RN 216 1, 2, 3, 5, 13, 14, 27

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.) A. Addiction is a chronic physiologic disease process. B. Physical dependence and addiction are the same thing. C. Pseudoaddiction can result in withdrawal symptoms. D. Tolerance is a normal response to regular opioid use. E. Tolerance is said to occur when opioid effects decrease. F. Physical dependence occurs after repeated doses of an opioid.

A. Addiction is a chronic physiologic disease process. D. Tolerance is a normal response to regular opioid use. E. Tolerance is said to occur when opioid effects decrease. F. Physical dependence occurs after repeated doses of an opioid. Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the nurse's clinical reasoning. What nurse actions does the manager observe to help form this judgment? (Select all that apply.) A. Anticipating consequences of actions B. Delegating appropriately C. Interpreting data D. Noticing cues E. Setting priorities

A. Anticipating consequences of actions C. Interpreting data D. Noticing cues E. Setting priorities

Which action by the nurse working with a client best demonstrates respect for autonomy? A. Asks if the client has questions before signing a consent. B. Gives the client accurate information when questioned. C. Keeps the promises made to the client and family. D. Treats the client fairly compared to other clients.

A. Asks if the client has questions before signing a consent.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) A. Collaborating with an interprofessional team B. Implementing evidence-based care C. Providing family-focused care D. Routinely using informatics in practice E. Using quality improvement in client care F. Formalizing systems thinking when implementing care

A. Collaborating with an interprofessional team B. Implementing evidence-based care D. Routinely using informatics in practice E. Using quality improvement in client care

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) A. Calculate pulse pressure with each blood pressure reading. B. Assess skin turgor using the back of the client's hand. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium.

A. Calculate pulse pressure with each blood pressure reading. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium. Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. Assess skin turgor on the chest or forehead.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? A. Call the Rapid Response Team. B. Document and continue to monitor. C. Notify the primary health care provider. D. Repeat the blood pressure in 15 minutes.

A. Call the Rapid Response Team.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first? A. Cardiac rate and rhythm B. Skin and mucous membranes C. Musculoskeletal strength D. Level of orientation

A. Cardiac rate and rhythm Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. The nurse responds by performing a thorough cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal system, and neurologic system, but assessing for the cardiovascular complications comes first.

What factor best predicts a nurse's willingness to employ critical thinking? A. Caring B. Knowledge C. Presence D. Skills

A. Caring

A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? (Select all that apply.) A. Chicken breast B. Orange juice C. Boost supplement D. Spinach salad E. Cantaloupe F. Whole wheat bread

A. Chicken breast B. Orange juice C. Boost supplement D. Spinach salad

The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange abnormalities first? A. Involved in motor vehicle crash, has broken femur. B. Brought in unconscious by roommate after opioid overdose. C. Asthmatic client being discharged after bronchodilator therapy. D. History of COPD, presents to ED after being bitten by a dog.

B. Brought in unconscious by roommate after opioid overdose.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? A. Client being discharged later on a complicated analgesia regimen. B. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. C. Postoperative client who received oral opioid analgesia 45 minutes ago. D. Client who has returned from physical therapy and is resting in the recliner.

B. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs at least 30 minutes for the oral medication to become effective and would be seen shortly to assess for effectiveness. The client going home requires teaching, which would be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? A. Encourage oral fluid intake. B. Connect the client to a cardiac monitor. C. Assess urinary output. D. Administer oral calcitonin.

B. Connect the client to a cardiac monitor. This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse working in a medical home would do which of the following as part of the job? A. Advocate with insurance companies. B. Coordinate interprofessional care. C. Hold monthly team meetings. D. Provide out-of-network specialty referrals.

B. Coordinate interprofessional care.

A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? A. Avoid embarrassing the client by asking questions. B. Don't make assumptions about his or her health needs. C. Most LGBTQ people do not want to share information. D. No differences exist in communicating with this population.

