1460C - Module 1 & 2

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 Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.

a. Check for kinking of the catheter. Fluid flow through the infusion system requires that pressure on the external side be greater than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no longer functional. Removal of the IV catheter and placement of a new IV catheter should be completed when no other option has resolved the problem.

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

a. Client with pancreatitis who has continuous nasogastric suctioning A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should 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 interdisciplinary team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care

a. Collaborating with an interdisciplinary team b. Implementing evidence-based care d. Routinely using informatics in practice e. Using quality improvement in client care The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused care, using informatics in client care, and using quality improvement in client care.

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 - 26 mEq/L. Which question should the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?

b. "You appear anxious. What is causing your distress?" The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance.

Which statement about family systems theory is inaccurate? a. A family system is part of a larger suprasystem. b. A family as a whole is equal to the sum of the individual members. c. A change in one family member affects all family members. d. The family is able to create a balance between change and stability.

b. A family as a whole is equal to the sum of the individual members. A family as a whole is greater than the sum of its parts. The other statements are characteristics of a system that states that a family is greater than the sum of its parts.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student 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 All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the client's safety.

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

b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client EBP consists of utilizing current evidence, the client's values and preferences, and the nurse's expertise when planning care. It does not include cost-saving measures.

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

b. Place warm compresses on the site. At the first sign of phlebitis, the catheter should be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

The nurse is caring for a patient with a new diagnosis of diabetes type 2. Which of the following statements indicates a negative coping response? a. "I will look up information on the Internet about diabetes." b. "I will join a support group." c. "I will only focus on learning to manage my medication first." d. "I will make changes slowly so I can adapt to each change."

c. "I will only focus on learning to manage my medication first." When the patient puts limits on learning by stating he/she will only learn about medication, he/she is using avoidance strategies to alleviate stress. Using strategies such as information gathering (seeking information about diabetes) is positive. Joining support groups and making changes slowly to adapt is also taking direct action by moving forward.

The nurse is caring for a patient who has B-positive blood. The patient is severely anemic and requires a blood transfusion. Which types of blood can the patient receive? (Select all that apply.) a. AB positive b. AB negative c. B negative d. B positive e. O positive f. O negative

c. B negative d. B positive e. O positive f. O negative The patient with B-positive blood may receive B-negative and B-positive blood as well as O-negative and O-positive blood. The patient does not have A-type antigens in his blood, so he cannot safely receive AB-positive or AB-negative blood.

A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital 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 is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school.

c. Find a hospital that is accredited by The Joint Commission. Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on safety. Nurse-client ratios differ by unit type and change over time. New technology doesn't necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most important.

Health care functions carried out by families to meet their members' needs include: a. Developing family budgets. b. Socializing children. c. Meeting nutritional requirements. d. Teaching family members about birth control.

c. Meeting nutritional requirements Meeting nutritional requirements is a fundamental health promotion behavior. Although creating a family budget may be helpful, it does not indicate that funds will be allotted to meet health needs if money is scarce. Often families cannot afford preventive care and rely on emergency departments for their health care needs. Socialization of children may be important, but it is not directly related to the health care of individuals in a family unit. Birth control may be important, but it is not a basic survival health care function.

A traditional family structure in which male and female partners and their children live as an independent unit is known as a(n): a. Extended family. b. Binuclear family. c. Nuclear family. d. Blended family.

c. Nuclear family. About two thirds of U.S. households meet the definition of a nuclear family. Extended families include additional blood relatives other than the parents. A binuclear family involves two households. A blended family is reconstructed after divorce and involves the merger of two families.

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) for a few days to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert in order to administer the patient's medication? a. Peripherally inserted central catheter b. Midline inside-the-needle catheter c. Central venous catheter d. Over-the-needle catheter

d. Over-the-needle catheter Intermittent doses of IV diuretics are best administered via an over-the-needle angiocatheter that is connected to a saline lock. The other IV catheter options are used when the patient requires a vesicant drug that could cause significant damage to tissues or when the patient requires weeks of IV therapy.

