Saunders: Foundation HESI

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1. Oranges 2. Broccoli 3. Margarine 4. Cream cheese 5. Luncheon meats 6. Broiled haddock

3, 4, 5 Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.

Apostoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

1, 2, 3 Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1, 2, 3 Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide.

The nurse is caring for a client with a diagnosis of cancer who is immunocompromised. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 1) 2000 mm3 2) 5800 mm3 3) 8400 mm3 4) 11,500 mm3

1) 2000 mm3 Rationale: The normal WBC count ranges from 5000- 10,000 mm3 (5-10 Â 109 /L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1) 3.2 mEq/L 2) 3.8 mEq/L 3) 4.2 mEq/L 4) 4.8 mEq/L

1) 3.2 mEq/L Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1. Peas 2. Nuts 3. Cheese 4. Cauliflower 5. Processed oat cereals

1, 2, 4 Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

1, 2, 4, 5, 6 Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1, 2, 4, 6 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35 Â 109 /L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 µmol/L) 6. White blood cells, 3000 mm3 (3.0 Â 109 /L)

1, 2, 4, 6 Rationale: The normal values include the following: platelets 150,000-400,000 mm3 (150-400 Â 109 /L); sodium 135- 145 mEq/L (135-145 mmol/L); potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L); segmented neutrophils 60%-70% (0.60- 0.70); serum creatinine 0.6-1.3 mg/dL (53-115 µmol/L); and white blood cells 5000-10,000 mm3 (5.0-10.0 Â 109 /L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1, 2, 5 Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such asseemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1, 5 Rationale: There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

A client develops an anaphylactic reactions after receiving morphine. The nurse should plan to institute which actions? SATA 1. administer oxygen 2. quickly assess the clients respiratory status 3. document the event, interventions and client's response 4. keep the client supine regardless of the blood pressure readings 5. leave the client briefly to contact a primary health care provider 6. start an IV infusion of D5W and administer a 500 mL bolus

1,2,3 Rationale: an anaphylactic section requires immediate actions, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroids 4. A client receiving frequent wound irrigations

1. A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1. Administration of digoxin 2. Administrations of whole blood 3. Administration of intravenous fluids 4. Administration of packed red blood cells

1. Administration of digoxin Rationale: the client in this question is likely experiencing cariogenic shock secondary to heart failure exacerbation. It is important to note that if the shocks state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore restoration of cardiac function is priority for this type of shock. Cardiotonic mediations such as digoxin, dopamine or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. The other options may complicate the client's condition

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on the elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Time: 11:00am. 11:15 am. 11:30 am. 11:45 am Pulse: 92 bpm. 96 bpm. 104 bpm. 118 bpm Resp: 24 breaths. 26 breaths. 28 breaths. 32 breaths per min. per min. per min. per min BP: 140/88 128/82 104/68 88/58 1. Cardiogenic shock 2. cardiac tamponade 3. pulmonary embolism 4. dissecting thoracic aortic aneurysm

1. Cardiogenic shock Rationale: cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a paid pulse that becomes weaker; decreased urine output and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissection aortic aneurysm usually are accompanied by back pain.

The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the HCP can be contacted. 4. Administer the recommended dose until the HCP can be located.

1. Contact the nursing supervisor. Rationale: If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice 3. Bacon, cantaloupe melon, tomato juice 4. Cured pork, grits, strawberries, orange juice

1. Cream of wheat, blueberries, coffee Rationale: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which CHAPTER 11 Nutrition 131 is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1. Malnutrition Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia

The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy (CRRT) without the use of a hemodialysis machine. The nurse determines that which parameters is most important in ensuring success of this treatment? 1. Mean arterial pressure (MAP) 2. Systolic blood pressure (SBP) 3. Diastolic blood pressure (DBP) 4. Central venous pressure (CVP)

1. Mean arterial pressure (MAP) Rationale: CRRT provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours; it is used primarily for clients with AKI or critical ill patients with CKD who cannot tolerate hemodialysis. Water, electrolytes and other solutes are removed as the client's blood passes through a hemofilter. If CRRT does not require a hemodialysis machine, the client's MAP needs to be maintained above 60 mmHg and arterial and venous access sites are necessary.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. Reassess the client. Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss due to broken bones 4. Metabolic alkalosis from taking analgesics containing base products

1. Respiratory acidosis from inadequate ventilation Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST? 1. Slow the IV infusion 2. Sit the client up in bed 3. Remove the IV catheter 4. Call the primary health care provider (PHCP)

1. Slow the IV infusion Rationale: the client's symptoms are compatible with circulatory overload. This may be verified by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP. the IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia

A nurse caring for a client who has been receiving intravenous(IV) diuretics suspects that the client is experiencing fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased heart rate 3. Decreased hematocrit and increased urine output 4. Increased respirations and increased blood pressure

1. Weight loss and poor skin turgor Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1. deficient fluid volume related to acute blood loss 2. risk for aspiration related to acute bleeding in the GI tract 3. risk for infection related to acute disease process and medications 4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism

1. deficient fluid volume related to acute blood loss Rationale: the priority problem for the client with a cute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood loss. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25, PaCO2 50 mmHg 2. pH 7.35, PaCO2 40 mmHg 3. pH 7.50, PaCO2 52 mmHg 4. pH 7.52, PaCO2 28 mmHg

1. pH 7.25, PaCO2 50 mmHg Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the PaCO2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

1. twitching Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1) 3 mg/DL 2) 15 mg/dL 3) 29 mg/dL 4) 35 mg/dL

2) 15 mg/dL Rationale: The normal BUN level is 6 to 20 mg/dL (2.1 to 7.1 mmol/L). Values of 29 mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.