B. Don't make assumptions about his or her health needs.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) A. Cost-saving measures B. Nurse's expertise C. Client preferences D. Research findings E. Values of the client E. Plan-do-study-act model

B. Nurse's expertise C. Client preferences D. Research findings E. Values of the client

A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best? A. Anxiety is causing the client to breathe rapidly. B. The client is trying to get rid of excess body acids. C. The rapid respirations cause buildup of bicarbonate. D. An increased respiratory rate is due to increased metabolism.

B. The client is trying to get rid of excess body acids.

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? A. Numeric pain scale B. Behavioral assessment C. Client's self-report D. Objective observation

C. Client's self-report Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

A nurse is planning primary prevention measures for community-dwelling adults to prevent visual impairment. What action by the nurse will best meet this objective? A. Provide glaucoma screening. B. Assess visual acuity. C. Teach clients about instilling eyedrops. D. Offer a healthy lifestyle class.

D. Offer a healthy lifestyle class.

Once the nurse has considered all possible collaborative and client problems, what action does the nurse take next? A. Act on the observed cues. B. Determine desired outcomes. C. Generate solutions. D. Prioritize the hypotheses.

D. Prioritize the hypotheses.

To demonstrate clinical reasoning skills, what action does the nurse take? A. Collaborating with co-workers to buddy up for lunch breaks B. Delegating frequent vital signs on a new postoperative patient C. Documenting a complete history and physical on an admission D. Requesting the provider order medication for a client with high potassium

D. Requesting the provider order medication for a client with high potassium

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? A. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. B. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. C. A 67 year old who is experiencing pain and is prescribed ibuprofen. D. A 73 year old with tachycardia who is receiving digoxin.

A. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? A. "Being able to sleep doesn't mean pain doesn't exist." B. "Have you ever experienced any type of pain?" C. "The client should be assessed for drug addiction." D. "You're right; I would put the medication back."

A. "Being able to sleep doesn't mean pain doesn't exist." A client's description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose and is unethical.

The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate? A. "Find a trusted friend and role play." B. "Don't worry it will get easier." C. "A sexual assessment is usually not needed." D. "It's hard for me to do, too."

A. "Find a trusted friend and role play."

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate? A. "Help me understand how pain is affecting you right now." B. "I wish I could do more; is there anything I can get for you?" C. "You cannot have more pain medication for 3 hours." D. "Why do you think the medication is not helping your pain?"

A. "Help me understand how pain is affecting you right now." A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question.

A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify as having a risk for impaired immunity? (Select all that apply.) A. 86 years old B. Has type 2 diabetes C. Taking prednisone D. Has many allergies E. Drinks a beer a day F. Low socioeconomic status

A. 86 years old B. Has type 2 diabetes C. Taking prednisone F. Low socioeconomic status

The nurse understands which information regarding patient-centered care? A. A competency recognizing the client as the source of control of his or her care B. A project addressing challenges in implementing patient-centered care C. Purposeful, informed, and outcome-focused care of clients or families D. The ability to use best evidence and practice when making care-related decisions

A. A competency recognizing the client as the source of control of his or her care

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? A. Assess physiologic indicators and vital signs. B. Do not give pain medication as no pain is indicated. C. Document the findings and continue to monitor. D. Try a small dose of analgesic medication for pain.

A. Assess physiologic indicators and vital signs. Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial. The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? A. Assess the client's respiratory rate, rhythm, and depth. B. Measure the client's pulse and blood pressure. C. Document findings and monitor the client. D. Call the health care primary health care provider.

A. Assess the client's respiratory rate, rhythm, and depth. In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? A. Assesses for cultural influences affecting health care. B. Ensures that all the client's basic needs are met. C. Tells the client and family about all upcoming tests. D. Thoroughly orients the client and family to the room.

A. Assesses for cultural influences affecting health care.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) A. Attend hand-off rounds to coach and mentor. B. Create a template of suggested topics to include in report. C. Encourage staff to ask questions during hand-off. D. Give raises based on compliance with reporting. E. Provide education on the SBAR method of communication

A. Attend hand-off rounds to coach and mentor. B. Create a template of suggested topics to include in report. C. Encourage staff to ask questions during hand-off. E. Provide education on the SBAR method of communication

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) A. Avoid using other medications that cause sedation. B. Delay giving medication if the client is sleeping. C. Give the lowest dose that produces good control. D. Identify clients at high risk for unwanted sedation. E. Use an oximeter to monitor clients receiving analgesia.