The nurse should be aware that during the childbearing experience an African-American woman is most likely to: a. Seek prenatal care early in her pregnancy. b. Avoid self-treatment of pregnancy-related discomfort. c. Request liver in the postpartum period to prevent anemia. d. Arrive at the hospital in advanced labor.

d. Arrive at the hospital in advanced labor. African-American women often arrive at the hospital in far-advanced labor. These women may view pregnancy as a state of wellness, which is often the reason for delay in seeking prenatal care. African-American women practice many self-treatment options for various discomforts of pregnancy, and they may request liver in the postpartum period, but this is based on a belief that the liver has a high blood content.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

d. Teach the client fall prevention measures. The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

The nurse knows that when patients are experiencing stress, the following change can be seen in their signs and symptoms: (Select all that apply.) a. Increase in heart rate b. Increase in gastric motility c. Pupil dilation d. Decrease in blood pressure e. Increase in respiratory rate

a. Increase in heart rate c. Pupil dilation e. Increase in respiratory rate The physiologic response to stress, whether physical or psychological, is activation of the autonomic nervous system, resulting in an increase in heart rate, blood pressure, and respirations along with pupil dilation and a decrease in gastric motility and blood flow to the skin.

The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse? a. Instruct the patient to always call for assistance before getting out of bed. b. Assist the patient to change into dry clothing after episodes of diaphoresis. c. Teach stress-relieving techniques, including progressive muscle relaxation. d. Measure urine output hourly and notify physician if urine output is less than 30 mL/hr.

a. Instruct the patient to always call for assistance before getting out of bed. The patient with hypercalcemia should always call for assistance before getting out of bed because of the risk of falling as a result of muscle weakness, soft bones, and lethargy. Diaphoresis and decreased urine output are not common symptoms of hypercalcemia. Teaching stress-relieving techniques is not a priority, especially since lethargy and stupor are symptoms of hypercalcemia.

The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication? a. Check for blood return and compatibility prior to administration. b. Use a new IV tubing set each time the medication is administered. c. Document the date, time, and nurse's initials after each dose is administered. d. Use sterile gloves when drawing up and administering the medication.

a. Check for blood return and compatibility prior to administration. Phenytoin (Dilantin) can cause significant irritation to blood vessels and tissues when administered via IV. For this reason, the nurse must ensure that the IV catheter is located correctly in the vein by checking for a blood return prior to administration. Dilantin may not be given with IV fluids that contain dextrose as precipitation and crystallization, so the nurse must also check compatibility with the patient's prescribed IV fluids.

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action? a. Discontinue the IV and start another line in the other arm. b. Aspirate to check for blood return and flush the IV with sterile saline. c. Clean the IV site with chlorhexidine and apply a new sterile dressing. d. Change the IV tubing and administer prescribed pain medication.

a. Discontinue the IV and start another line in the other arm. An IV site that is puffy and painful should be discontinued promptly because the fluid has infiltrated outside the vein and is causing localized irritation. The IV should be restarted in the other arm if possible.

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results? a. Gastroenteritis with severe nausea, vomiting, and diarrhea b. Widespread tissue ischemia caused by cardiogenic shock c. Respiratory failure caused by pneumonia with pleural effusions d. Hyperventilation after a panic attack

a. Gastroenteritis with severe nausea, vomiting, and diarrhea Gastroenteritis with nausea, vomiting, and diarrhea will lead to a metabolic alkalosis resulting from loss of electrolytes and acids through emesis and loose stools. Metabolic alkalosis features the elevated pH of 7.56, elevated HCO3 42 mEq/L and normal PaCO2 of 32 mm Hg. Widespread tissue ischemia would lead to metabolic acidosis with low pH resulting from release of lactic acid from the tissues. Respiratory failure leads to a respiratory acidosis with a low pH and elevated PaCO2 level. Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO3 level.

The nurse knows that certain personality factors have been shown to buffer the impact of stress. These factors are: (Select all that apply.) a. resilience. b. sense of coherence. c. gender. d. hardiness. e. coping style.

a. resilience. b. sense of coherence. d. hardiness. Personality factors such as resilience, hardiness, and sense of coherence can buffer the impact of stress, reducing the negative consequences. Gender is not a personality factor. Coping style refers to a pattern of measures taken to relieve stress but is not a personality factor.

