daily routine." RATIONALE: A client with hepatitis needs considerable rest during the acute phase of illness to promote healing of the liver. The permissible level of physical activity is based on the client's degree of fatigue and the severity of disease. Rest periods should be arranged throughout the day. The client should eat small frequent meals that are high in carbohydrate and low in fat. Close personal contact (e.g., kissing, sexual activity) should be discouraged until testing for hepatitis B surface antigen (HBsAg) returns a negative result.

The nurse provides instructions to a client with type 1 diabetes mellitus with regard to foot care. The nurse determines there is a need for further teaching if the client makes which statement? I will inspect my feet daily. I will walk barefoot only at home. I will wash my feet with warm water and a mild soap. I will check my shoes for foreign objects before putting them on.

I will walk barefoot only at home. RATIONALE: In clients with diabetes mellitus, minor foot problems may progress to major problems, in some cases severe enough to necessitate amputation. Many foot problems can be prevented with proper foot care. The client is instructed not to walk barefoot, even at home. Inspecting the feet daily, using warm water and a mild soap to wash the feet, and checking shoes for foreign objects before putting them on are all appropriate foot care measures for the diabetic client. The client should also avoid thermal injuries from hot water, heating pads, and baths; prevent moisture from accumulating between the toes; wear socks to keep the feet warm and change them daily; and trim toenails straight across and smooth nails with an emery board.

The nurse assists a primary health care provider in performing a liver biopsy. In what position should the nurse place the client after the procedure? Prone Left Sims On the left side On the right side

On the right side RATIONALE: After a liver biopsy, the client is positioned on the right side for at least 2 hours to splint the puncture site and help prevent bleeding. Prone, left Sims, and left side-lying positions are all incorrect options. TEST-TAKING STRATEGY: Focus on the subject - liver biopsy - and recall the anatomical location of the liver when answering this question. Knowing that the liver is located in the right side of the upper abdomen will direct you to the correct option.

A nurse is caring for a client who has had a cast applied to his arm after fracturing his humerus. The nurse is teaching the client how to care for the injured area once he has been discharged home. Which statements by the client indicate a need for further instruction? Select all that apply. "I should keep my arm in an elevated position as much as possible." "I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." "I should do isometric exercises to make sure my arm muscles stay strong." "If I notice any wet spots on the cast or a funny smell, I should contact my doctor."

"I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." RATIONALE: The nurse should teach the client with a casted arm to keep the arm elevated, which will help prevent or ease swelling. The client is also taught the signs and symptoms of infection (e.g., the presence of wet spots on the cast, foul odor). The client should also be taught to perform isometric exercises, which will help prevent muscle atrophy. Numbness and tingling are signs of circulatory compromise, and the client should be instructed to contact the health care provider if these signs are noted. The client must also be instructed not to stick anything inside the cast because of the risk of disrupting skin integrity. The nurse should tell the client that if he experiences itching inside the cast, he may aim a hairdryer adjusted to the cool setting into the cast.

The nurse provides information to a client treated for cystitis about measures to prevent its recurrence. Which statement by the client indicates a need for further teaching? "I should wear cotton underpants." "I need to wipe from front to back when I use the bathroom." "I should urinate and drink a glass of water after sex." "I can soak in a bathtub to relieve the pain and prevent infections in the future."

"I can soak in a bathtub to relieve the pain and prevent infections in the future." RATIONALE: The nurse should instruct the client in measures to prevent urinary tract infections: good perineal care, wiping from front to back, avoiding bubble baths and tub baths and vaginal deodorants and sprays, voiding every 2 to 3 hours, voiding and drinking a glass of water after intercourse, wearing cotton underpants, avoiding tight clothing or pantyhose with slacks, and refraining from sitting in a wet bathing suit for prolonged periods.

The nurse provides information to the client about measures to treat gastroesophageal reflux disease (GERD). Which statement by the client indicates the need for further teaching? "I should stop drinking caffeinated coffee." "I should lie down for at least an hour after I eat." "I should prop up the head of my bed." "I shouldn't eat or drink anything for 2 hours before bedtime."

"I should lie down for at least an hour after I eat." RATIONALE: The client with GERD should avoid foods and positioning that decrease lower esophageal sphincter pressure or cause esophageal irritation. The client should consume a low-fat, high-fiber diet in small, frequent meals; minimize the amount of liquids drunk at mealtimes; and avoid reclining for 1 hour after eating; The client should also avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and elevate the head of the bed on 6- to 8-inch blocks.

A nurse has provided information to a client about measures to promote a normal urinary pattern and prevent urinary tract infections. Which statement by the client indicates the need for further information? "I should take my diuretic in the morning." "I should drink plenty of fluids during the day." "I should eat foods that will make my urine acidic." "I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge."

"I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge." RATIONALE: As a means of promoting normal urination, the client should be instructed to urinate at regular intervals and when the urge to void is felt. Holding the urine in the bladder may lead to urinary stasis, possibly resulting in infection. The client is encouraged to consume foods and fluids that will acidify the urine (e.g., cranberry juice, meats, eggs, whole-grain breads, cranberries, prunes, plums) and to drink 2000 to 2500 mL of fluid daily to flush microorganisms from the urethra. Diuretics are prescribed to be taken in the morning to prevent nocturia. TEST-TAKING STRATEGY: Note the strategic words "need for further information." Focusing on the subject, prevention of urinary tract infections, and recalling that urinary stasis can lead to infection will direct you to the correct option

Louis has had no episodes of urinary incontinence today and is preparing for discharge home. Which statement by Louis indicates that he understands his discharge teaching? "I won't need to continue the bladder retraining program." "You can tell that my bladder is back under control because I wasn't incontinent at all today." "I'll keep using parts of the bladder retraining program at home." "I will just try to do everything my doctor want me to."

"I'll keep using parts of the bladder retraining program at home." RATIONALE: The goal of a bladder retraining program is to restore a normal pattern of urination. Although the program may be started in the hospital or rehabilitation unit, it may need to be continued at home for some time. If Louis' bladder control has been totally regained, discontinuation of the bladder retraining program would be appropriate, but being continent today could just be a result of inadequate fluid intake. The nurse would encourage the client to continue the program at home. A doctor's prescription is not required.

Lydia is transferred to the ambulatory care unit from the recovery room with plans for discharge home later in the day. She is alert and oriented and is experiencing minimal abdominal pain. The nurse offers Lydia toast and tea, which she is able to tolerate, and Lydia voids 300 mL of clear yellow urine. The nurse determines that Lydia is ready to be discharged and reinforces the discharge instructions with Lydia. Which statements by Lydia indicate that she needs further instruction? Select all that apply. "I should increase my activity slowly." "I'm looking forward to having fried chicken for dinner." "My pain may be severe and may get worse, but this is expected." "I can't take a shower until I'm seen by my surgeon at my follow-up visit." "My incisions are small, but they may drain a little blood, so I'll wear Band-Aids on them." "When I get home, I'll take my baby grandson for a walk and play with him in the swimming pool."

"I'm looking forward to having fried chicken for dinner." "My pain may be severe and may get worse, but this is expected." "I can't take a shower until I'm seen by my surgeon at my follow-up visit." "When I get home, I'll take my baby grandson for a walk and play with him in the swimming pool." RATIONALE: After cholecystectomy, the client should eat a light meal and limit fat intake. Fat will be reintroduced to the diet gradually. Lydia is instructed to notify the surgeon if the pain medication does not control the pain or if the pain suddenly increases. Showering is usually allowed and is helpful in preventing wound infection. Depending on the incision, the client may be instructed to cover the incisions before showering. The incisions may be covered to avoid staining of clothing with serosanguinous fluid, if desired. The nurse instructs Lydia to increase activity slowly, balance rest with activity, and avoid straining the surgical wound or surrounding area. Therefore, play with him in the swimming pool. The nurse will remind Lydia about the signs/symptoms of wound infection, such as redness and drainage, and instruct Lydia to contact the surgeon if signs/symptoms of infection occur.

After Louis has been home for a few days, the nurse calls Louis to follow up on his progress. Which comments indicate a need for follow-up? Select all that apply. "I'm voiding a lot of urine." "I'm not having any urine leakage." "I have burning when I go to the bathroom." "I still have trouble starting the urine stream." "I don't like the bladder retraining exercises, but I'm doing them."

"I'm voiding a lot of urine" "I have burning when I go to the bathroom" RATIONALE: In this client, who has diabetes mellitus, voiding a lot of urine may indicate hyperglycemia. A burning sensation during voiding may indicate an infection. These findings indicate the need for follow-up. Not having urine leakage is one goal of a bladder retraining program. Louis' statement that he dislikes the bladder retraining exercises does not require follow-up, because Louis indicates that he still is doing them. Difficulty starting the urine stream is probably a result of the benign prostatic hypertrophy and not a new occurrence for Louis.

On arriving at the ambulatory care unit, Lydia is interviewed by a nurse. She tells the nurse that she has "mixed feelings" about having the surgery because of all of the risks the surgeon has described to her. Which of the following initial responses by the nurse is most appropriate? "Tell me about your concerns regarding the risks." "Do you want to cancel the surgery? You have the right to do that." "I'll put a call in to your surgeon's office so that the surgeon can explain the risks to you again." "There are risks to any surgical procedure, but the likelihood of their happening is minimal."

"Tell me about your concerns regarding the risks." RATIONALE: The most appropriate initial statement is the one that encourages Lydia to express her concerns about the surgery. A client's consent for surgery may be withdrawn at any time, including after permission has been signed; however, the statement giving Lydia the option of canceling the surgery disregards Lydia's concerns. Calling the surgeon's office is inappropriate. Lydia has not indicated that she does not understand the risks; rather, she is concerned about the risks. Reassuring Lydia about the low likelihood that any of the risks will become reality provides false reassurance and, again, does not address Lydia's concerns. TEST-TAKING STRATEGY: Focus on the subject, the most appropriate initial statement. Use your knowledge of therapeutic communication techniques. Remembering to always focus on the client's feelings will direct you to the correct option.

A client in whom prostate cancer has just been diagnosed is told that surgery followed by chemotherapy will be necessary. The client says to the nurse, "A friend of mine came to visit me last night and told me that I should try complementary therapy. Do you do that here in this hospital? Do you think I should try it?" How should the nurse respond to the client? "You need to ask your doctor about it." "I'd try anything I could if I had cancer." "No, we don't do that here, and besides, it will interact with the chemotherapy." "There are many different forms of complementary therapies. Let's talk about them."

"There are many different forms of complementary therapies. Let's talk about them." RATIONALE: Complementary and alternative therapies are a wide variety of treatment modalities that are used in addition to conventional treatment. These therapies should be approved by the client's health care provider to ensure that the treatment does not interact with prescribed therapy. Although the health care provider should approve the use of a complementary therapy and although the use of some of these therapies may interact unfavorably with prescribed treatments, these statements are inappropriate. "I'd try anything I could if I had cancer" is inappropriate and does not address the client's question. The nurse should address the client's question and encourage discussion.

Since Louis began the bladder retraining program, the incidence of incontinence has decreased. Louis tells the nurse that when it is time to urinate, he now sometimes has difficulty starting the flow of urine. Which instruction should the nurse give to Louis? "Wait an hour, then try again to urinate." "Sit on the toilet to urinate instead of standing." "Bear down and force the urine to begin flowing." "Turn the water on in the bathroom sink and listen as it runs."

"Turn the water on in the bathroom sink and listen as it runs." RATIONALE: The components of a bladder retraining include teaching the client exercises to strengthen the pelvic floor; initiating an individualized toileting schedule based on the client's urination pattern, including frequency and times of urination; using alternative methods (e.g., running water) to aid relaxation and stimulate urination; and teaching the client to take prescribed diuretics in the morning and to consume foods and fluids that increase diuresis early in the day. The client should be encouraged to assume the best position for the initiation of urination. Men generally urinate best from a standing position, whereas women generally sit on the toilet. The client should follow the individualized voiding schedule and should not bear down to force urine flow. Rather, the client should relax the muscles of the perineal floor.