A. Avoid using other medications that cause sedation. C. Give the lowest dose that produces good control. D. Identify clients at high risk for unwanted sedation. E. Use an oximeter to monitor clients receiving analgesia. Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse would identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client's oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

The expert nurse understands that critical thinking requires which elements to be present? (Select all that apply.) A. Based on logic, creativity, and intuition B. Driven by needs C. Focused on safety and quality D. Grounded in a specific theory E. Guided by standards F. Requires forming options about evidence

A. Based on logic, creativity, and intuition B. Driven by needs C. Focused on safety and quality E. Guided by standards

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? A. Bring a list of all medications and what they are for. B. Keep the provider's phone number by the telephone. C. Make sure that all providers wash hands before entering the room. D. Write down the name of each caregiver who comes in the room.

A. Bring a list of all medications and what they are for.

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.) A. Consult with the surgeon and voice objections. B. Delegate administration of the placebo to another nurse. C. Give the placebo and reassess the client's pain. D. Notify the nurse manager of the placebo prescription. E. Tell the client what medications were prescribed.

A. Consult with the surgeon and voice objections. D. Notify the nurse manager of the placebo prescription. Nurses would never give placebos to treat a client's pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse would voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse would not delegate giving the placebo to someone else, nor would the nurse give it. Telling the client about the placebo prescription before voicing objections would not be beneficial.

A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) A. Consults with other disciplines on client care. B. Coordinates discharge planning for home safety. C. Participates in comprehensive client rounding. D. Routinely asks other disciplines about client progress. E. Shows the nursing care plans to other disciplines. F. Delegate tasks to unlicensed personnel appropriately.

A. Consults with other disciplines on client care. B. Coordinates discharge planning for home safety. C. Participates in comprehensive client rounding. D. Routinely asks other disciplines about client progress. F. Delegate tasks to unlicensed personnel appropriately.

A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) A. Decreased immune response B. Development of chronic pain C. Increased gastrointestinal (GI) motility D. Possible immobility E. Slower healing F. Negative quality of life

A. Decreased immune response B. Development of chronic pain D. Possible immobility E. Slower healing F. Negative quality of life There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand. Decreased quality of life includes depression, anxiety, fear, anger, hopelessness, and insomnia; impaired family, work, and social relationships; and difficulty with ADLs.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? A. Depth of respirations B. Bowel sounds C. Grip strength D. Electrocardiography

A. Depth of respirations A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

According to the WHO, what does primary care involve? (Select all that apply.) A. Empowered people and communities B. Essential public functions C. Multisectoral policy and action D. Primary care E. Priority consideration of chronic diseases

A. Empowered people and communities B. Essential public functions C. Multisectoral policy and action D. Primary care

A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? A. Encourage the client and family to be active partners. B. Have the client monitor hand hygiene in caregivers. C. Offer the family the opportunity to stay with the client. D. Tell the client to always wear his or her armband.

A. Encourage the client and family to be active partners.

A client had a recent thromboembolism and must resume work which requires frequent car and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this client? A. Get up and walk around at least every 2 hours while traveling. B. Use a soft toothbrush and an electric razor for safety. C. Be sure to sit with the legs elevated as much as possible. D. Increase fiber in the diet so as not to strain to move the bowels.