The nurse manager of a busy oncology unit is concerned about compassion fatigue among her nursing staff. Which of the following signs and symptoms would alter her to this problem? (Select all that apply.) a. Nurses become very emotionally upset without an apparent cause. b. Nurses start to avoid caring for certain patients. c. Nurses start to call in sick more often. d. Nurses begin working more overtime. e. Nurses have difficulty showing empathy for patients.

a. Nurses become very emotionally upset without an apparent cause. b. Nurses start to avoid caring for certain patients. c. Nurses start to call in sick more often. e. Nurses have difficulty showing empathy for patients. Compassion fatigue occurs when deeply caring and empathetic nurses become overwhelmed by the constant needs of patients and families. Symptoms include mood swings, avoidance of working with some patients, frequent sick days, irritability, reduced memory, poor concentration, and a decreased ability to show empathy.

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient's collapse? a. Orthostatic hypotension b. Circulatory overload c. Hemolytic reaction d. Catheter embolism

a. Orthostatic hypotension The patient with dehydration is at risk for orthostatic hypotension, or falling of the blood pressure when the patient rises to a standing position. When the blood pressure falls sufficiently, fainting may occur. The patient should be assisted to rise slowly from a supine to a sitting position first before slowly getting to his feet.

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform? a. Perform regular neurologic checks and institute seizure precautions. b. Encourage the patient to eat foods that are high in sodium. c. Administer hypotonic IV solutions as ordered by the physician. d. Assess for signs and symptoms of digoxin (Lanoxin) toxicity.

a. Perform regular neurologic checks and institute seizure precautions. A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia.

The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient? a. Risk for injury related to weakened bones that may easily fracture b. Deficient knowledge related to need for supplemental calcium in diet c. Risk for constipation caused by decreased gastrointestinal motility d. Activity intolerance related to muscle cramping and spasms

a. Risk for injury related to weakened bones that may easily fracture Chronic hypercalcemia can lead to weakened bones as strengthening calcium is removed over time. Pathologic fractures can easily result, so risk for injury is a high priority nursing diagnosis for this patient. The other nursing diagnoses apply but are less important than the safety of the patient.

The nurse manager of the unit is implementing a program to assist the nursing staff in managing compassion fatigue. Which intervention will be the most successful? (Select all that apply.) a. Support group that nurses can participate in that meets on the unit b. Exercise completion to encourage nurse to exercise and log their time c. Organized break times so nurses can get off the unit for breaks and lunches d. Quiet area on the unit where the nurses can go during break e. Promotion of work-life balance

a. Support group that nurses can participate in that meets on the unit b. Exercise completion to encourage nurse to exercise and log their time c. Organized break times so nurses can get off the unit for breaks and lunches d. Quiet area on the unit where the nurses can go during break e. Promotion of work-life balance To care most effectively for others, nurses must first take time to care for themselves. Many of the stress reduction interventions incorporated into patient care plans can be effective in addressing the stressors faced by nurses. Exercise, balanced nutrition, and mindfulness therapy have been shown to help health care professionals in coping with the demands of patient care. Interventions designed specifically to prevent nurse burnout and address compassion fatigue include mentoring programs, quiet areas on a nursing unit for relaxation, availability of pastoral care, the sharing of feelings with trusted colleagues, and promotion of work-life balance.

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored? a. The patient had 1300 mL of light yellow urine in the last 24 hours. b. The patient's lung sounds are clear bilaterally. c. The patient has no jugular venous distention. d. The patient verbalizes need for adequate daily fluid intake.

a. The patient had 1300 mL of light yellow urine in the last 24 hours. The goal that best indicates that the patient's dehydration has been corrected is output of 1300 mL of clear yellow urine in the last 24 hours. Dark concentrated urine is a symptom of dehydration. Jugular venous distention and presence of crackles in the lungs are both indicative of fluid volume overload.

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient? a. The patient has generalized 3+ pitting edema. b. The patient is confused and disoriented. c. The patient's urine is dark and very concentrated. d. The patient lung sounds are very diminished.

a. The patient has generalized 3+ pitting edema. The patient's low albumin level will lead to generalized pitting edema because there isn't enough protein in the blood to keep water within the bloodstream. Lack of oncotic pressure from low serum albumin leads to edema.

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse? a. The patient's lung sounds will remain clear. b. The patient will have urine output of at least 30 mL/hr. c. The patient will verbalize understanding of fluid restrictions. d. The patient's pitting pedal edema will resolve within 72 hours.

a. The patient's lung sounds will remain clear. Oxygenation is the highest priority for the patient with congestive heart failure and fluid volume excess. Keeping the patient's lungs clear is the most important goal for the nurse to consider when caring for this patient.