A client who has undergone a renal biopsy calls the nurse in the primary health care provider's office and tells her/him that he/she has a minor headache and would like to know what he/she can take to relieve it. After checking with the primary health care provider, which medication does the nurse inform the client that it is acceptable to take? Ibuprofen Naproxen Acetaminophen Acetylsalicylic acid

Acetaminophen RATIONALE: The nurse tells the client that it is acceptable to take acetaminophen. Bleeding is a complication of renal biopsy. To prevent bleeding, the client is instructed to avoid lifting heavy objects and engaging in strenuous activity for 2 weeks after biopsy. The client is also instructed not to take any anticoagulant or antiplatelet medications until permission is given by the primary health care provider. Nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen) can cause nephrotoxicity. Acetylsalicylic acid inhibits platelet aggregation and has an anticoagulant effect. Acetaminophen is hepatotoxic but not nephrotoxic.

The nurse takes Rosanne's temperature by way of the axillary route and gets a reading of 101.2° F (38.4 C). In which order should the nurse take the following actions in response to the finding? Assign the number 1 to the first action and the number 4 to the last. Administer antipyretic as prescribed. Assess possible sites for localized infection and for related data suggesting systemic infection. Obtain the other vital signs. Retake the temperature with a tympanic thermometer.

Administer antipyretic as prescribed. Assess possible sites for localized infection and for related data suggesting systemic infection. Obtain the other vital signs. Retake the temperature with a tympanic thermometer. RATIONALE: A second temperature measurement confirms an initial finding of abnormal body temperature. The normal WBC count is 4500 to 11,000 cells/mm3. The normal platelet count is 150,000 to 400,000 cells/mm3. When the client's WBC count is low, the client is at risk for infection. When the platelet count is low, the client is at risk for bleeding. If the client is at risk for bleeding, taking the temperature rectally is avoided because the tissue in the rectal area is friable and easily damaged, resulting in bleeding. If the client has mouth sores, the oral method of taking the temperature is avoided. The client's temperature would be retaken by way of the tympanic route. Heart rate and blood pressure increase when the temperature is increased, so measurement of vital signs is important. Determining the condition of possible sites of localized or systemic infection (e.g., Rosanne's central line) will help the primary health care provider determine the course of treatment. If an antipyretic is prescribed, it will be administered for the client's comfort. The primary health care provider is also notified of the client's condition.

A client who has just undergone bowel resection calls the nurse and reports feeling a "popping sensation" while performing coughing and deep-breathing exercises. The nurse removes the client's abdominal dressing and notes that a loop of bowel is protruding through the abdominal incision. The nurse immediately places the client in a low Fowler's position with knees bent and contacts the surgeon. Which action should the nurse take next? Administer pain medication Check the client's temperature Apply a sterile normal saline dressing to the incision Ask a nursing assistant to stay with the client until the surgeon arrives

Apply a sterile normal saline dressing to the incision RATIONALE: The nurse should next apply a non-adherent sterile dressing (e.g., a normal saline dressing) to the incision. Wound evisceration is the protrusion of an internal organ through an abdominal incision. It is a surgical emergency, and the surgeon must be notified. The client is placed in a low Fowler's position. Although wound infection is a concern, checking the client's temperature is not the priority. Although the client may experience pain with an evisceration, administering pain medication is not the next action. Additionally, the client will need to undergo surgical repair, and the surgeon may prescribe specific medications before the procedure. It is inappropriate to ask a nursing assistant to stay with the client. The client must be monitored closely for signs/symptoms of shock.

Jean determines that John is unconscious. John's wife cries, "I want to help! What can I do? Just tell me what to do and I'll do it!" What is the appropriate response? Asking her to perform chest compressions on John Quickly teaching her how to perform mouth-to-mouth resuscitation Asking her to call 911 to get help and an automatic external defibrillator (AED) Tell her that there is nothing that she can do unless she knows how to perform CPR

Asking her to call 911 to get help and an automatic external defibrillator (AED) RATIONALE: Once it has been determined that a victim is unconscious, emergency medical services (EMS) should be activated. Jean would most appropriately ask John's wife to go to the nearest telephone, if she does not have a cell phone with her, and call 911 to get help. Bringing an AED, if one is available, is also important, because early defibrillation improves the victim's chance of survival. Jean would not ask John's wife to perform chest compressions unless she first determined that his wife was certified in CPR. Quickly teaching John's wife to perform mouth-to-mouth resuscitation would delay lifesaving measures. Telling the woman that there is nothing she can do unless she knows how to perform CPR is incorrect.

A nurse is having dinner with a friend at a restaurant when a woman at a nearby table suddenly clutches her neck with both hands. Suspecting that the woman is choking, the nurse quickly approaches her. What action should the nurse take first? Asking the woman whether she can speak Helping the woman into a supine position Striking the woman's back forcefully with a fist Opening the woman's airway and attempting to perform ventilation

Asking the woman whether she can speak RATIONALE: One sign of airway obstruction is the universal signal for choking (the victim clutches the neck with one or both hands). When someone appears to be choking, the first action is to ask the victim, "Are you choking?" or "Can you speak?" If the victim can cough forcefully or speak, the rescuer need not intervene and should monitor the victim. The victim will not be able to speak or cough if he or she is choking. If an obstruction is present, the rescuer administers the abdominal thrust maneuver and notifies the emergency response system. Opening the woman's airway and attempting to perform ventilation and placing the woman in a supine position are both steps of the abdominal thrust maneuver for an unconscious victim. Striking the woman on the back forcefully with a fist is an incorrect action, can be harmful, and is not a component of the abdominal thrust maneuver.

Which action on the part of the nurse in the preoperative period is a priority for ensuring that Larry is properly positioned? Assessing the circulation, sensation, and motion of Larry's left foot Positioning Larry on his side periodically to help prevent the development of pressure ulcers Repositioning Larry to decrease the uncomfortable pulling sensation imparted by the traction Positioning Larry on the side of the bed nearest his overbed table so he can reach his things

Assessing the circulation, sensation, and motion of Larry's left foot RATIONALE: It is essential to check the circulation, sensation, and motion of Larry's left foot to detect any diminished tissue perfusion that might be caused by compression of blood vessels and nerves as a result of the traction. Larry will need to remain on his back to keep the traction and his body aligned. Analgesics would be used to decrease the discomfort from the traction. Larry should be positioned in the middle of the bed to help ensure his safety and to prevent misalignment of the bones. TEST-TAKING STRATEGY: Note the strategic word "priority." Use your knowledge of the ABCs — airway, breathing, and circulation — to direct you to the correct option. Review: the principles of the safe use of traction.

A nurse provides home care instructions to a client who has been hospitalized for acute diverticular disease. Which instruction is a priority for the nurse to give the client to prevent the occurrence of an acute episode? Avoid lifting, straining, or coughing. Restrict fluid intake to 1000 mL daily. Avoid foods that contain whole grains. Restrict consumption of fruits and vegetables.

Avoid lifting, straining, or coughing. RATIONALE: Acute diverticular disease is managed by means of the prevention of constipation through the use of a high-fiber diet containing fruits, vegetables, and whole grains. The client is instructed to increase fluid intake to 2500 to 3000 mL daily unless this is contraindicated. The client should also consume a small amount of bran daily, as prescribed, to increase stool mass and softness. The client should refrain from lifting, straining, coughing, or bending as a means of avoiding increased intraabdominal pressure.

A home care nurse is providing instructions to a client who is having difficulty sleeping about measures to promote sleep. Which instructions should the nurse provide to the client? Select all that apply. Avoid taking naps during the day. Eat a light snack at bedtime if hungry. Be sure that the room is kept very warm. Engage in aerobic exercise just before bedtime. Leave the television or radio on when going to bed.

Avoid taking naps during the day. Eat a light snack at bedtime if hungry. RATIONALE: To promote sleep, the nurse should encourage the client to get up at the same time each day and to avoid naps during the day. A light snack at bedtime may help induce sleep if the client is hungry at that time. However, heavy meals at bedtime should be avoided. The room temperature should be comfortable, neither very cold nor very warm. Daily exercise is important but should be done in the morning or afternoon; vigorous exercise should be avoided in the evening within 3 hours of bedtime. Distracting activities (e.g., watching television or listening to a radio) should be avoided.

While holding his airway open, Jean assesses John for spontaneous respiration and notes that it is absent. Which action should Jean take next? Turning John on his side Calling emergency medical services Maintaining an open airway until EMS arrives Blowing two slow, full breaths into John's mouth, ensuring that his chest rises with each breath

Blowing two slow, full breaths into John's mouth, ensuring that his chest rises with each breath RATIONALE: If John is not breathing, Jean must maintain an open airway and administer mouth-to-mouth respirations by blowing two slow, full breaths into John's mouth, ensuring that his chest rises with each breath. EMS should have been activated as soon as it was determined that the client was unconscious. Turning John onto his side is incorrect, because Jean would not be able to administer CPR with him in this position. Maintaining an open airway until EMS arrives delays lifesaving measures.

The nurse interprets a client's temperature reading, knowing that certain factors can affect body temperature. Which statements regarding body temperature are accurate? Select all that apply. Stress can cause a decrease in body temperature. Body temperature increases just before ovulation. Body temperature increases when the client has an infection. Body temperature is usually higher in the afternoon than in the morning. Body temperature may be lower than the true temperature if the temperature in the client's room is cool.

Body temperature increases when the client has an infection. Body temperature is usually higher in the afternoon than in the morning. Body temperature may be lower than the true temperature if the temperature in the client's room is cool. RATIONALE: Emotions (stress) increase hormone secretion, leading to increased heat production and a higher-than-normal temperature. Body temperature decreases slightly just before ovulation and usually increases by 1° F above normal during ovulation. Infective agents and the inflammatory response may cause an increase in temperature. Afternoon body temperature may be high normal as a result of the metabolic process, activity, and environmental temperature. Body temperature is lower in cold weather and higher in warm weather.

The nurse is teaching a client about the late signs of testicular cancer. The nurse recognizes the client understands the teaching if the client selects which signs of late testicular cancer? Select all that apply. Bone pain Fluid in the scrotum Painless testicular swelling Presence of abdominal masses

Bone pain Fluid in the scrotum Presence of abdominal masses RATIONALE: Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from nongerminal epithelium from other structures in the testicles. It may metastasize to the lung, liver, bone, and the adrenal glands. Early detection is made through routine testicular self-examination. The client may experience painless testicular swelling or a dragging sensation in the scrotum as early signs. Late signs, indicating metastasis, include testicular pain, back or bone pain, fluid in the scrotum, and respiratory symptoms; palpable lymphadenopathy, abdominal masses, and gynecomastia may also denote metastasis.

Lydia arrives at the ambulatory care unit of the hospital on the day of surgery with her husband, and the nurse begins preparing Lydia for the procedure. Identify the nursing interventions in the order that they will be performed, with 1 indicating the first nursing intervention and 5 denoting the intervention performed just before the surgery: Completing the checklist, including checking for allergies Taking Lydia's vital signs Asking Lydia to void in the bathroom Administering preoperative anesthetic medications Checking Lydia's chart for the signed informed consent form

Checking Lydia's chart for the signed informed consent form Taking Lydia's vital signs Completing the checklist, including checking for allergies Asking Lydia to void in the bathroom Administering preoperative anesthetic medications RATIONALE: The first nursing intervention is ensuring that a signed informed consent form is in Lydia's chart. If the form is not present, surgical preparation may not be implemented. The nurse next checks Lydia's vital signs (temperature, pulse, respirations, blood pressure) and records her height and weight. The vital signs provide a baseline for further assessment, and the height and weight will be used to calculate the dosages of anesthetic medications. Next the nurse completes any parts of the surgical checklist that were not completed at the preoperative visit, including documentation of allergies and the results of laboratory and other diagnostic tests. Next, the nurse asks Lydia to void. Preoperative anesthetic medications are administered last to help avoid confusion and injury of the client. Once the medications have been administered, Lydia is not allowed to get out of bed because of the risk of injury.