2, 3, 4 Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2, 3, 4, 6 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

2, 4 Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. 1. Document a late entry in the client's record. 2. Draw 1 line through the error, initialing and dating it. 3. Try to erase the error for space to write in the correct data. 4. Use whiteout to delete the error to write in the correct data. 5. Write a concise statement to explain why the correction was needed. 6. Document the correct information and end with the nurse's signature and title

2, 6 Rationale: If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? SELECT ALL THAT APPLY 1. Restrict fluids 2.Assess for airway patency 3.Administer oxygen as prescribed 4.Place a cooling blanket on the client 5.Elevate extremities if no fractures are present 6.Prepare to give oral pain medication as prescribed

2,3,5 Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated tp assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the watered gastrointestinal function that occurs as a result of a burn injury

The nurse is caring for a postoperative client who is receiving a demand-dose hydromorphone via PCA pump for pain control. The nurse enters the clients room and finds the client drowsy and records the following vital signs: temperature 97.2 F orally, pulse 52 BPM, blood pressure 101/58 mmHg, respiratory rate 11 breaths/minute and SpO2 of 93% on 3 L of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings 2. Attempt to arouse the client 3. Contact the HCP immediately 4. Check the administration history on the PCA pump

2. Attempt to arouse the client Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.

which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply 1.Urine output 50 mL/hour 2.Hypoactive bowel sounds 3.Temperature of 102 degrees F 4.Heart rate of 96 beats/minute 5.Mean arterial pressure 65 mmHg 6.Systolic blood pressure 110 mmHg

3,4,5 Rationale: sepsis diagnostic criteria are as follows: fever (temp higher than 100.9 degrees F), hypothermia (core temp lower than (97 degrees F), tachycardia (HR above 90 bpm), tachypnea (RR above 22 breaths/minute), systolic BP less than or equal to 100 mmHg, altered mental status, positive fluid balance, edema, mottling of skin.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. Refuse to float to the ICU based on lack of unit orientation. 2. Clarify with the team leader to make a safe ICU client assignment. 3. Ask the nursing supervisor to review the hospital policy on floating. 4. Submit a written protest to nursing administration, and then call the hospital lawyer.

2. Clarify with the team leader to make a safe ICU client assignment. Rationale: Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 (35) seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. respiratory irregularities may occur.

The nurse is caring for a client with a nasogastric tube that is attached to low suction.The nurse monitors the cline for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

Aclient is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

2. Oranges Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 20 mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 1.3 mEq/L 4. Phosphorus level of 3.0 mEq/L

2. Potassium level of 3.0 mEq/L Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Required nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL (559 umol/L)

2. Required nasogastric suction Rationale: the normal serum potassium level is 3.5-5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suctioning, placing client at risk for hypokalemia.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mm Hg (30 mm Hg), and HCO3 À of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PaCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? 1. Libel 2. Slander 3. Assault 4. Negligence

2. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68. The nurse minimally suspects which stage of shock based on this data? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Rationale: Stage 2 is characterized by cardiac output of less than 4 to 6 L per minute, systolic blood pressure less than 100 mmHg, decreased urinary output, confusion and cerebral perfusion pressure than is less than 70 mmHg

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UPA). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic.

2. Taking an oral temperature for a client with a cough and nasal congestion Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Takinga rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2. Vitamin B12 Rationale: Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. SELECT ALL THAT APPLY 1. Excessive Bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3,4,5,6 Rationale: the bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing.Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube of water in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client retuning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural system

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids

3. A client who requires urine specimen collections Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by UAPs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration

The nurse is caring for a client with heart failure. On assessment the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client of excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as an overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess: cough, dyspnea, crackles, tachypnea, tachycardia, elevated BP, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distension, altered LOC, and decreased hematocrit.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the incident. 4. Call the laboratory and ask for the name of the individual who sent the photograph.

3. Call the nursing supervisor and report the incident. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor. Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Ice pop

3. Custard Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. Aclear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

A client is admitted to a hospital with a diagnosis of diabetic keto acidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mol/L). A continous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 250 mg/dL (13.37 mml/L). The nurse would next prepare to administer which medication? 1. an ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

3. IV fluids containing dextrose Rationale: emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema can occur. During management of DKA, when the blood glucose level falls to 250-300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL or until the client recovers from ketosis.