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH? a. The patient's respirations are very deep and rapid. b. The patient's urine is dark and concentrated. c. The patient's skin is pale, cool, and diaphoretic. d. The patient is sleepy and difficult to arouse.

a. The patient's respirations are very deep and rapid. The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide through deep, rapid respirations. Since carbon dioxide is converted to carbonic acid, removal of carbon dioxide will help shift the body's pH to a less acidotic state.

The nurse knows that the coping strategies that are more frequently seen in older adults are: (Select all that apply.) a. anger. b. withdrawal. c. information gathering. d. avoidance. e. problem focused.

a. anger. b. withdrawal. Cognitive changes may affect an older adult's ability to cope. Anger or withdrawal as coping strategies may be used more frequently than in the past.

The nurse knows that childhood stress related to the school experience centers on: (Select all that apply.) a. goal achievement. b. family dissolution. c. life changes. d. test anxiety. e. competition.

a. goal achievement. d. test anxiety. e. competition. Childhood stress related to the school experience centers on competition, goal achievement, and test anxiety. Family dissolution and life changes are not related to the school experience.

To provide competent care to an Asian-American family, the nurse should include which of the following questions during the assessment interview? a. "Do you prefer hot or cold beverages?" b. "Do you want milk to drink?" c. "Do you want music playing while you are in labor?" d. "Do you have a name selected for the baby?"

a. "Do you prefer hot or cold beverages?" Asian-Americans often prefer warm beverages. Milk usually is excluded from the diet of this population. Asian-American women typically labor in a quiet atmosphere. Delaying naming the child is common for Asian-American families.

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"

a. "Grade 3 phlebitis at IV site" The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.

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 clients' 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 Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect, compassion, client education, and empowerment. By assessing the effect of the client's culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered 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. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off. e. Give raises based on compliance with reporting.

a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off. A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE stands for standardize critical information, hardwire within your system, allow opportunities to ask questions, reinforce quality and measurement, and educate and coach. Attending hand-off report gives the manager opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is hardwiring within the system. Encouraging staff to ask questions and think critically about the information is allowing opportunities to ask questions. The manager may need to tie raises into compliance if the staff is resistive and other measures have failed, but this is not part of the SHARE model.

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 doctor's phone number by the telephone. c. Make sure 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. Medication errors are the most common type of health care mistake. The Joint Commission's Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors.

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 by the nurse is best? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes.

a. Call the Rapid Response Team. The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The client's blood pressure should be reassessed frequently, but the priority is getting the rapid care to the client.

A nurse is interested in making interdisciplinary 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

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 Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to 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. Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

A mother's household consists of her husband, his mother, and another child. She is living in a(n): a. Extended family. b. Single-parent family. c. Married-blended family d. Nuclear family.

a. Extended family. An extended family includes blood relatives living with the nuclear family. Both parents and a grandparent are living in this extended family. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. Married-blended refers to families reconstructed after divorce. A nuclear family is where male and female partners and their children live as an independent unit.

A married couple lives in a single-family house with their newborn son and the husband's daughter from a previous marriage. On the basis of the information given, what family form best describes this family? a. Married-blended family b. Extended family c. Nuclear family d. Same-sex family

a. Married-blended family Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join together to create a new household. Members of an extended family are kin, or family members related by blood, such as grandparents, aunts, and uncles. A nuclear family is a traditional family with male and female partners and the children resulting from that union. A same-sex family is a family with homosexual partners who cohabit with or without children.

The woman's family members are present when the home care maternal-child nurse arrives for a postpartum and newborn visit. What should the nurse do? a. Observe the family members' interactions with the newborn and one another. b. Ask the woman to meet with her and the baby alone. c. Do a brief assessment on all family members present. d. Reschedule the visit for another time so that the mother and infant can be assessed privately.

a. Observe the family members' interactions with the newborn and one another. The nurse should introduce herself to the patient and the other family members present. Family members in the home may be providing care and assistance to the mother and infant. However, this care may not be based on sound health practices. Nurses should take the opportunity to dispel myths while family members are present. The responsibility of the home care maternal-child nurse is to provide care to the new postpartum mother and her infant, not to all family members. The nurse can politely ask about the other people in the home and their relationships with the woman. Unless an indication is given that the woman would prefer privacy, the visit may continue.