A client who is undergoing dialysis for renal failure reports to the nurse in the dialysis center that he was unable to adhere to his prescribed renal diet over a long holiday weekend. As a result, fluid retention has developed. Which foods, as reported by the client, does the nurse suspect were most likely to have contributed to this problem? Select all that apply. Gravy Fresh green beans Cheese dip and canned green chiles Fruit salad with blueberries, pineapple and grapes

Cheese dip and canned green chiles Gravy RATIONALE: A diet for clients undergoing dialysis to treat a renal disorder is restricted in sodium, calcium, potassium, and pork, beef, and other very-high-protein foods. Among the foods listed, the gravy has a high sodium level. The cheese dip with canned green chiles is high in both calcium and sodium. Fresh green beans, fruit salad with blueberries, pineapple, and grapes, and applesauce do not contain large amounts of potassium. These foods can be consumed by a client undergoing dialysis treatment.

The nurse is preparing to perform an initial assessment of an Asian-American client with a diagnosis of acute pancreatitis. What aspect should the nurse consider while conducting the assessment? Clients of Asian descent may avoid the outward expression of pain. Clients of Asian descent express pain only to others of the same culture. Clients with acute pancreatitis often experience pain that is alleviated by eating. Clients with acute pancreatitis often do not experience pain resulting from the condition.

Clients of Asian descent may avoid the outward expression of pain. RATIONALE: During the assessment, the nurse considers the client's culture, because cultural variations exist with regard to such factors as diet, religion, treatment, and the pain experience. The nurse must remember that although some Asian-American clients will express pain and the need for comfort interventions to the health care provider, others may avoid the outward expression of pain. Therefore, the nurse must be alert to nonverbal expressions of pain in the client. Acute pancreatitis is accompanied by unrelenting pain in the upper left quadrant of the abdomen that radiates to the back. Eating triggers the release of pancreatic enzymes, worsening the pain. Therefore nothing-by-mouth status is instituted for clients with acute pancreatitis. TEST-TAKING STRATEGY: Eliminate the option that contains the closed-ended word "only" first.

The nurse is providing pre-procedure instructions to a client who is scheduled for a endoscopic colonoscopy. Which teaching should be provided to the client? General anesthesia is required for the test to be performed. Hospitalization is required for 24 hours after the procedure. Complete bowel preparation is necessary before the procedure. Liquids and soft foods only are allowed on the morning before the test.

Complete bowel preparation is necessary before the procedure. RATIONALE: The client should consume a liquid diet for at least 24 hours before a colonoscopy and is usually on NPO status after midnight on the night before the procedure. Complete bowel preparation is necessary to enable the primary health care provider to visualize the entire colon. The primary health care provider prescribes medication that will help relax the client; general anesthesia is not necessary. The procedure is usually performed in an ambulatory care setting, and the client is discharged home after the procedure once his or her condition is stable.

A client hospitalized with prostate cancer is undergoing chemotherapy. While the nurse is helping the client with hygiene care, the client suddenly complains of severe back pain and numbness of the lower extremities. The nurse should take which immediate action? Contact the health care provider Administer pain medication Take the client's blood pressure Allow the client to rest and complete the bath later

Contact the health care provider RATIONALE: Spinal cord compression and damage occur when a tumor enters the spinal cord or when the vertebral column collapses as a result of tumor entry. A tumor may begin in the spinal cord or spread from another area of the body, such as the prostate gland, lung, breast, or colon. Spinal cord compression causes back pain, usually before neurological deficits occur. Such deficits include tingling; numbness; loss of urethral, vaginal, and rectal sensation; and muscle weakness. If paralysis occurs, it is usually permanent. The nurse would contact the health care provider to report the occurrence. Although pain medication may be needed, it is most appropriate to contact the health care provider so that a thorough evaluation of the client's pain may be conducted. Allowing the client to rest and completing the bath at a later time may be necessary, but this action delays necessary intervention. The nurse would expect the client's blood pressure to be increased if the client is in pain, and although the blood pressure would be measured, the most appropriate action is to contact the health care provider about the sudden occurrence of severe pain.

A client who has undergone vascular surgery of the legs suddenly complains of dyspnea and sharp chest pain. The nurse quickly checks the client and notes the presence of tachycardia on the cardiac monitor. Which action should the nurse take immediately? Contact the surgeon Contact the respiratory therapist Check the client's apical heart rate Check the client's peripheral pulses

Contact the surgeon RATIONALE: Any complaint of sudden sharp chest or upper abdominal pain must be reported immediately to the surgeon. Pulmonary embolism is a serious postoperative complication that can cause sudden death. A clot or part of a clot breaks away from a vessel and travels through the heart and into the pulmonary circulation and may occlude a pulmonary vessel, resulting in a pulmonary embolism. Common signs/symptoms include dyspnea, sudden sharp chest or upper abdominal pain, tachypnea and tachycardia, anxiety, and cyanosis. A respiratory therapist may be needed during treatment, but contacting the therapist would not be the immediate action. There is no useful reason for checking the client's apical heart rate, because the client is attached to a cardiac monitor, which displays the heart rate. Likewise, there is no useful reason for checking the peripheral pulses.

The mother of a child with leukemia who has not had varicella (chickenpox) receives a telephone call from the school nurse, who tells her that one of her child's classmates has contracted chickenpox. Which instruction to the mother by the nurse is most appropriate? Contacting the child's pediatrician Monitoring her child closely for signs of infection Encouraging her child to wear a mask while in school Keeping her child out of school until the child with varicella recovers

Contacting the child's pediatrician RATIONALE: Chickenpox can be deadly to the immunocompromised child, whose body may not be able to fight varicella adequately. If a child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Therefore, the mother is advised to contact the child's pediatrician. It is unnecessary to keep the child out of school or to have the child wear a mask while in school. Although the mother should monitor her child for signs of infection, this is not the most appropriate instruction of those provided in the options.

A nurse is monitoring a client who has returned from colostomy surgery with an ostomy pouch system in place. On checking the stoma, the nurse notes that it is purple and firm. Which initial action by the nurse is appropriate? Documenting the findings Contacting the health care provider Placing warm packs over the stoma Changing the ostomy pouch system

Contacting the health care provider RATIONALE: A healthy stoma should be reddish pink and moist and will protrude about ¾ inch from the abdominal wall. A small amount of bleeding at the site of the stoma is normal. If the nurse checks the stoma and notes that it shows signs of ischemia (a dark-red, purplish, or black stoma or a stoma that is dry, firm, or flaccid), the health care provider must be notified immediately. Although the nurse would document the findings, this is not the initial appropriate action. Placing warm packs over the stoma or changing the ostomy pouch system are incorrect actions that are not helpful and delay necessary intervention.

A nurse checking the laboratory results of a client with renal calculi notes that the creatinine level is 4.5 mg/dL (398 mcmol/L) and the BUN is 45 mg/dL (16.1 mmol/L). In light of these results, which action should the nurse take first? Contacting the primary health care provider to report the results Placing the results in the client's medical record Instructing the client to decrease dietary intake of protein Letting the client know that the results are normal, indicating that there is no kidney damage

Contacting the primary health care provider to report the results RATIONALE: The nurse would place the results in the client's medical record but would contact the primary health care provider first. The normal creatinine level ranges from 0.6 to 1.3 mg/dL, and the normal BUN reading ranges from 8 to 25 mg/dL. Because the client's laboratory values are higher than normal, the nurse should contact the primary health care provider and report the results. Decreasing the client's intake of protein is not an appropriate action unless this type of diet is prescribed.

The nurse asks a colleague to assist in counting a client's pulse to determine whether the client with a dysrhythmia has a pulse deficit. The nurse's colleague counts the client's apical heart rate while the nurse counts the client's radial rate. The nurse's colleague reports an apical heart rate of 90 beats/min, and the nurse obtains a radial rate of 76 beats/min. Which nursing action is most appropriate? Reassessing the client for a pulse deficit in 15 minutes Documenting that the client has a pulse deficit of 14 beats Asking another colleague to count the apical rate to verify the findings Asking the client to ambulate and then reassess the apical and radial rates

Documenting that the client has a pulse deficit of 14 beats RATIONALE: In the two-examiner technique for detecting a pulse deficit, the nurse and a colleague count the radial and apical pulses simultaneously and then compare the rates. The difference between the apical and radial pulse rates is the pulse deficit. If the client has an apical heart rate of 90 beats/min and a radial rate of 76 beats/min, the pulse deficit is 14 beats. The nurse would document this finding. The nurse would also report the finding to the primary health care provider. Although the nurse would continue to check for a pulse deficit, it would not be necessary to do so in 15 minutes. Asking a second colleague to count the apical rate to verify the findings raises doubt about the first colleague's ability to assess the apical heart rate. There is no useful reason for reassessing the pulse rates after asking the client to ambulate.

A community health nurse is preparing a poster for an educational session for a group of women with whom she will be discussing the risk factors for breast cancer. Which factors increase the risk for breast cancer and should be listed on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer Exposure of the chest to high-dose radiation Previous cancer of the breast, uterus, or ovaries

Early menarche Family history of breast cancer Exposure of the chest to high-dose radiation Previous cancer of the breast, uterus, or ovaries RATIONALE: Risk factors for breast cancer include family history; age; early or late menarche; late menopause; previous cancer of the breast, uterus, or ovaries; nulliparity or late first birth; exposure of the chest to high-dose radiation.

A nurse caring for a client who is immobilized and restricted to bed notes that the client is expectorating secretions that are clear but thicker than expected. The client's temperature is 98.6° F (37.0° C) and lungs sounds are clear bilaterally. Which action should the nurse take first? Contacting the client's health care provider Encouraging increased fluid intake Consulting with the health care provider about initiating antibiotics Encouraging the client to cough and deep-breathe at least every 4 hours

Encouraging increased fluid intake RATIONALE: The immobile client should take in at least 2000 mL of fluid daily, if not contraindicated, to help keep mucociliary clearance normal. In clients free of infection and with adequate hydration, pulmonary secretions will appear thin, watery, and clear. The client can easily remove the secretions by coughing. Without adequate hydration, secretions are thick and difficult to remove. There is no information in the question to indicate that the health care provider should be notified or that the client needs antibiotics. The client should be encouraged to cough and deep-breathe every 1 to 2 hours; every 4 hours is too infrequently. Additionally, coughing and deep breathing will not thin the secretions as fluids will.

A nurse is preparing to assist a hospitalized client with personal hygiene. Which intervention would be best in this situation? Asking the client's spouse to bathe the client. Asking an assistive personnel (AP) to completely bathe the client. Completely bathing the client to conserve the client's energy. Encouraging the client to perform as much of the bath as possible.

Encouraging the client to perform as much of the bath as possible RATIONALE: While providing hygiene, the nurse must preserve as much of the client's independence as possible. Therefore, encouraging the client to perform as much of the bath as possible is the best option of those provided. Although it may be appropriate to include the client's family in providing care, asking the spouse to give the bath is not the best option. During the bath, the nurse can integrate other nursing activities, including client assessment and interventions such as range-of-motion exercises, application of dressings, skin inspection, and care for intravenous sites, so asking a AP to completely bathe the client is not the appropriate choice. TEST-TAKING STRATEGY: Eliminate the comparable or alike options in that another person is being asked to bathe the client. From the remaining options, note the strategic word "best" and recall that it is best to encourage client independence. Review: the guidelines for providing hygiene care.

A nurse is explaining coughing exercises and the procedure for splinting an incision to a client who is scheduled for abdominal surgery. Which instruction should the nurse provide to the client? Sit upright and lean as far forward as possible. Fold the arms over a pillow placed over the abdominal incision and press gently. Use the fingertips of both hands and press as deeply as possible over each side of the incision. Stand and lean over a bedside table, then hold a pillow over the abdominal incision with one hand while providing support for standing with the other hand.