A. Get up and walk around at least every 2 hours while traveling.

A nurse wishes to work in a community-based practice setting. Which areas would this nurse explore for employment? (Select all that apply.) A. Hospice facility B. "Minute clinic" C. Mobile mammography unit D. Small community hospital E. Telehealth F. Home health care

A. Hospice facility B. "Minute clinic" C. Mobile mammography unit E. Telehealth F. Home health care

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) A. Hypokalemia—muscle weakness with respiratory depression B. Hypermagnesemia—bradycardia and hypotension C. Hyponatremia—decreased level of consciousness D. Hypercalcemia—positive Trousseau and Chvostek signs E. Hypomagnesemia—hyperactive deep tendon reflexes F. Hypernatremia—weak peripheral pulses

A. Hypokalemia—muscle weakness with respiratory depression B. Hypermagnesemia—bradycardia and hypotension C. Hyponatremia—decreased level of consciousness E. Hypomagnesemia—hyperactive deep tendon reflexes F. Hypernatremia—weak peripheral pulses Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) A. Increased pulse rate B. Distended neck veins C. Decreased blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances

A. Increased pulse rate B. Distended neck veins E. Skeletal muscle weakness F. Visual disturbances Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? A. Increased rate and depth of respirations B. Increased urinary output C. Increased thirst and hunger D. Increased release of acids from the kidneys

A. Increased rate and depth of respirations This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are signs and symptoms of hyperglycemia but are not compensatory mechanisms for acid- base imbalances. The kidneys do not release acids.

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) A. Neuropathic pain sometimes accompanies amputation. B. Nociceptive pain originates from abnormal pain processing. C. Deep somatic pain is pain arising from bone and connective tissues. D. Somatic pain originates from skin and subcutaneous tissues. E. Visceral pain is often diffuse and poorly localized.

A. Neuropathic pain sometimes accompanies amputation. C. Deep somatic pain is pain arising from bone and connective tissues. D. Somatic pain originates from skin and subcutaneous tissues. E. Visceral pain is often diffuse and poorly localized. Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address potential complications? (Select all that apply.) A. Perform a depression screen once a day. B. Consult physical therapy for range of motion. C. Increase fiber in the client's diet. D. Decrease fluid intake. E. Allow client to stay in a position of comfort.

A. Perform a depression screen once a day. B. Consult physical therapy for range of motion. C. Increase fiber in the client's diet.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) A. Reports of palpitations B. Slow, shallow respirations C. Orthostatic hypotension D. Paralytic ileus E. Skeletal muscle weakness F. Tall, peaked T waves on ECG

A. Reports of palpitations E. Skeletal muscle weakness F. Tall, peaked T waves on ECG Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

A nurse is planning a community education event-related to impaired cellular regulation. What teaching topics would the nurse include in this event? (Select all that apply.) A. Ways to minimize exposure to sunlight B. Resources available for smoking cessation C. Strategies to remain hydrated during hot weather D. Use of term-44indoor tanning beds instead of sunbathing E. Creative cooking techniques to increase dietary fiber F. How to determine sodium content in food?

A. Ways to minimize exposure to sunlight B. Resources available for smoking cessation E. Creative cooking techniques to increase dietary fiber

A nurse asks the charge nurse to explain the difference between critical thinking and clinical judgment. What statement by the charge nurse is best? A. "Clinical judgment is often clouded by erroneous hypotheses." B. "Clinical judgment is the observable outcome of critical thinking." C. "Critical thinking requires synthesizing interactions within a situation." D. "Critical thinking is the highest level of nursing judgment."

B. "Clinical judgment is the observable outcome of critical thinking."

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? A. "At least you know that the pain after surgery will diminish quickly." B. "Discuss acceptable pain control after your operation with the surgeon." C. "Opioids often cause nausea but you won't have to take them for long." D. "The nursing staff will give you pain medication when you ask them for it."

B. "Discuss acceptable pain control after your operation with the surgeon." The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? A. "All staff nurses are required to participate in quality improvement here." B. "Even being new, you can implement activities designed to improve care." C. "It's easy to identify what indicators would be used to measure quality." D. "You should ask to be assigned to the research and quality committee."