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse's best response? a. "You should ask your doctor to decrease the dose." b. "Take the diuretic early in the morning before breakfast." c. "Eat foods high in potassium and limit your salt intake." d. "Restrict your fluid intake after dinner and in the evening."

b. "Take the diuretic early in the morning before breakfast." The patient should be instructed to take the diuretic early in the morning so that the effects will wear off before the patient goes to bed at night. Decreasing the dose could lead to fluid overload and pulmonary edema.

The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin when he is not diabetic. What is the nurse's best answer? a. "The doctor has prescribed these medications for you to help heal your kidneys." b. "These medications will lower your potassium level and prevent an irregular heart rate." c. "These medications will prevent you from having a seizure from too little magnesium." d. "These medications will increase your urine output until your kidneys recover."

b. "These medications will lower your potassium level and prevent an irregular heart rate." Serum potassium levels above 7.0 mEq/L can lead to dangerous cardiac arrhythmias, so the potassium level must be lowered promptly. Administration of IV insulin with 50% dextrose will push potassium into the cells to avoid hyperkalemia symptoms.

The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance? a. "Check to make sure that your urine is a bright yellow color." b. "Weigh yourself every morning before breakfast." c. "Count your heart rate every evening before you go to bed." d. "Drink plain water rather than soda, coffee, or fruit juice."

b. "Weigh yourself every morning before breakfast." Checking the weight every morning before breakfast is a sensitive indicator of the patient's fluid volume status. Weight gain of 2 to 3 lb over 1 to 2 days generally indicates fluid retention and should be reported to the physician.

The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction? a. 100 mL b. 150 mL c. 250 mL d. 300 mL

b. 150 mL The patient has had an oral fluid intake of 900 mL and an IV fluid intake of 150 mL, giving a total of 1050 mL. This leaves 150 mL that the patient may consume for the rest of the evening to stay within the prescribed fluid restriction.

The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information? a. Alternative therapies can include relaxation techniques. b. Alternative therapies are used in conjunction with medical therapies. c. Alternative therapies can be used when patients are experiencing stress. d. Some alternative therapists require certification.

b. Alternative therapies are used in conjunction with medical therapies. Alternative therapies are used in place of medical treatment. These types of interventions are useful when patients are experiencing physiologic and psychological responses to stress. Some complementary and alternative therapies such as therapeutic touch, Reiki, biofeedback, and massage therapy require additional certification and training, whereas muscle relaxation and guided imagery do not.

The nurse is providing discharge instructions for a patient with multiple sclerosis (an autoimmune disease). Which discharge instruction is aimed at preventing a future exacerbation? a. Engage in some form of exercise as tolerated. b. Avoid highly stressful situations. c. Check your skin regularly for pressure sores. d. Eat a diet with lots of fiber.

b. Avoid highly stressful situations. High stress levels are known to exacerbate multiple sclerosis and other autoimmune diseases. Exercise helps keep muscles loose and helps with balance, and assessing skin for pressure sores and eating a diet with high fiber prevents complications from multiple sclerosis.

The nurse knows that when coordination between multiple health care disciplines is needed, the following role is used: a. Pastoral care b. Case manager c. Social worker d. Dietitian

b. Case manager If coordination of care between multiple health care disciplines is needed, a case manager is used. Pastoral care plays a significant role in addressing stress and anxiety issues when the patient has a preferred religion or strong faith background. A social worker identifies appropriate services and resources. A dietician can provide education regarding dietary needs and food choices.

The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank? a. Identify the blood group, type, and expiration date with another nurse. b. Insert an 18- or 20-gauge angiocatheter into the patient's other arm. c. Program the IV infusion pump so that the transfusion will complete within 4 hours. d. Obtain a new microdrip tubing and extension tubing from the clean utility room.

b. Insert an 18- or 20-gauge angiocatheter into the patient's other arm. Blood products such as packed red blood cells and whole blood should be infused through an IV catheter than is no smaller than a 20 gauge. An 18- or 20-gauge IV should be started in the patient's other arm before picking up the packed red blood cells from the blood bank. Identification of the blood group and expiration date will be done once the blood is obtained from the blood bank. Microdrip tubing is never used for blood transfusions.