Fold the arms over a pillow placed over the abdominal incision and press gently. RATIONALE: Splinting an abdominal incision with the use of a pillow or rolled blanket provides support to the incision and aids in coughing and expectoration of secretions. The client may assume a supine, side-lying, or semi-Fowler's to Fowler's position. The client folds the arms over a pillow or rolled towel placed over the abdominal incision and presses gently during breathing and coughing exercises. Leaning forward as far as possible, pressing as deeply as possible at the sides of the abdominal incision, and leaning over a bedside table holding the incision with one hand will all be uncomfortable and will not provide support to the incision; these actions are also unsafe for the client.

Heidi tells the nurse that she thinks she should continue taking the goldenseal because it stimulates the immune system and will help prepare her body for surgery. Which information should the nurse to Heidi? Goldenseal can cause an increase in blood pressure. Goldenseal is helpful in preventing postoperative bleeding. Heidi's surgeon will give her permission to take the goldenseal. Because of its action, goldenseal is acceptable until 1 day before surgery.

Goldenseal can cause an increase in blood pressure. RATIONALE: Goldenseal, an herbal substance, has antiinflammatory and antimicrobial effects and stimulates the immune system. It may increase blood pressure, however, and has anticoagulant effects. Although Heidi may wish to discuss the use of goldenseal with the surgeon, the client who has been scheduled for surgery may be advised to stop taking the herbal substance 2 to 3 weeks before surgery. TEST-TAKING STRATEGY: Recalling the subject, herbal substances may need to be stopped 2 to 3 weeks before surgery, and recalling the effects of goldenseal will direct you to the correct option. Review: the effects of goldenseal.

The nurse is planning care for a client who has had a cholecystectomy with T-tube placement. Which nursing intervention should be emphasized as the priority in the plan of care? Provide a full liquid diet once clear liquids are tolerated. Help position the client into the semi-Fowler position. Administer pain and antiemetics as promptly as possible. Have the client turn, cough, and deep breathe every 2 hours.

Have the client turn, cough, and deep breathe every 2 hours. RATIONALE: It is most critical to prevent atelectasis following abdominal surgery, as the client may hypoventilate, due to the location of the incision. Providing full liquids is not as high a priority as preventing atelectasis. Positioning the client into the semi-Fowler position allows bile to drain into the bile bag, but preventing atelectasis is a higher priority. It is crucial to administer pain and antiemetics promptly, but preventing atelectasis is a higher priority.

Lydia has undergone the laparoscopic cholecystectomy and is in the immediate postoperative stage of recovery. During assessment, Lydia states that she is in pain, is cold, and feels sick to her stomach; she has diminished lung sounds and a small amount of bleeding from the incisional wound sites. Which actions by the nurse are appropriate? Select all that apply. Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths Removing the dressings to evaluate how much bleeding is occurring

Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths RATIONALE: The nausea that Lydia is experiencing could lead to vomiting. In the immediate postoperative stage of recovery, the gag reflex may not have returned. If Lydia vomits, she could aspirate the vomitus, which in turn could lead to pneumonia. Having Lydia lie on her left side will help prevent aspiration and help move the gas pocket of carbon dioxide that was used for the surgery away from the diaphragm. Covering Lydia with a blanket will help prevent the hypothermia that may occur during the postoperative period. Prescribed pain medication should be administered if Lydia is in pain and if the prescribed analgesic is due. The diminished lung sounds could lead to atelectasis if Lydia does not perform coughing and deep breathing or use her incentive spirometer. Bleeding may indicate a problem, but the amount of bleeding that would place the client at risk of hypovolemia or shock would be evident before the nurse removed the dressing.

A nurse preparing to administer a tube feeding checks the nasogastric tube for placement and residual volume. The nurse determines that the tube is correctly placed but aspirates 275 mL of contents from the client's stomach. Which action by the nurse is appropriate? Administering half of the prescribed feeding Hold the feeding and notifying the primary health care provider of the volume of aspirate Maintaining the client in a high Fowler position while administering the feeding Removing the 275 mL of aspirate from the client's stomach and discarding it, then administering the current feeding

Hold the feeding and notifying the primary health care provider of the volume of aspirate RATIONALE: If a large volume of aspirate (250 mL or more) is obtained, the aspirate is returned to the client's stomach (unless it is abnormal), the feeding is withheld, and the primary health care provider is notified. A large volume of aspirate indicates delayed gastric emptying, which may contribute to gastric distension, esophageal reflux, and vomiting, all of which place the client at risk for aspiration. Returning aspirate to the client prevents excessive loss of electrolytes.

A nurse provides instructions to a client with type 1 diabetes mellitus about home care measures to treat hypoglycemia. The nurse determines that the client understands the instructions if which statement is made? I will eat six saltine crackers I will call the health care provider I will report to the emergency department I will take an additional dose of regular insulin

I will eat six saltine crackers RATIONALE: Hypoglycemia is the term used to describe a blood glucose level below 70 mg/dL. If hypoglycemia is suspected, the client should obtain a glucose reading immediately. The client must consume a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (nondiet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. Administering regular insulin will lower the blood glucose. It is not necessary to notify the health care provider or to report to the emergency department for a single episode of hypoglycemia. The client should, however, contact the health care provider if hypoglycemia were to persist or hypoglycemic episodes were frequent.

A primary health care provider prescribes that the ammonia level be tested in a client with hepatic cirrhosis. The nurse transcribes the prescription and schedules the test for the next morning. Which appropriate action should the nurse take in preparation for the test? Requesting a liquid breakfast for the client on the morning of the test Imposing NPO status for the client starting 10 hours before the test Asking the dietary department to send an early breakfast to the client on the morning of the test Instructing the client to eat a high-fat snack at bedtime on the evening before the test and again on the morning of the test

Imposing NPO status for the client starting 10 hours before the test RATIONALE: The client must fast for 8 to 10 hours, except for water, and refrain from smoking for 8 to 10 hours before the test, because smoking increases the ammonia level. Ammonia, a byproduct of protein catabolism, is created mainly by bacteria acting on proteins present in the gut. Ammonia is metabolized by the liver and excreted by the kidneys as urea. An increased level resulting from hepatic dysfunction may lead to encephalopathy. In the incorrect options, the client is being allowed to consume fluids other than water and to eat.

The nurse who scheduled the surgery, performing a preliminary preoperative assessment, discovers that Heidi is taking milk thistle and goldenseal. Heidi says to the nurse, "I don't understand why I have this problem. I take the milk thistle faithfully and still end up with gallstones. Should increase the dose?" Which action should the nurse take? Informing Heidi that the milk thistle must be discontinued Telling Heidi that the milk thistle has no effect on the gallbladder Telling Heidi that herbal supplements never have a beneficial effect on the body Advising Heidi to increase the dose as long as it doesn't exceed the recommended dosage

Informing Heidi that the milk thistle must be discontinued RATIONALE: Milk thistle, an herbal substance, is an antioxidant. It stimulates the production of new liver cells, reduces liver inflammation, and protects the liver from damage. It is used in liver and gallbladder disease. The client would not be told to increase the dose. Reactions may occur when herbal substances are taken with prescription medications, and a client who has been scheduled for surgery may be advised to stop taking the herbal substance 2 to 3 weeks before surgery. TEST-TAKING STRATEGY: Eliminate the option containing the closed-ended word "never." Telling a client to increase the dose is not within the scope of nursing practice and is therefore incorrect. To select from the remaining options, recall that some herbal substances can cause serious interactions when taken with prescription medications; this will assist you in answering correctly. Review: the limitations of the use of herbal substances.

Which interventions should the nurse include in the plan of care for a client with hypothyroidism? Select all that apply. Providing a cool environment for the client Instructing the client to consume a high-fat diet Instructing the client about thyroid-replacement therapy Encouraging the client to consume fluids and high-fiber foods Instructing the client to contact the health care provider if chest pain occurs Informing the client that radioactive iodine preparations may be prescribed to treat the disorder

Instructing the client about thyroid-replacement therapy Encouraging the client to consume fluids and high-fiber foods Instructing the client to contact the health care provider if chest pain occurs RATIONALE: The signs/symptoms of hypothyroidism are the result of decreased metabolism caused by low levels of thyroid hormones. Interventions are aimed at replacing the hormones and addressing the signs and symptoms of decreased metabolism. The nurse encourages the client to consume a balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to help prevent constipation. The client is often intolerant of cold and requires a warm environment. The client should be instructed to notify the health care provider if chest pain occurs, because this could be an indication of overreplacement of thyroid hormone. Radioactive iodine preparations may be used to destroy thyroid cells in the treatment of hyperthyroidism.

The nurse is providing home care information to a client who has undergone a skin biopsy. Which information should the nurse include in the instructions? Soak the site in warm water three times a day Expect redness and drainage at the biopsy site Expect a significant amount of pain at the biopsy site Keep the dressing dry and in place for at least 8 hours

Keep the dressing dry and in place for at least 8 hours RATIONALE: After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for at least 8 hours. After the dressing is removed, the site is cleansed daily with tap water or saline solution to remove dried blood or crusts. The primary health care provider may also prescribe a topical antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report the presence of redness or excessive drainage at the biopsy site. Pain should be minimal after a skin biopsy.

The nurse is developing a plan of care for a client in skeletal traction. Which interventions should the nurse include in the plan of care? Select all that apply. Expect to note some purulent drainage from the pin sites. Ensure that there are no knots in any of the traction ropes. Monitor color, motion, and sensation in the affected extremity. Lift the weights only when it is necessary to reposition the client. Ensure that the weights for the traction device hang freely and do not touch the floor.

Monitor color, motion, and sensation in the affected extremity. Ensure that the weights for the traction device hang freely and do not touch the floor.

A nurse is monitoring the intake and output of a client with a Foley catheter who returned from surgery at 1 p.m. On the client's return, the nurse empties 100 mL of urine from the catheter drainage bag. At 4 p.m., the nurse checks the client's urine output and notes that the bag contains 40 mL. What is the most appropriate action for the nurse to take? Continue to monitor the client's urine output. Increase the rate of administration of IV fluids. Notify the surgeon of the decreased urine output. Document the urine output on the fluid balance form.

Notify the surgeon of the decreased urine output. RATIONALE: Although the nurse would document the urine output, the most appropriate action would be to contact the surgeon. Urine output is closely monitored after surgery until normal urinary tract function has been reestablished. A urine output of at least 30 mL/hr is required to maintain adequate kidney function. Because the client has produced only 40 mL of urine in 3 hours, the surgeon should be notified. Continuing to monitor the client's urine output would delay necessary interventions. The nurse would not increase the rate of administration of IV fluids without a specific prescription to do so.

A nurse reviews a client's laboratory results and notes that the client's potassium level is 3.1 mEq/L (mmol/L). In light of this finding, which action by the nurse is most appropriate? Filing the report in the client's medical record Notifying the client's primary health care provider of the potassium level Asking the laboratory to repeat the test and verifying the potassium level Asking the dietary department to restrict potassium-containing foods and fluids in the client's meals

Notifying the client's primary health care provider of the potassium level RATIONALE: The normal potassium level ranges from 3.5 to 5.1 mEq/L. A potassium level of 3.1 mEq/L is low and the most appropriate action would be to report it to the primary health care provider. Although the report would be filed in the client's record, the nurse must also notify the primary health care provider. There is no reason to ask the laboratory to repeat the test to verify the result, although the test might be repeated after treatment for the low level. The client is given a diet containing potassium-rich foods if the potassium level is low.