The nurse is reading a HCPs progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily". The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract

3. Integumentary output Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

3. Iron deficiency anemia Rationale: The normal hemoglobin level for an adult female client is 12-16 g/dL (120-160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1. Apples 2. Bananas 3. Smoked sausage 4. Steamed vegetables

3. Smoked sausage Rationale: Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables, which are low in sodium.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The client was found lying on the floor. Rationale: The incident report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3. Transport the victim to the operating room for surgery. Rationale: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? 1. "Oh, really? I will discuss this situation with your son." 2. "Let's talk about the ways you can manage your time to prevent this from happening." 3. "Do you have any friends who can help you out until you resolve these important issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10" 2. "I know that I should follow up after giving medication to make sure it is effective" 3. "I know that pain in the older client might manifest as sleep disturbances or depression" 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain"

4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain"

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request."

4. "I will call the nursing supervisor to seek assistance regarding your request." Rationale: Instructional directives (living wills) are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by UAP. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14Â109 /L) and a temperature of 38.4 °C

4. A client with a white blood cell count of 14,000 mm3 (14Â109 /L) and a temperature of 38.4 °C Rationale:The nurse should plan to care for the client who hasan elevated white blood cell count and a fever first because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noticing that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote 2. Draw a sample for type and crossmatch and transfuse the client 3. Draw a sample for an activated partial thromboplastin time (aPTT) level 4. Draw a sample of prothrombin time (PT) and international normalized ratio (INR)

4. Draw a sample of prothrombin time (PT) and international normalized ratio (INR) Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determ ine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.

Anursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients

4. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

A client with a 3-day history of nausea and vomiting presents to the ED. The client is hyperventilating and has a respiratory rate of 10 breaths/minute. The ECG monitor displays tachycardia, with a heart rate of 120 beats/ minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PaCO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3 4. An increased pH and an increased HCO3

4. An increased pH and an increased HCO3 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 À to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? 1. Ignore the resistance. 2. Exert coercion on the UAP. 3. Provide a positive reward system for the UAP. 4. Confront the UAP to encourage verbalization of feelings regarding the change.

4. Confront the UAP to encourage verbalization of feelings regarding the change. Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. Administer an antihistamine and begin the transfusion 3. Administer 2 tablets of acetaminophen 4. Delay hanging the blood and notify the primary health care provider (PHCP)

4. Delay hanging the blood and notify the primary health care provider (PHCP) Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further instructions. The PHCP will likely prescribe that the blood be administered regardless of the temperature or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCPs prescription to administer medication to the client.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds (65 seconds). The nurse anticipates which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is Rationale: The normal aPTT varies between 28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42 to 52.5) and 2.5 (70 to 87.5) times normal. This means that the client's value should not be less than 42 seconds or greater than 87.5 seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1. Milk 2. Chicken 3. Broccoli 4. Legumes

4. Legumes Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Legumes are especially rich in this vitamin. Other good food sources include nuts, whole-grain cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid

Anursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables

4. Oranges and dark green leafy vegetables Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000. The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count 2. Report the abnormally high count 3. Place the client on bleeding precautions 4. Place the normal report in the client's medical record

4. Place the normal report in the client's medical record Rationale: A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 Â 109 /L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 Â 109 /L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4. Preventing and recognizing hyperglycemia Rationale: The normal reference range for the glycosylated hemoglobin A1c is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 9% is 212 mg/dL (11.8 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

A client who is found unresponsive gas arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90 mmHg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis the pH is decreased and the PCO2 is elevated. The normal bicarbonate (HCO3 À) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acidbase disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2. Boiled shrimp 3. Instant oatmeal 4. Summer squash

4. Summer squash Rationale: Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium

The nurse is caring for a cline thawing respiratory distress due to an anxiety attack . Recent arterial blood gas values are pH 7.53, PaO2 72 mmHg, HCO3 28. Which conclusion about the client should the nurse make? 1. The client has acidotic blood 2. The cline is probably overreacting 3. The client is fluid volume overloaded 4. The client is probably hyperventilating

4. The client is probably hyperventilating Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. The cline twitch colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

On review of the clients' medical records, the nurse determines which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus

4. The client with kidney disease and a 12-year history of diabetes mellitus Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit

A client in shock develops a central venous pressure of 2mmHg and a mean arterial pressure of 60 mmHg. Which prescribed intervention should the nurse implement first? 1. increase the rate of O2 flow 2.obtain arterial gas results 3. insert an indwelling urinary catheter 4. increase the rate of IV fluids

4. increase the rate of IV fluids Rationale: the MAP and CVP are both low for this patient, indicating a state of shock. Shock is the result of inadequate perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of ARDS? 1. bilateral wheezing 2. inspiratory crackles 3. intercostal retractions 4. increased respiratory rate

4. increased respiratory rate Rationale: The earliest detectable sign of ARDS is an increased respiratory rate, which begins from 1 to 96 hours after the initial insult to the body. This is followed by dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.