The nurse knows that the body's response to the release of hormones in the "fight or flight" response is which of the following? (Select all that apply.) a. Decreased respiratory rate b. Slowing of the digestive process c. Glucose being mobilized from the liver d. Pupils dilating e. Smooth muscles in the bronchi constricting

b. Slowing of the digestive process c. Glucose being mobilized from the liver d. Pupils dilating The release of hormones increases the heart rate, resulting in increased cardiac output and elevated blood pressure. There is an increase in the flow of blood to muscles at the expense of the digestive and other systems not immediately needed in the fight-or-flight response. Smooth muscles in the bronchi relax and dilate the bronchi and smaller airways, and the respiratory rate increases, allowing for an enhanced flow of well-oxygenated blood to muscles and other organs. The motility of the digestive tract is decreased, slowing digestive processes, but glucose and fatty acids are mobilized from the liver and other stores to support increased mental activities (alertness) and skeletal muscle function. Pupillary dilation produces a larger visual field.

The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient's plan of care? a. Carefully document all assessments of the catheter site. b. Use strict sterile procedure when performing dressing changes. c. Label each new dressing with the date, time, and nurse's initials. d. Ensure that the CVC is discontinued as soon as possible.

b. Use strict sterile procedure when performing dressing changes. Strict sterile procedure is mandatory when changing CVC dressings because of the high risk of septicemia and/or sepsis.

The nurse is measuring her patient's blood glucose levels after an acute myocardial infarction (MI). She knows the rationale for doing this is: a. damaged muscle tissue releases glucose. b. corticosteroids increase glucose. c. myocardial infarctions are often seen in diabetics. d. all patients should have their blood glucose checked.

b. corticosteroids increase glucose. The endocrine system responds to stress on the body such as what happens during an acute MI. Corticosteroids are important in the stress response because they increase serum glucose levels and inhibit the inflammatory response. Although MIs can be seen in diabetics, there is nothing to indicate this patient is diabetic. All patients do not routinely have their blood glucose checked regularly.

The nurse knows that one theory explaining the variation in response to stress among individuals is called: a. stress appraisal. b. sense of coherence. c. allostasis. d. homeostasis.

b. sense of coherence. Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious assessment of a demand or stressor. Allostasis is an alternative term for the stress response. Homeostasis is the tendency of the body to seek and maintain a condition of balance or equilibrium.

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. 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 should 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." The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. A: "I would like you to order a different pain medication." b. B: "This client has allergies to morphine and codeine." c. R: "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." d. S: "This client had a vaginal hysterectomy 2 days ago."

b. B: "This client has allergies to morphine and codeine." SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call physician might order. Situation describes what is happening right now that must be communicated; the client's surgery 2 days ago would be considered background. Assessment would include an analysis of the client's problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired; this information about the surgeon's preference might be better placed in background.

A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about their 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 their health needs. Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse should never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0 to 10

b. Report of headache and stiff neck Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F are signs of meningitis and should be reported to the provider immediately. The other findings are important but do not require immediate intervention.

The nurse should be aware that the criteria used to make decisions and solve problems within families are based primarily on family: a. Rituals and customs. b. Values and beliefs. c. Boundaries and channels. d. Socialization processes.

b. Values and beliefs. Values and beliefs are the most prevalent factors in the decision-making and problem-solving techniques of families. Although culture may play a part in the decision-making process of a family, ultimately values and beliefs dictate the course of action taken by family members. Boundaries and channels affect the relationship between the family members and the health care team, not the decisions within the family. Socialization processes may help families with interactions with the community, but they are not the criteria used for decision making within the family.

The nurse is educating the patient on the use of relaxing therapy. Which statement by the patient indicates a need for further education? a. "I should relax my muscles from head to toe." b. "I visual the relaxed muscle." c. "I should do this three times a week." d. "I focus on muscles that are tense."

c. "I should do this three times a week." This technique should be done daily. Typically, relaxation progresses from head to toe. With practice, the patient visualizes an image of the relaxed muscles and will be able to relax muscles from the mental image. Progressive relaxation is implemented by having patients focus on muscles that are tensed and then intentionally relax those muscle groups.

The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient's belief system? a. "Do you engage in prayer to help you during times of stress?" b. "Do you go to church or other form of organized worship?" c. "Do you have certain beliefs that are helpful during times of stress?" d. "Do you want spiritual counseling while you are here?"

c. "Do you have certain beliefs that are helpful during times of stress?" The nurse needs to obtain a knowledge base of the patient's culture as well as identify health beliefs and cultural values from the patient's worldview. Asking the patient specific questions about prayer or church or spiritual counseling is inappropriate until the nurse first understands what the patient's own beliefs and practices are.