The nurse is assigned to care for a client who has a Salem Sump tube inserted into the stomach and will be attached to low continuous suction. Which actions should the nurse plan to take? Select all that apply. Irrigating the air vent (pigtail) lumen every 4 hours Clamping the air vent lumen to prevent drainage from the lumen Positioning the client with the head of the bed elevated 30 degrees Positioning the air vent lumen so that it is higher than the client's stomach Instilling 30 mL of air into the air vent and irrigating the main lumen with normal saline solution if leakage occurs through the air vent

Positioning the client with the head of the bed elevated 30 degrees Positioning the air vent lumen so that it is higher than the client's stomach Instilling 30 mL of air into the air vent and irrigating the main lumen with normal saline solution if leakage occurs through the air vent RATIONALE: The Salem Sump tube has two lumens, one for removal of gastric contents and one to provide an air vent. A blue "pigtail" is the air vent that connects with the second lumen. The head of the bed is elevated 30 degrees unless otherwise prescribed. When the sump tube's main lumen is connected to suction, the air vent permits free, continuous drainage of secretions. The air vent should never be clamped off, connected to suction, or used for irrigation, and it should be kept higher than the client's stomach to prevent drainage. If leakage occurs through the air vent, 30 mL of air is instilled into the vent and the main lumen is irrigated with normal saline solution. TEST-TAKING STRATEGY: Focus on the subject - the Salem Sump tube - and apply knowledge of its use to answer this question. Recall that the air vent is not routinely irrigated or clamped.

The nurse is caring for a client who has undergone surgery. The client is anxious and complains of incision pain. The nurse conducts a pain assessment, checks the client's vital signs, and notes that the client's blood pressure and pulse rate have increased. On the basis of these findings, which action by the nurse is most appropriate? Contacting the primary health care provider Preparing to administer pain medication Checking for signs/symptoms of postoperative hemorrhage Consulting with the primary health care provider about administering an antianxiety medication

Preparing to administer pain medication RATIONALE: Because increases in pulse and blood pressure are expected in a client who is anxious and in pain, most appropriate action by the nurse would be to prepare and administer pain medication. Anxiety, fear, pain, and emotional stress all result in sympathetic stimulation, which increases the heart rate, cardiac output, and peripheral vascular resistance. Sympathetic stimulation also increases the blood pressure. There is no reason to contact the primary health care provider at this time. Hemorrhage would result in a decrease in blood pressure. Although a prescription for an antianxiety medication may be an option, it is not the most appropriate action to take on the basis of the information in the question.

A nurse is preparing a list of instructions regarding stoma and laryngectomy care to a client who has undergone laryngectomy. Which instructions should be included in the list? Select all that apply. Restrict fluid intake. Obtain a medical alert bracelet. Keep humidity in the home low. Avoid wearing high-collared clothing. Prevent debris from entering the stoma. Avoid swimming and use care when showering

Prevent debris from entering the stoma. Avoid swimming and use care when showering. Obtain a medical alert bracelet. RATIONALE: The nurse should teach the client how to care for the stoma, tailoring the instructions to the type of laryngectomy that has been performed. Most interventions focus on protection of the stoma and the prevention of infection. The client is instructed to avoid swimming and to use care when showering, to avoid exposure to people with infections, to prevent debris from entering the stoma, and to obtain a medical alert bracelet. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing humidity in the home, and increasing fluid intake to 3000 mL/day to keep secretions thin.

Blood tests are performed on a female client who has been complaining of weakness and fatigue. The results indicate a hemoglobin level of 11 g/dL (110 mmol/L) and a hematocrit of 32%. Which action should the nurse take on the basis of these results? Telling the client that the results are normal Telling the client she will need a blood transfusion Providing instruction regarding foods that contain iron Telling the client that the result is critically low and preparing to administer IV iron

Providing instruction regarding foods that contain iron RATIONALE: The nurse would provide instruction to the client regarding foods that contain iron. In a female client, the normal hemoglobin level is 12 to 15 g/dL and the normal hematocrit is 35% to 47%. A hemoglobin level of 11 g/dL (110 mmol/L) and a hematocrit of 32% are lower than normal but not critically low. The client would not require a blood transfusion or IV iron. Recall the normal levels of hemoglobin and hematocrit. Knowing that the levels identified in the question are not normal will assist you in eliminating the option in which the nurse tells the client that results are normal. Next eliminate options that are comparable or alike in that they indicate that the client's levels are low and require aggressive intervention.

A client returns from the PACU after abdominal surgery. Which position in the bed does the nurse initially select for the client after helping move the client from the stretcher to the bed? Prone Supine Low Fowler's High Fowler's

RATIONALE: Unless contraindicated, the client is placed in the low Fowler's position after surgery to maximize thorax size for lung expansion. The high Fowler's position would restrict thorax size. Occasionally the primary health care provider prescribes the side-lying position; however, this position is not presented as one of the options. Because of the risk of aspiration, the nurse should avoid using the supine position until pharyngeal reflexes have returned. In the prone position, the client lies on the stomach; this is not safe or comfortable for the client who has undergone abdominal surgery.

A nurse is reading the results of a biopsy of cervical lymph nodes from a client with suspected Hodgkin's lymphoma. Which finding should the nurse expect to see documented in the results if Hodgkin's lymphoma is confirmed? Blast cells in the blood Increased platelet count Bence-Jones protein in the urine Reed-Sternberg cells in the lymph nodes

Reed-Sternberg cells in the lymph nodes RATIONALE: Hodgkin's lymphoma is a cancer that usually originates in a single lymph node or a single chain of nodes. The lymphoid tissues within the node undergo malignant transformation, usually initiating some inflammatory processes. These nodes contain a specific transformed cell, known as the Reed-Sternberg cell, which is a marker for Hodgkin's lymphoma. Blast cells, cells in an immature phase, may be seen in leukemia. The platelet count usually decreases when treatment (i.e., radiation or chemotherapy) is started. In multiple myeloma, the abnormal plasma cells produce an abnormal antibody (myeloma protein, a.k.a. Bence-Jones protein), which is found in the blood and urine.

CHOICES Select the correct answer. The nurse checks Rosanne's oxygen saturation with the use of a pulse oximeter and obtains a reading of 90%. What does the nurse do first? Contact the primary health care provider Administer 100% oxygen by way of face mask Reposition the sensor probe and reassess the level Obtain another sensor probe and oximetry machine

Reposition the sensor probe and reassess the level RATIONALE: Oxygen saturation normally ranges from 95% to 100%, but a range of 90% to 100% is acceptable. On seeing a reading of 90%, the nurse would initially reposition the sensor probe and reassess the oxygen saturation, since the reading is at the low end of acceptable. If the reading remained at 90% after reassessment the nurse would encourage the client to take deep breaths and place the client in a semi-Fowler or high Fowler position. If the client's oxygen saturation did not improve after implementation of these measures, the nurse would contact the health care provider and prepare to initiate or adjust the level of delivered oxygen as prescribed.

A client whose father has polycystic kidney disease reports to the clinic for a physical examination. The client tells the nurse that she is concerned about the possibility of inheriting the disease. Which information should the nurse provide to the client? She shouldn't worry about inheriting the disorder. It is unlikely that she will inherit the disease, because it always skips a generation. She needs to get on with her life, because there is no known way to prevent the disease. She should be aware of the signs/symptoms of the disease and seek medical attention if they occur.

She should be aware of the signs/symptoms of the disease and seek medical attention if they occur. RATIONALE: Adult polycystic kidney disease is inherited as an autosomal dominant trait. It usually appears after the age of 40, although it may begin as early as age 20 or as late as age 80. The client with a family history of the disease should be told about its hereditary nature and about the clinical manifestations of the disease and advised to seek medical attention if these manifestations occur. Telling the client not to worry, that it is unlikely that she will inherit the disease, that it skips a generation, or that she should just get on with her life is inappropriate and does not address the client's concerns.

A nurse is grocery shopping when a woman screams, "Help me! He's choking on a piece of candy!" On rushing to the scene, the nurse sees that the woman's 4-year-old son is having respiratory difficulty and hears high-pitched inspiratory noises from the child. Which action should the nurse immediately take? Calling 911 on a cell phone Laying the child on the floor Placing the child across her lap and delivering five back blows Standing behind the child and administering abdominal thrusts

Standing behind the child and administering abdominal thrusts RATIONALE: The abdominal thrust maneuver is recommended for use in adults and children 1 year of age and older. If the victim is coughing but the cough is ineffective or if the victim exhibits respiratory difficulty accompanied by a high-pitched noise while inhaling, help is needed. The nurse must immediately stand behind the child and administer abdominal thrusts. Although the emergency response system should be activated, this is not the nurse's immediate action. The nurse must stay with the child and administer care and ask the child's mother to call 911. Back blows and chest thrusts are administered to an infant who is choking. An unconscious child would be placed in a supine position.

A client is being assessed for the presence of postural (orthostatic) hypotension. Which procedure should the nurse perform to assess the client for this condition? Taking the client's pulse while the client is standing, asking the client to lie down and retaking the pulse in 30 minutes, and finally, comparing the findings Taking the client's pulse while the client is lying down, asking the client to sit in a chair and retaking the pulse in 3 minutes, and, finally, comparing the findings Taking the client's blood pressure while the client is lying down, asking the client to sit in a chair and retaking the blood pressure in 1 to 3 minutes, asking the client to stand for 1 to 3 minutes and retaking the blood pressure a third time, and, finally comparing the findings Taking the client's blood pressure while the client is standing, asking the client to sit in a chair for 1 to 3 minutes and retaking the blood pressure, asking the client to lie down for 1 to 3 minutes and retaking the blood pressure a third time, and, finally, comparing the findings

Taking the client's blood pressure while the client is lying down, asking the client to sit in a chair and retaking the blood pressure in 1 to 3 minutes, asking the client to stand for 1 to 3 minutes and retaking the blood pressure a third time, and, finally comparing the findings RATIONALE: Postural (orthostatic) hypotension is the presence of signs/symptoms of low blood pressure on rising to an upright position in a normotensive individual. The blood pressure is checked with the client supine, sitting, and standing. The readings are obtained 1 to 3 minutes after the client changes position. When documenting orthostatic blood pressure measurements, the nurse records the client's position in addition to the client's blood pressure.

Jean runs to John, who is lying supine on the sand, and kneels at his side. Number the following actions that Jean will take in the order of priority, with number 1 as the first action and number 4 as the last. Sequencing Option Delivering compressions and at a rate of 100 compressions per minute Opening John's airway with a jaw-thrust maneuver and delivering 2 breaths for every 30 compressions Checking John's carotid pulse Tapping or gently shaking John and shouting, "Are you OK?"

Tapping or gently shaking John and shouting, "Are you OK?" Checking John's carotid pulse Delivering compressions and at a rate of 100 compressions per minute Opening John's airway with a jaw-thrust maneuver and delivering 2 breaths for every 30 compressions RATIONALE: A person who appears to be unconscious may actually be asleep, deaf, or even intoxicated. Therefore Jean must first determine whether John is unconscious by gently shaking, tapping, or moving his shoulders and shouting, "Are you OK?" Next Jean should assess circulation by palpating the carotid pulse (for no longer than 10 seconds) and begin chest compressions, if this is necessary. Finally the nurse would open John's airway with the use of the jaw-thrust maneuver and deliver rescue breaths, if they are necessary.

A nurse is watching an assistive personnel (AP) transfer a client from the sitting position on the bed to a wheelchair. Which observations indicate to the nurse that the nursing assistant is using proper body mechanics? Select all that apply. The AP uses a wide base of support. The AP faces in the direction of movement. The AP bends at the waist to help the client stand. The AP twists the waist and back while pivoting the client. The AP bends at the knees and keeps the trunk erect while helping the client stand.

The AP uses a wide base of support. The AP faces in the direction of movement. The AP bends at the knees and keeps the trunk erect while helping the client stand. RATIONALE: To prevent injury, health care staff must use proper body mechanics in moving and lifting clients. The nurse or AP should obtain assistance whenever possible and ask the client to aid in moving and lifting, if he or she is able to do so. The AP uses a wide base of support and keeps the feet about shoulder width apart; faces in the direction of movement; bends and flexes the knees; uses thigh, arm, and leg muscles rather than back muscles; avoids bending or twisting at the waist; and keeps the elbows and the client close to the body during the transfer.