B. "Even being new, you can implement activities designed to improve care."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? A. "I must drink a quart (liter) of water or other liquid each day." B. "I will weigh myself each morning before I eat or drink." C. "I will use a salt substitute when making and eating my meals." D. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

B. "I will weigh myself each morning before I eat or drink." One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

A nurse is confused on why systems thinking is important since working on the unit involves caring for a few specific clients. What explanation by the nurse manager is best? A. "It's a good way to conduct root-cause analysis." B. "It is important for quality improvement and safety." C. "Systems thinking helps you see the bigger picture." D. "You may enter management 1 day and need to know this."

B. "It is important for quality improvement and safety."

A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? A. "I would like you to order a different pain medication." B. "This client has allergies to morphine and codeine." C. "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." D. "This client had a vaginal hysterectomy 2 days ago."

B. "This client has allergies to morphine and codeine."

A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition? A. A 28-year-old client 2 days post-open cholecystectomy B. An 88-year-old client 3 days post-hemorrhagic stroke C. A 32-year-old client with a 20-pack-year history of smoking D. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)

B. An 88-year-old client 3 days post-hemorrhagic stroke

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? A. Client taking furosemide. B. Anxious client who has tachypnea. C. Client who is on fluid restrictions. D. Client who is constipated with abdominal pain.

B. Anxious client who has tachypnea. Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? A. Measure intake and output every 4 hours. B. Assess client further for fall risk. C. Increase the IV flow rate to 250 mL/hr. D. Place the client in a high-Fowler position.

B. Assess client further for fall risk. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

The assistive personnel (AP) reports to the registered nurse that a postoperative client has a pulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate? A. Ask the AP to repeat the client's vital signs in 15 minutes. B. Assess the client for pain. C. Ask the client if something is bothersome. D. Instruct the AP to reposition the client.

B. Assess the client for pain.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? A. Administer high-ceiling (loop) diuretics. B. Assess the client's lung sounds every 2 hours. C. Place a pressure-relieving overlay on the mattress. D. Weigh the client daily at the same time on the same scale.

B. Assess the client's lung sounds every 2 hours. All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first? A. Apply oxygen at 4 L/min. B. Attempt to arouse the client. C. Give naloxone (Narcan). D. Notify the Rapid Response Team.

B. Attempt to arouse the client. The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? A. 25-pack-year smoking history B. Drinking 3 to 5 beers a day C. Previous peptic ulcer D. Taking warfarin

B. Drinking 3 to 5 beers a day The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? A. Desipramine B. Duloxetine C. Morphine sulfate D. Nortriptyline

B. Duloxetine Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, SNRIs are better tolerated than tricyclics, which eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) A. Ask for a physical therapy consult. B. Educate the client on cold therapy. C. Offer to provide a heating pad. D. Repeat the ice application. E. Teach the client relaxation techniques. F. Offer the client headphones with music.

B. Educate the client on cold therapy. D. Repeat the ice application. E. Teach the client relaxation techniques. Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse would focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. Other nonpharmacologic methods to reduce pain include distraction, imagery, and mindfulness. A physical therapy consult will not help relieve acute pain of a fracture. Heat would not be a good choice for this type of injury.

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? A. Attending to holistic client needs B. Ensuring client safety C. Not making medication errors D. Providing client-focused care

B. Ensuring client safety

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? A. Hydrocodone and acetaminophen B. Hydromorphone C. Meperidine D. Tramadol

B. Hydromorphone Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose the combination with acetaminophen because it contains acetaminophen and the client has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and is often restricted.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) A. Hypomagnesemia—kidney failure B. Hyperkalemia—salt substitutes C. Hyponatremia—heart failure D. Hypernatremia—hyperaldosteronism E. Hypocalcemia—diarrhea F. Hypokalemia—loop diuretics

B. Hyperkalemia—salt substitutes C. Hyponatremia—heart failure D. Hypernatremia—hyperaldosteronism E. Hypocalcemia—diarrhea F. Hypokalemia—loop diuretics Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? A. Assess and record vital signs every 4 hours. B. Instruct the client to report any unrelieved pain. C. Monitor for numbness and tingling in the legs. D. Perform frequent neurologic assessments.

B. Instruct the client to report any unrelieved pain. Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours. Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the primary health care provider.