The nurse is assessing the patient's use of coping skills in response to stressful situations. Which of the following questions is the most useful? a. "Have you been evaluated for stress?" b. "Do you have someone you can go to for help when you are stressed?" c. "How have you managed stressful situations in the past?" d. "Does stress cause you to experience muscle tension or headaches?"

c. "How have you managed stressful situations in the past?" The use of open-ended questions assists in obtaining accurate information regarding the patient's stressors and coping skills. Questions that elicit yes/no answers will not allow the patient to provide as much information. Asking the patient about headaches and tension is asking about physical symptoms, not coping skills.

The nurse is providing education to a patient around anger management strategies. Which statement indicates a need for further education by the patient? a. "Exercise can help me deal with the anger." b. "I can use humor." c. "I can punch things." d. "I can take a time out."

c. "I can punch things." Strategies should focus on non-violent methods. Some anger management interventions include expressing feelings in a calm, non-confrontational manner; exercising; identifying potential solutions; taking a time out; forgiving; diffusing the situation with humor; owning one's feelings; and breathing deeply.

The nurse is seeing a patient during a follow-up visit after discharge in which the patient had a nursing diagnosis of Ineffective coping. Which statement by the patient would be a cause for concern? a. "I am sleeping better most nights." b. "I feel less anxious." c. "I do not need to do the relaxation exercises anymore." d. "I am continuing my exercises every day."

c. "I do not need to do the relaxation exercises anymore." Patients should continue using the stress-reduction techniques to maintain a feeling of well-being. Once stress decreases, patients typically report feeling better, sleeping more soundly, and feeling less anxious. Continuing their positive activities such as exercising is good.

The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress? a. Blood pressure of 120/84 b. Temperature of 37.5° C c. Heart rate of 110 beats/min d. Respiratory rate of 10 breaths/min

c. Heart rate of 110 beats/min The release of hormones increase the heart rate, resulting in increased cardiac output and elevated blood pressure. A reading of 120/84 is a normal blood pressure, and temperature is elevated is indicative of an infection. The respiratory rate increases in stress not decreases.

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur as a result of this therapy? a. Hypocalcemia b. Hypernatremia c. Hypokalemia d. Hyperphosphatemia

c. Hypokalemia Furosemide (Lasix) is a loop diuretic that causes loss of potassium through the urine. Patients taking Lasix are at risk for hypokalemia, so the nurse should check the patient's electrolyte values closely, particularly the serum potassium level.

The nurse is caring for a patient on a medical-surgical inpatient unit. The patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do? a. Notify the health care provider. b. Make a referral to psychiatric services. c. Implement one-on-one observations. d. Document in the electronic medical record.

c. Implement one-on-one observations. Verbalization of suicidal ideation or a suicide plan must be taken seriously. In the case of a hospitalized patient, one-on-one observation should be implemented to ensure patient safety. Once the patient is under observation, the health care provider is notified to put in the referral; nurses generally do not put in the referral. Documentation is always done after the patient's safety is ensured.

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately? a. Serum chloride level 85 mEq/L b. Serum sodium level 134 mEq/L c. Serum potassium level 6.8 mEq/L d. Serum magnesium level 2.3 mEq/L

c. Serum potassium level 6.8 mEq/L Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8 mEq/L is very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be reported to the physician immediately.

The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse? a. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F. b. Recheck the patient's blood pressure in 15 minutes after administering pain medication. c. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. d. Double-check that the transfusion blood type is an exact match to the patient.

c. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.

The nurse knows an appropriate goal for the nursing diagnosis of Ineffective coping would be: a. The patient will report an ability to remember discharge instructions. b. The patient's family will understand how to access respite care services. c. The patient will discuss possible coping strategies during weekly counseling sessions. d. The patient will attend an online support group weekly.

c. The patient will discuss possible coping strategies during weekly counseling sessions. An appropriate goal for Ineffective coping would be to discuss coping strategies. Remembering discharge instructions is an appropriate goal for Anxiety. Understanding how to access respite care services is an appropriate goal for Caregiver role strain, and attending a support group is an appropriate goal for Readiness for enhanced coping.