Blood is drawn from a client with suspected hyperparathyroidism for a calcium assay, and a calcium level of 18 mg/dL (4.5 mmol/L) is detected. How should the nurse interpret this result? The calcium level is normal. The calcium level is low, indicating hyperparathyroidism. The calcium level is higher than normal, indicating hyperparathyroidism. The calcium level is on the low end of the normal range, indicating the need to increase dietary calcium.

The calcium level is higher than normal, indicating hyperparathyroidism. RATIONALE: Calcium functions in bone formation, nerve impulse transmission, and contraction of myocardial and skeletal muscles. It also aids in blood clotting by converting prothrombin to thrombin. The calcium concentration normally ranges from 8.6 to 10.0 mg/dL. Therefore, a calcium level of 18 mg/dL (4.5 mmol/L) is high, and the other options are incorrect.

A client undergoes transplantation of a kidney from her brother. Which information should the nurse, in home care instructions to the client about graft rejection, provide to the client? Rejection always occurs during the 48 hours after surgery. Rejection is not a problem when the donor is a direct family member. The client should contact the primary health care provider if she notices weight gain or edema. The client should not be concerned about rejection, because immunosuppressive medications prevent its occurrence.

The client should contact the primary health care provider if she notices weight gain or edema. RATIONALE: Rejection is a serious complication of kidney transplantation. The client must be educated about the signs/symptoms of rejection and told to notify the primary health care provider immediately if they occur. Hyperacute rejection occurs at the time of anastomosis of the organ. Acute rejection usually occurs within 6 weeks of transplantation but may occur at any time after the surgery. Chronic rejection occurs slowly, over a period of months to years. Signs/symptoms include fever, malaise, hypertension, graft tenderness, weight gain or edema, signs/symptoms of deteriorating renal function, increased WBC count, and increased levels of BUN and creatinine. Receiving a donor kidney from a direct family member does not guarantee that rejection will not occur. Immunosuppressive medication is taken to prevent rejection but does not ensure that rejection will not occur.

A nurse is observing as a nursing student prepares and administers a tap water enema to an adult client. Which observation by the nurse indicates the need to intervene before allowing the nursing student to proceed? The student inserts the tube 1 inch into the client's rectum. The student places the client in the left-side Sims position. The student clamps the tubing when the client complains of abdominal cramping. The student checks the temperature of the enema solution before administering it.

The student inserts the tube 1 inch into the client's rectum. RATIONALE: In an adult client, the rectal tube is pointed in the direction of the client's umbilicus and inserted 3 to 4 inches. If the rectal tube were inserted just 1 inch, solution would leak from the anus instead of flowing into the rectum. The rectal tube is inserted 2 to 3 inches in a child and 1 to 1.5 inches in an infant. Putting the client in the left-side Sims position, checking the temperature of the enema solution, and clamping the tubing if the client complains of abdominal cramping are all correct procedures in the administration of an enema.

The nurse is working with a new nurse employee, caring for a child who has had a craniotomy via supratentorial approach to remove a brain tumor in the right hemisphere. The nurse realizes the new employee understands positioning guidelines after surgery if the new employee states that the child should be positioned in which manner? Trendelenburg Flat on the left side Flat on the right side With the head elevated

With the head elevated RATIONALE: A supratentorial tumor is located within the anterior two thirds of the brain, mainly in the cerebrum. In a supratentorial procedure, the head is usually elevated above the level of the heart to facilitate drainage of CSF and to decrease excessive blood flow to the brain to prevent hemorrhage. In an infratentorial procedure, the child is usually positioned flat and on one side or the other. The child is not placed in the Trendelenburg position, which increases ICP and therefore the risk of hemorrhage.

After Heidi undergoes cholecystectomy, she is transferred to the recovery area in the ambulatory care unit. Heidi indicates during an assessment that she is experiencing incision pain and rates it at 8 on a scale of 1 to 10, with 10 being the worst pain possible. Heidi says she prefers not to take medication to relieve it, however. Which of the following measures that does not require a health care provider's prescription does the nurse plan to relieve Heidi's pain? Select all that apply. Zinc Ginger Humor Exercise Spiritual measures Relaxation therapy

humor spiritual measures relaxation therapy RATIONALE: Humor, spiritual measures, and relaxation therapy, which can all be implemented without a health care provider's prescription, may help relieve Heidi's pain. Ginger (an antiemetic) and zinc (an antiviral) do not relieve pain. Exercise immediately after surgery could strain the incisions and worsen Heidi's pain. TEST-TAKING STRATEGY: Focus on the subject, measures to relieve pain that do not require a health care provider's prescription. Recalling that ginger and zinc do not relieve pain will assist you in eliminating these options. Of the remaining options, select those that are noninvasive and would not be harmful to the client.

A nurse and an assistive personnel (AP) found an adult client on the bathroom floor who has a pulse but is unresponsive and not breathing. The nurse determines the AP is delivering an adequate number of rescue breaths if the AP delivers how many breaths per minute? 6 10 16 20

10 RATIONALE: During cardiopulmonary resuscitation (CPR), the rescuer delivers 8 to 10 breaths per minute to the adult victim. Each rescue breath is delivered over 1 second at a rate of 1 breath every 6 to 8 seconds. Six, 16, and 20 breaths per minute are incorrect.

Lydia is told that the surgery must be performed while she is under general anesthesia, and the anesthesiologist explains this type of anesthesia to her. The nurse tells Lydia that because she will be undergoing general anesthesia and because her surgery is scheduled for 7 a.m., she may not eat after what time? 3 a.m. on the day of surgery 7 a.m. on the day before surgery Noon on the day before surgery 11 p.m. on the night before surgery

11 p.m. on the night before surgery RATIONALE: The client must refrain from eating or drinking (nothing-by-mouth, or NPO, status) for 8 hours before a surgical procedure if general anesthesia is planned. Therefore, the remaining options are incorrect.

A physician prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21

A client has a prescription for a unit of packed red blood cells (RBCs). Which of the following IV solutions should the nurse obtain to hang with the blood product at the client's bedside? A 0.9% sodium chloride B Lactated Ringer's solution (LR)C 5% dextrose in 0.9% sodium chlorideD 5% dextrose in water in 0.45% sodium chloride

A 0.9% sodium chloride

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F. What should the nurse do next? A Call the healthcare provider B Begin the transfusion as prescribedC Administer an antihistamine and begin the transfusionD Administer 2 tablets of acetaminophen (Tylenol) and begin the transfusion

A Call the healthcare provider

A nurse is monitoring a client with hyperparathyroidism for signs of hypocalcemia and prepares to test the client for the Trousseau sign. Which item should the nurse obtain to perform this test? Cotton Tongue blade Reflex hammer Blood pressure cuff

Blood pressure cuff RATIONALE: The presence of the Trousseau sign is an indication of hypocalcemia. To test for the Trousseau sign, the nurse places a blood pressure cuff around the client's upper arm, inflates the cuff to a pressure greater than the client's systolic pressure, and keeps the cuff inflated for 1 to 4 minutes. In a positive result, the client's hands and fingers go into spasm in palmar flexion under these hypoxic conditions. Cotton, a tongue blade, and a reflex hammer are not needed to perform this test.

Because Heidi does not want to take medication to relieve her pain, the nurse intervenes and instructs Heidi in the use of imagery to help her relax and help relieve the pain. What should the nurse tell Heidi to do? Listen to the music coming from the bedside radio Focus on the pain and relax the abdominal muscles Tense her leg and arm muscles and focus on those areas Create a mental image of something positive, then relax and focus on the image

Create a mental image of something positive, then relax and focus on the image RATIONALE: Imagery is the process of using mental images to create a desired state (e.g., pain relief). Listening to music is a type of mind-body intervention known as music therapy. Focusing on the pain and tensing the muscles would increase Heidi's incision pain.

A nurse is making initials rounds on a group of assigned clients. Which of the following clients should the nurse see first? A A client receiving parenteral nutrition (PN) at a rate of 50 mL/hr for the last 24 hoursB A client receiving PN at a rate of 50 mL/hr whose temp was 99° F on the previous shiftC A client receiving PN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to voidD A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

D A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which of the following actions does the nurse identify as a priority in the plan of care for this client? A Monitoring urine outputB Encouraging increased fluidsC Monitoring the client's temperatureD Monitoring the client's respiratory rate

D Monitoring the client's respiratory rate

A nurse has a written prescription to remove an intravenous (IV) line. Which of the following items should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? A Adhesive bandageB Alcohol swabC Povidone-iodine (Betadine) swabD Sterile 2 × 2 gauze

D Sterile 2 × 2 gauze

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving parenteral nutrition (PN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A Turn the head to the leftB Turn the head to the rightC Exhale slowly and evenlyD Take a deep breath and hold it

D Take a deep breath and hold it

A nurse is reviewing the results of laboratory tests performed on a female client. Which of the following findings are abnormal and warrant primary health care provider notification? Select all that apply. Albumin, 4 g/dL (40 g/L) Protein, 6.0 g/dL (60 g/L) Ammonia, 40 mcg/dL (28.6 mcmol/L) Triglycerides, 150 mg/dL (1.69 mmol/L) Direct bilirubin, 1.2 mg/dL (20.5 mcmol/L) Total cholesterol, 250 mg/dL (6.47 mmol/L)

Direct bilirubin, 1.2 mg/dL (20.5 mcmol/L) Total cholesterol, 250 mg/dL (6.47 mmol/L) RATIONALE: Normal values for these parameters are: albumin, 3.4 to 5 g/dL; protein, 6.0 to 8.0 g/dL; ammonia, 10 to 80 mcg/dL; triglycerides, less than 200 mg/dL; direct bilirubin, 0 to 0.3 mg/dL; and total cholesterol, 140 to 199 mg/dL.

A client has been given instructions regarding the recently prescribed levothyroxine. The nurse determines the teaching was effective if the client states the medication should be taken in which manner? With food At bedtime With a snack at 3 p.m. In the morning, on an empty stomach

In the morning, on an empty stomach RATIONALE: Levothyroxine should be taken on an empty stomach to enhance its absorption. The daily dose should be taken in the morning, 1 hour before breakfast. Therefore, the remaining options are incorrect.

During the admission assessment, the nurse asks Louis about the medications he is currently taking. Which medication does the nurse recognize as a possible contributor to the urine retention? Furosemide Humulin N insulin Humulin R insulin Diphenhydramine

RATIONALE: Diphenhydramine is an antihistamine and can cause urine retention. This medication must be used with caution in a client with diabetes mellitus or prostatic hypertrophy. Other medications that can cause urine retention include anticholinergic drugs, some antihypertensive agents, and beta-adrenergic blockers. Diuretics (e.g., furosemide) increase urine output. Insulin does not cause urine retention.

A client is undergoing high-dose warfarin sodium therapy. The nurse checks the client's laboratory results and sees that the INR is 3.5. Which determination should the nurse make on the basis of this result? This value is expected. The dose of warfarin sodium needs to be adjusted. The primary health care provider should be notified, because the INR is too low. The primary health care provider should be notified, because the INR is too high.

This value is expected. RATIONALE: The INR should be maintained at 2.0 to 3.0 in a client undergoing standard warfarin sodium therapy and 3.0 to 4.5 in a client undergoing high-dose therapy. A value of 3.5 is therefore expected.

At 1600 the nurse checks a client's parenteral nutrition (PN) infusion bag and finds 1100 mL remaining in the 3000-mL bag. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at: A 1700B 1800 C 2000D 2100

B 1800

A client is receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the PN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A Chills B PallorC Headache D Chest and back pain E Nausea and vomiting F Subnormal temperature

A Chills C Headache D Chest and back pain E Nausea and vomiting

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side effect of the medication does the nurse monitor the client's laboratory results? A Hypokalemia B HypocalcemiaC HypernatremiaD Hypermagnesemia

A Hypokalemia

An adult client who recently underwent surgery suddenly experiences sharp chest pain and dyspnea and lapses into unconsciousness. The client is not breathing and does not have a pulse. The nurse calls a code and begins CPR. How many chest compressions per minute does the nurse deliver? 40 50 70 100

100 RATIONALE: The proper number of chest compressions per minute should be delivered to ensure adequate cardiac output. In an adult client, the correct number of chest compressions is at least 100 per minute. Forty, 50, and 70 are all incorrect.