A nurse wishes to participate in an activity that will influence health outcomes. What action by the nurse best meets this objective? A. Creating a transportation system for health care appointments B. Lobbying with a national organization for health care policy C. Organizing a food pantry in an impoverished community D. Running for election to the county public health board

B. Lobbying with a national organization for health care policy

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.) A. Induction B. Modulation C. Sensory perception D. Transduction E. Transmission F. Transition

B. Modulation C. Sensory perception D. Transduction E. Transmission The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) A. Sodium: 160 mEq/L (mmol/L): Overhydration B. Potassium: 5.4 mEq/L (mmol/L): Dehydration C. Osmolarity: 250 mOsm/L: Overhydration D. Hematocrit: 68%: Dehydration E. BUN: 39 mg/dL: Overhydration F. Magnesium: 0.8 mg/dL: Dehydration

B. Potassium: 5.4 mEq/L (mmol/L): Dehydration C. Osmolarity: 250 mOsm/L: Overhydration D. Hematocrit: 68%: Dehydration F. Magnesium: 0.8 mg/dL: Dehydration In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

The nurse caring for a client with malnutrition assesses which laboratory value as the priority? A. Albumin B. Prealbumin C. Prothrombin time D. Serum sodium

B. Prealbumin

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) A. Urine output of 25 mL/hr B. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) C. Urine specific gravity of 1.02 g/mL D. Serum sodium level of 128 mEq/L (128 mmol/L) E. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

B. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) E. Blood osmolality of 250 mOsm/kg (250 mmol/kg) Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? A. Assesses the client's pain level per agency policy. B. Monitors the client's respiratory rate and sedation. C. Presses the button when the client cannot reach it. D. Reinforces client teaching about using the PCA pump.

C Presses the button when the client cannot reach it. The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button, and would not press the button for the client. Pressing the button for the client ("PCA by proxy") indicates the need to review the information about this treatment modality. The other actions are appropriate.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? A. "Have you spouse watch you for irritability and anxiety." B. "Notify the clinic if you notice muscle twitching." C. "Call your primary health care provider for diarrhea." D. "Bake or grill your meat rather than frying it."

C. "Call your primary health care provider for diarrhea." One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

The new nurse asks the preceptor how context affects clinical judgment. What response by the preceptor is best? A. "Context considers the whole of the patient's story and circumstances." B. "It shouldn't, only nursing knowledge would affect clinical judgment." C. "Outside influences such as environment in which you provide care, influence your decisions." D. "The context of the situation provides an extra layer of complexity to consider."

C. "Outside influences such as environment in which you provide care, influence your decisions."

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? A. A 36 year old who is prescribed long-term steroid therapy. B. A 55 year old who recently received intravenous fluids. C. A 76 year old who is cognitively impaired. D. An 83 year old with congestive heart failure.

C. A 76 year old who is cognitively impaired. Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first? A. Client who is crying and agitated B. Client with a heart rate of 104 beats/min C. Client with a Pasero Scale score of 4 D. Client with a verbal pain report of 9

C. Client with a Pasero Scale score of 4 The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse would see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? A. Numeric rating scale B. Verbal Descriptor Scale C. FACES Pain Scale-Revised D. Wong-Baker FACES Pain Scale

C. FACES Pain Scale-Revised All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? A. Ask the hospitals there about standard nurse-client ratios. B. Choose the hospital that has the newest technology. C. Find a hospital that has achieved Magnet status. D. Work in a facility affiliated with a medical or nursing school.

C. Find a hospital that has achieved Magnet status.

A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) A. Ask the client to point out any areas of numbness or tingling. B. Determine how many people are needed to ambulate the client. C. Perform a bladder scan if the client is unable to void after 4 hours. D. Remind the client to use the incentive spirometer every hour. E. Take and record the client's vital signs per agency protocol.

C. Perform a bladder scan if the client is unable to void after 4 hours. D. Remind the client to use the incentive spirometer every hour. E. Take and record the client's vital signs per agency protocol. The AP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and would ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? A. Prepare to administer patiromer by mouth. B. Provide a heart-healthy, low-potassium diet. C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. D. Prepare the client for hemodialysis treatment.