A nurse is preparing a plan of care for a client with renal colic who is receiving meperidine hydrochloride (Demerol) for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A Hypotension B Constipation C BradycardiaD Urine retention E Respiratory depression

A Hypotension B Constipation D Urine retention E Respiratory depression

A nurse suspects that a client receiving parenteral nutrition (PN) through a central line has an air embolism. The nurse immediately positions the client on the: A Left side with the head lower than the feet B Left side with the head higher than the feetC Right side with the head lower than the feetD Right side with the head higher than the feet

A Left side with the head lower than the feet

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced: A Phlebitis of the vein B Infiltration of the IV lineC Hypersensitivity to the IV solutionD An allergic reaction to the IV catheter material

A Phlebitis of the vein

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? A Remove the IV B Apply a warm compressC Check for blood returnD Measure the area of infiltration

A Remove the IV

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse first: A Removes the IV catheter B Slows the rate of infusionC Notifies the healthcare providerD Checks for loose catheter connections

A Removes the IV catheter

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which of the following actions should the nurse take? Select all that apply. A Removing the IV catheter at that site B Applying warm, moist compresses to the IV site C Notifying the healthcare provider about the finding D Encouraging the client to scrub the site while in the showerE Starting a new IV line in a proximal portion of the same vein

A Removing the IV catheter at that site B Applying warm, moist compresses to the IV site C Notifying the healthcare provider about the finding

A home care nurse has been assigned a client who has been discharged home with a prescription for parenteral nutrition (PN). Which of the following parameters does the nurse plan to check at each visit as a means of identifying complications of the PN therapy? Select all that apply. A Weight B Glucose test C Temperature D Peripheral pulsesE Hemoglobin and hematocrit

A Weight B Glucose test C Temperature

The nurse is caring for a client who has had acute pancreatitis. Which change best indicates the client is recovering from pancreatitis? An increased amylase level A decrease in the lipase level Active bowel sounds in all four quadrants Abdominal pain that is relieved by lying down

A decrease in the lipase level RATIONALE: Pancreatitis is characterized by an increased amylase and lipase level, abdominal pain, even in the recumbent position. The bowel sounds can remain active. A decreased lipase level indicates the client is recovering.

Rectally administered lactulose is prescribed for a client with hepatic encephalopathy. Which parameter should the nurse monitor to evaluate the effectiveness of the medication? Blood pressure Ammonia level Electrolyte levels Looseness of stools

Ammonia level RATIONALE: Lactulose is a hyperosmotic laxative and ammonia detoxicant. It can enhance intestinal excretion of ammonia and decrease the blood ammonia level in a client with portal hypertension and hepatic encephalopathy. Diarrhea is an indicator of overdose, not effectiveness. Used correctly, the medication should result in the production of two or three soft stools per day. Blood pressure is not associated with the action or effectiveness of this medication. Electrolyte levels are monitored in clients who must take this medication frequently, in large doses, or for prolonged periods because of the risk of electrolyte disturbance.

A client with Hodgkin's disease will be receiving chemotherapy with doxorubicin. Which action should the nurse plan to take as a means of monitoring the client for toxicity specific to this medication? Checking the client's temperature Attaching a cardiac monitor to the client Assessing the client for peripheral edema Drawing a blood specimen to check the client's platelet count

Attaching a cardiac monitor to the client RATIONALE: Doxorubicin can cause both acute and delayed injury to the heart. Acute effects (dysrhythmias, electrocardiographic changes) may develop within minutes of administration. (In most cases these reactions are transient, lasting no more than 2 weeks.) Delayed cardiotoxicity, which appears as heart failure resulting from diffuse cardiomyopathy, is often unresponsive to treatment. Checking the client's temperature, assessing the client for peripheral edema, and checking the client's platelet count may all be sound nursing interventions, but they are not specifically related to cardiotoxicity, a toxic effect of doxorubicin.

A nurse provides instructions to a client who will be taking furosemide (Lasix). Which of the following statements by the client indicates to the nurse that the client needs additional instruction? A "I need to sit or stand up slowly."B "I should expect to have ringing in my ears." C "I need to maintain my fluid intake."D "This medication will make me urinate."

B "I should expect to have ringing in my ears."

A physician prescribes the administration of parenteral nutrition (PN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the PN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse immediately: A Obtains blood for cultureB Clamps the PN infusion line C Obtains a sample for blood glucose testingD Obtains an electrocardiogram (ECG)

B Clamps the PN infusion line

A nurse discontinues infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which of the following actions does the nurse take next? A Removing the IV catheterB Contacting the healthcare providerC Changing the solution to 5% dextrose in waterD Obtaining a culture of the tip of the catheter device removed from the client

B Contacting the healthcare provider

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse tells the client to: A Shake the NPH insulin bottle before mixing the two typesB Draw the regular insulin into the syringe first C Remove all of the air from the bottle before mixing the two typesD Keep insulin refrigerated at all times

B Draw the regular insulin into the syringe first

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of parenteral nutrition (PN), a solution containing 25% glucose. Which of the following actions should be taken by the nurse? A Hanging the IV solution as prescribedB Questioning the healthcare provider about the prescription C Hanging the IV solution but setting the infusion at just half the prescribed rateD Diluting the solution with sterile water to half-strength

B Questioning the healthcare provider about the prescription

A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will be piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which of these actions should the nurse take? A Shaking the bottle vigorouslyB Requesting a new bottle from the pharmacy C Rotating the bottle gently back and forth to mix the globulesD Running the bottle under warm water until the globules disappear

B Requesting a new bottle from the pharmacy

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply. A TinnitusB Tarry stools C Slowed pulseD Bleeding from the gums E Increased blood pressure

B Tarry stools D Bleeding from the gums

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which of the following parameters does the nurse assess just before hanging the transfusion? A Skin colorB Vital signs C Latest platelet countD Urine output over the last 24 hours

B Vital signs

Disulfiram (Antabuse) is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A "When did you have your last full meal?"B "Do you have a history of diabetes insipidus?"C "When was your last drink of alcohol?" D "Do you have a history of thyroid problems?" E "Do you have a history of cancer in your family?"

C "When was your last drink of alcohol?" D "Do you have a history of thyroid problems?"

A nurse is caring for a group of adult clients on an acute care nursing unit. Which of the following clients does the nurse recognize as the least likely candidate for parenteral nutrition (PN)? A 61-year-old client with pancreatitisB 52-year-old client with severe sepsisC 45-year-old client who has undergone repair of a hiatal hernia D 24-year-old client with a severe exacerbation of ulcerative colitis

C 45-year-old client who has undergone repair of a hiatal hernia

The first bag of parenteral nutrition (PN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which of the following essential pieces of equipment does the nurse obtain before hanging the solution? A Pulse oximeterB Blood glucose meterC Electronic infusion device D Noninvasive blood pressure monitor

C Electronic infusion device

A nurse is monitoring a client who is receiving parenteral nutrition (PN). Which of the following signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A Pallor, weak pulse, and anuriaB Nausea, vomiting, and oliguriaC Nausea, thirst, and increased urine output D Sweating, chills, and decreased urine output

C Nausea, thirst, and increased urine output

A client has just undergone insertion of a central venous catheter by the healthcare provider at the bedside. Which of the following results would the nurse be sure to check before initiating infusion of the IV solution that the healthcare provider has prescribed? A Serum osmolalityB Serum electrolytesC Portable chest x-ray D Intake and output record

C Portable chest x-ray

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which of the following actions should the nurse take first? A Removing the IVB Sitting the client up in bedC Shutting off the IV infusion D Slowing the rate of infusion

C Shutting off the IV

EMS has arrived. Which actions should Jean take at this time? Select all that apply. Helping the emergency medical technicians (EMTs) with the AED Continuing CPR until she is asked to stop Talking to John's wife while the EMTs work on John Going for a run to relieve the stress of the situation Preparing to go with John and his wife to the hospital Telling the EMTs what has happened since she has been there

Continuing CPR until she is asked to stop Talking to John's wife while the EMTs work on John Telling the EMTs what has happened since she has been there RATIONALE: Jean will continue CPR until the EMTs are ready to take over. She will also give them report about the situation and answer their questions about what has happened while she has been with John. When the EMTs no longer need Jean's or John's wife's attention, Jean will be able to talk to John's wife to help her understand what the EMTs are doing and calm her as needed. Jean would not help the EMTs with the AED; the EMTs are trained to perform this procedure. She would not go to the hospital with John and his wife unless they asked her to go and she wanted to do so; this is not an expected nursing action. She might go for a run to relieve her stress, but she would not do it at this time.

A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? A Administering an antiemeticB Administering the daily dose of digoxinC Discontinuing the morning dose of furosemideD Checking the result of laboratory testing for potassium on the sample drawn 3 hours agoD

D Checking the result of laboratory testing for potassium on the sample drawn 3 hours ago

A client with HIV infection has been started on therapy with zidovudine (AZT, Retrovir). The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which of the following laboratory tests is most important in light of the therapy that has been prescribed for this client? A CreatinineB Serum potassiumC Blood urea nitrogen (BUN)D Complete blood count (CBC)

D Complete blood count (CBC)

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the healthcare provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the healthcare provider with the procedure. As further preparation for the procedure, the nurse places the client: A Flat on the left sideB In the prone positionC In the supine positionD In a slight Trendelenburg position

D In a slight Trendelenburg position

A nurse has taught a client with type 1 diabetes mellitus how to draw up and mix the prescribed dose of NPH insulin 20 units and regular insulin 6 units. The nurse realizes the teaching has been effective if the client draws up the insulins in which order?

Putting 20 units of air into the NPH insulin bottle Putting 6 units of air into the regular insulin bottle Drawing up the regular insulin Drawing up the NPH insulin RATIONALE: When the prescribed treatment calls for the administration of both NPH and regular insulin, it is desirable to mix the two types rather than inject them separately, because this eliminates the need for a second injection. To prepare a mixture of NPH and regular insulin, the client should first add the air to the NPH insulin bottle, then add air to the regular insulin bottle, invert the bottle, and draw up the dose of regular insulin. The client would draw up the NPH insulin second.

Oral prednisone, 10 mg/day, has been prescribed for a hospitalized client with a history of type 1 diabetes mellitus for the treatment of an acute exacerbation of asthma. The nurse should monitor the client closely for which occurrence? Signs of hypoglycemia Signs of hyperglycemia The need to decrease the prescribed daily insulin dose The need to change the prescribed daily insulin to an oral hypoglycemic medication

Signs of hyperglycemia RATIONALE: Because of their effect on glucose production and utilization, glucocorticoids can increase the plasma glucose level, causing hyperglycemia and glycosuria. Clients with diabetes mellitus may need to increase the dosage of insulin or oral hypoglycemic medications during treatment with a glucocorticoid. Decreasing the prescribed insulin dose, needing to change the prescribed insulin to an oral hypoglycemic medication, and watching for signs of hypoglycemia are all therefore incorrect.

Following a kidney, ureters, and bladder (KUB) x-ray, the client has been diagnosed with urolithiasis. The nurse provides home care instructions to the client and provides the client with which instruction(s)? Select all that apply. Strain all urine for stones. Drink plenty of fluids daily. Avoid walking or other activity. Apply ice to the area where the pain is located. Restrict food intake until the stone has passed.

Strain all urine for stones. Drink plenty of fluids daily. RATIONALE: Urolithiasis refers to the formation of urinary stones or calculi, which are usually formed in the ureter. Home care measures are directed toward promoting passage of the stone. The client is encouraged to ingest daily fluids as prescribed by the primary health care provider to facilitate passage of the stone and prevent infection. All urine is strained for stones, which are sent to the laboratory for analysis as prescribed to assist in determining treatment. The client is instructed to take warm baths and apply heat to the area of discomfort; cold may cause spasms and will increase the discomfort. Ambulation is encouraged; this will assist in the passage of the stone. There is no useful reason to restrict food.

A client with breast cancer who has undergone a mastectomy will be receiving chemotherapy. The oncologist prescribes allopurinol, 100 mg orally daily, to be started before the initiation of chemotherapy. The nurse should tell the client that this medication is used for which purpose? To prevent nausea To prevent diarrhea To reduce postoperative incision pain To minimize an increase in the plasma uric acid level

To minimize an increase in the plasma uric acid level RATIONALE: Allopurinol is used to reduce the blood level of uric acid. The level of uric acid increases as a result of the breakdown of DNA that occurs after chemotherapy-induced cell death. As a means of minimizing any increase in the plasma level of uric acid, allopurinol should be administered before the start of chemotherapy. Allopurinol does not prevent nausea or diarrhea or reduce incision pain.

The nurse describes the bladder retraining program to Louis. Louis says, "I'm so worried about all of this. It's so embarrassing not to be able to control my urine. Do you think this will work? I've heard that diabetes causes these kinds of urinary problems. To top it off, I have this enlarged prostate!" Which therapeutic statement should the nurse make? "Diabetes mellitus has no effect on urination." "Don't worry. We'll have you back in shape in no time!" "Diabetes mellitus can cause alterations in urinary patterns because the condition affects the nerves that help the bladder function." "Having an enlarged prostate will make things difficult, but with hard work and compliance with the program, everything will work out fine."

"Diabetes mellitus can cause alterations in urinary patterns because the condition affects the nerves that help the bladder function." RATIONALE: Systemic diseases such as diabetes mellitus can affect renal and bladder function. The renal alterations result from injury to the glomeruli or renal tubule that interferes with the normal filtering, reabsorption, and secretory functions. Renal dysfunctions are first noted with microalbuminuria. The bladder dysfunction is affected by diabetic autonomic neuropathy. Therefore, stating diabetes-mellitus has no effect on urination is incorrect. Telling the client not to worry and that things will work out fine is incorrect because these are nontherapeutic responses that provide false reassurance.

A transfusion of packed red blood cells has been prescribed for Rosanne. Which statement indicates that Rosanne understands the pretransfusion teaching about vital signs? "You're going to take my vital signs every 15 minutes during the transfusion." "You'll take my vital signs just before you start the transfusion and 1 hour after it's done." "You'll take my vital signs 1 hour before you start the transfusion and 1 hour after it's done." "You'll take my vital signs just before you start the transfusion, during the transfusion, and one more time after the transfusion is done."

"You'll take my vital signs just before you start the transfusion, during the transfusion, and one more time after the transfusion is done." RATIONALE: Because of the danger of a transfusion reaction, it is important to take specific precautions in administering blood products. The nurse must obtain the client's baseline vital signs before the transfusion is begun. This information will allow the nurse to identify changes in vital signs that may indicate that a transfusion reaction is developing. The nurse will continue to monitor the client and obtain vital signs periodically during the transfusion as directed by agency policy. If a transfusion reaction occurs, the nurse checks the client's vital signs as often as every 5 minutes. The nurse also checks the client's vital signs after completion of the blood transfusion.

A nurse is caring for a client with a continuous bladder irrigation (CBI). The nurse notes that at the end of the shift a total of 3475 mL of irrigation fluid instilled and a total of 4725 mL was emptied from the urinary catheter bag. The nurse determines that the client's actual urine output is how many mL?

1250 mL RATIONALE: To determine the actual urine output for a client receiving a continuous bladder irrigation, the nurse would subtract the amount of irrigation fluid instilled into the bladder from the total urine output. Therefore, if 4725 mL was emptied from the urinary catheter bag and 3475 mL of irrigation fluid was instilled, the actual urine output is 1250 mL.

A client with sepsis has been receiving intravenous antibiotics, and acute kidney injury has developed as a result. The nurse assesses the client and reviews the laboratory results. Which findings should the nurse expect to note during the oliguric stage of acute kidney injury? Select all that apply. A calcium level of 8.0 mg/dL (2 mmol/L) A creatinine level of 2.0 mg/dL (178.8 mcmol/L) A serum sodium level of 159 mEq/L (159 mmol/L) A serum potassium level of 3.1 mEq/L (3.1 mmol/L) A blood urea nitrogen level of 25 mg/dL (8.9 mmol/L)

A blood urea nitrogen level of 25 mg/dL (8.9 mmol/L) A calcium level of 8.0 mg/dL (2 mmol/L) A creatinine level of 2.0 mg/dL (178.8 mcmol/L) RATIONALE: In the oliguric stage of acute kidney injury, the GFR decreases. The client exhibits hyperkalemia, a normal or decreased sodium level (sodium retention occurs but is masked by the dilutional effects of water retention), hypocalcemia, and increased BUN and creatinine levels. During the diuretic stage, the GFR begins to increase and hypokalemia, hyponatremia, and hypovolemia develop, with gradual decreases in the levels of BUN and creatinine. The normal potassium level ranges from 3.5 to 5 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal BUN level ranges from 5 to 20 mg/dL, and the normal creatinine level ranges from 0.6 to 1.3 mg/dL. The normal calcium level ranges from 8.6 to 10 mg/dL.

An adolescent client who underwent surgery after sustaining a femur fracture while rock climbing is in skeletal traction. For which complications related to immobility is the client at risk? Select all that apply. Anxiety Diarrhea Pneumonia Hypertension Urinary tract infection

Anxiety Pneumonia Urinary tract infection RATIONALE: Immobility is a client's inability to move about freely. Psychological complications of immobility include disorientation, confusion, boredom, anxiety, loneliness, and depression. This adolescent is at risk for complications of immobility. The adolescent who is immobile is at risk for psychological complications, including anxiety, most likely resulting from separation from his or her friends. Gastrointestinal complications of immobility include abdominal distention, constipation (not diarrhea), decreased appetite and weight loss, protein deficiency, and a negative nitrogen balance. Respiratory complications include atelectasis, pneumonia, and decreased gas exchange. Cardiovascular complications include thrombus formation, thrombophlebitis, pulmonary embolism, and orthostatic hypotension (not hypertension). Renal complications include urinary stasis and urinary tract infections, as well as the formation of renal calculi.

A nurse is conducting an assessment of a client who underwent partial gastrectomy 12 hours ago. On auscultating the abdomen, the nurse does not hear bowel sounds. What is the most appropriate action for the nurse to take? Contact the surgeon Document the findings Encourage the client to increase oral fluid intake Help the client walk and then check again for bowel sounds

Document the findings RATIONALE: An absence of bowel sounds 12 hours after surgery is an expected finding; the nurse would document the finding and continue assessing the client. After abdominal surgery, motility of the gastrointestinal tract is diminished and normal bowel tone and peristalsis may be faint or absent in all four abdominal quadrants. Motility normally resumes within 24 hours of surgery in the small intestine and within 3 to 5 days in the large intestine. It would not be necessary to contact the surgeon at this time. After partial gastrectomy, the client would be prohibited from eating or drinking and would have a nasogastric tube attached to suction. Encouraging the client to increase oral fluid intake is therefore incorrect. Ambulation will aid the restoration of normal gastrointestinal function but will not restore it immediately.

A client being seen in the clinic for the first time tells the nurse that his last physical examination was 10 years ago. A physical examination is performed, several laboratory tests are prescribed, and a follow-up appointment is scheduled for the client. The laboratory results are sent to the clinic, where the nurse reviews the results. Which values are abnormal? Select all that apply. BUN, 10 mg/dL (3.57 mmol/L) Magnesium, 2.0 mg/dL (0.82 mmol/L) WBCs, 5,000 cells/mm3 (5 x 109/L) Phosphorus, 9.6 mg/dL (3.1 mmol/L) Neutrophils, 900 cells/mm3 (0.09 x 109

Phosphorus, 9.6 mg/dL (3.1 mmol/L) Neutrophils, 900 cells/mm3 (0.09 x 109 RATIONALE: Normal values are phosphorus, 2.7 to 4.5 mg/dL; neutrophils, 56% or 1800 to 7800 cells/mm3; BUN, 8 to 25 mg/dL; magnesium, 1.6 to 2.6 mg/dL; WBCs, 4500 to 11,000 cells/mm3; and serum creatinine, 0.6 to 1.3 mg/dL.

Despite her attempts to ventilate John, Jean is unable to deliver the breaths. As Jean repositions John's head, his wife asks, "Could this have happened because of his cancer?" Which of the following oncologic emergencies could precipitate this situation? Hypercalcemia Tumor lysis syndrome (TLS) Superior vena cava (SVC) syndrome Syndrome of inappropriate antidiuretic hormone (SIADH)

Superior vena cava (SVC) syndrome RATIONALE: Superior vena cava (SVC) syndrome related to lung cancer or lymphoma is the most likely contributor to this situation because of its potential for respiratory compromise. Hypercalcemia and TLS may lead to electrocardiographic changes but would not contribute to respiratory obstruction. SIADH would not likely contribute to cardiac or respiratory arrest.

A nurse arrives at the home of a neighbor, who called for help when her husband fell off a ladder during a seizure. The neighbor tells the nurse that she called 911 and that an ambulance is on the way. The nurse assesses the man and determines that he is unconscious without a pulse. After performing 30 chest compressions, the nurse prepares to deliver rescue breaths and uses which method to open the man's airway? The jaw-thrust maneuver The head tilt-chin left method Lifting the chin and using the fingers to open the mouth Placing the fingers in the victim's mouth, using a hooking action

The jaw-thrust maneuver RATIONALE: When injury to the head, neck, or spinal cord is suspected, the jaw-thrust maneuver is used to open the airway. This maneuver maintains proper head and neck alignment, thereby reducing the risk of further damage. The head tilt-chin lift method is the preferred method of opening the victim's airway and is used if no head, neck, or spinal cord injury is suspected. Lifting the chin and using the fingers to open the mouth and placing the fingers in the victim's mouth with the use of a hooking action are incorrect methods that would not effectively open the airway. Additionally, the nurse would not place fingers in the mouth of a client who has had a seizure.

A client with a breast mass who is scheduled for an excisional breast biopsy asks the nurse about the procedure. What information should the nurse provide the client? The mass is removed entirely. Fluid is removed from the mass. Tissue is removed from the mass. Tissue is aspirated from the mass through a large-bore needle.

The mass is removed entirely RATIONALE: In an excisional biopsy, the mass itself is removed for histologic (cellular) evaluation. An incisional biopsy involves the surgical removal of tissue from a mass. Aspiration biopsy is the removal of fluid or tissue from a mass through a large-bore needle

During preparations for discharge, the nurse teaches Heidi wound care. Heidi tells the nurse that she only wants to use herbal or natural products. Which of the following treatments should the nurse tell Heidi to use? Select all that apply. Taking a shower Applying aloe gel Washing with saline solution Covering the wounds with bandages Washing with hydrogen peroxide Washing with povidone-iodine (Betadine)

taking a shower covering the wounds with bandages RATIONALE: The client will have small adhesive bandages on the puncture site incisions after the laparotomy. The client may remove the bandages the day after surgery and take a shower. Because there may be a small amount of oozing from the wounds, a dry bandage will help protect Heidi's clothing in addition to the wounds themselves. Aloe gel is not used on open wounds. The saline solution may sting. Hydrogen peroxide and povidone-iodine, which can damage new epithelial tissue, are not used in a clean, granulating wound. TEST-TAKING STRATEGY: Focus on the subject, herbal or natural products for wound care. Eliminate the treatments that would cause pain or tissue damage: saline solution, hydrogen peroxide, and povidone-iodine. Although aloe gel will soothe sunburn, it is not used on open wounds. The shower will wash away any drainage that could lead to bacterial growth; if soap is used, it will be rinsed from the wound by the flowing water. The dry bandage will protect the wounds and the client's clothing.