C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.`

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? A. Determining if the AP knew how to take blood pressure B. Double-checking the AP by taking another blood pressure C. Providing more appropriate supervision of the AP D. Taking the blood pressure instead of delegating the task

C. Providing more appropriate supervision of the AP

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? A. Notifies the pharmacy of the IV potassium order. B. Assesses the client's IV site every hour during infusion. C. Sets the IV pump to deliver 30 mEq of potassium an hour. D. Double-checks the IV bag against the order with the precepting nurse.

C. Sets the IV pump to deliver 30 mEq of potassium an hour. IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met? A. Client reports satisfaction with undergarments for incontinence. B. Client reports drinking 8 to 9 glasses of water each day. C. Skin in perineal area is intact without redness on inspection. D. Family states that client is more active and socializes more.

C. Skin in perineal area is intact without redness on inspection.

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) A. Respiratory rate of 8 breaths/min B. Absent deep tendon reflexes C. Strong productive cough D. Active bowel sounds E. U waves present on the electrocardiogram (ECG)

C. Strong productive cough D. Active bowel sounds A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

The registered nurse asks the nursing assistant why a cardiac client's morning weight has not yet been done. The nursing assistant says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers what information about weight? A. Decisions on treatment often depend on the daily weight. B. The nursing assistant needs to ensure that tasks are done on time. C. Weight is the most accurate noninvasive indicator of fluid status. D. A change in weight may indicate the need to change IV fluids.

C. Weight is the most accurate noninvasive indicator of fluid status.

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? A. "Are you worried about addiction to pain pills?" B. "Do you attach any spiritual meaning to pain?" C. "How high would you say your pain tolerance is?" D. "What pain rating would be acceptable to you?"

D. "What pain rating would be acceptable to you?" A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? A. Assesses the client's Chvostek and Trousseau sign. B. Keeps the client's room quiet and dimly lit. C. Moves the client carefully to avoid fracturing bones. D. Administers bisphosphonates as prescribed.

D. Administers bisphosphonates as prescribed. Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

A. nurse assesses a client who is prescribed furosemide for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? A. Client who appears to be sleeping soundly. B. Client with no bolus request in 6 hours. C. Client who is pressing the button every 10 minutes. D. Client with a respiratory rate of 8 breaths/min.

D. Client with a respiratory rate of 8 breaths/min. Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client "sleeping soundly" could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? A. Ask family members to speak quietly to keep the client calm. B. Assess urine color, amount, and specific gravity each day. C. Encourage the client to drink at least 1 L of fluids each shift. D. Dangle the client on the bedside before ambulating.

D. Dangle the client on the bedside before ambulating. An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? A. Slices of smoked ham with potato salad B. Bowl of tomato soup with a grilled cheese sandwich C. Salami and cheese on whole-wheat crackers D. Grilled chicken breast with glazed carrots

D. Grilled chicken breast with glazed carrots Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? A. As-needed pain medication after therapy B. Pain medications prior to therapy only C. Patient-controlled analgesia with a basal rate D. Round-the-clock analgesia with PRN analgesics

D. Round-the-clock analgesia with PRN analgesics Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

A nurse is assessing pain in an older adult. Which action by the nurse is best? A. Ask only "yes-or-no" questions so the client doesn't get too tired. B. Give the client a picture of the pain scale and come back later. C. Question the client about new pain only, not normal pain from aging. D. Sit down, ask one question at a time, and allow the client to answer.

D. Sit down, ask one question at a time, and allow the client to answer. Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, and then leaving, might give the impression that the nurse does not have time for the client. Also, the client may not know how to use it. There is no normal pain from aging.

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider? A. Bilateral lung crackles B. Hypoactive bowel sounds C. Self-reported pain of 3/10 D. Urine output of 20 mL/2 hr

D. Urine output of 20 mL/2 hr Drugs in this category can affect renal function. Clients need to be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse would consult with the primary health care provider (PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the PHCP.