The nurse knows that an appropriate goal for Readiness for enhanced coping would be: a. The patient will report an ability to focus on discharge instructions. b. The patient will attend a coping skills class on a weekly basis. c. The patient will discuss possible coping strategies during weekly office visits. d. The patient will discuss strategies for coping with relationship violence within 24 hours.

c. The patient will discuss possible coping strategies during weekly office visits. The patient will discuss possible coping strategies during weekly office visits is an appropriate goal for Readiness for enhanced coping. The patient will report an ability to focus on discharge instructions is an appropriate goal for Anxiety. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Strategies for coping with relationship violence within 24 hours (short timeframe) is an appropriate goal for Stress overload.

The nurse knows an appropriate goal for Stress overload is: a. The patient will attend a weekly support group. b. The patient will discuss possible coping strategies during weekly office visits. c. The patient will discuss strategies for coping with relationship violence within 24 hours. d. The patient's family will use respite care once a week for the next month.

c. The patient will discuss strategies for coping with relationship violence within 24 hours. Strategies for coping with relationship violence within 24 hours (short timeframe) is an appropriate goal for Stress overload. Attending a weekly support group is an appropriate goal for Readiness for enhanced coping. An appropriate goal for Ineffective coping would be to discuss possible coping strategies during weekly visits. Using respite care once a week for the next month is an appropriate goal for Caregiver role strain.

The nurse is caring for a patient who is undergoing a major cardiac procedure. The patient tells you her heart is racing and she feels nauseated. You know this is part of hormone response known as: a. sense of coherence. b. stress appraisal. c. fight or flight. d. sympathoadrenal response.

c. fight or flight. In the "fight or flight" response, the corticotropin-releasing hormone (CRH) released by the hypothalamus stimulates the pituitary to release adrenocorticotropic hormone (ACTH). These hormones increase the heart rate, resulting in increased cardiac output, and the motility of the digestive tract is decreased, slowing digestive processes that could result in abdominal distress. Sense of coherence (SOC) is a characteristic of personality that references one's perception of the world as comprehensible, meaningful, and manageable. Stress appraisal is the automatic, often unconscious, assessment of a demand or stressor. The sympathoadrenal response is a consequence of hypothalamic activation in sympathetic stimulation, which triggers epinephrine and norepinephrine release from the adrenal medulla.

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this client's teaching? a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device."

c. "Ask all providers to vigorously clean the connections prior to accessing the device. Clients should be actively engaged in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is 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 UAP knew how to take blood pressure b. Double-checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task

c. Providing more appropriate supervision of the UAP Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right away. An experienced UAP should know how to take vital signs and the nurse should not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the UAP.

Using the family stress theory as an intervention approach for working with families experiencing parenting, the nurse can help the family change internal context factors. These include: a. Biologic and genetic makeup. b. Maturation of family members. c. The family's perception of the event. d. The prevailing cultural beliefs of society.

c. The family's perception of the event. The family stress theory is concerned with the family's reaction to stressful events; internal context factors include elements that a family can control such as psychologic defenses. It is not concerned with biologic and genetic makeup, maturation of family members, or the prevailing cultural beliefs of society.

The nurse's care of a Hispanic family includes teaching about infant care. When developing a plan of care, the nurse bases interventions on the knowledge that in traditional Hispanic families: a. Breastfeeding is encouraged immediately after birth. b. Male infants typically are circumcised. c. The maternal grandmother participates in the care of the mother and her infant. d. Special herbs mixed in water are used to stimulate the passage of meconium.

c. The maternal grandmother participates in the care of the mother and her infant. In Hispanic families, the expectant mother is influenced strongly by her mother or mother-in-law. Breastfeeding often is delayed until the third postpartum day. Hispanic male infants usually are not circumcised. Olive or castor oil may be given to stimulate the passage of meconium.

The nurse is teaching her patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education? a. "Mild anxiety can help me remember things." b. "Moderate anxiety will narrow my focus." c. "Mild anxiety will help me be creative." d. "Moderate anxiety will increase my perception."

d. "Moderate anxiety will increase my perception." Moderate anxiety narrows a person's focus, dulls perception, and may challenge a person to pay attention or use appropriate problem-solving skills. Mild anxiety can be motivational, foster creativity, and actually increase a person's ability to think clearly.

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient's fluid imbalance? a. 0.33% normal saline b. 0.45% normal saline c. 0.9% normal saline d. 3% normal saline

d. 3% normal saline A hypertonic 3% saline solution will be used to correct the patient's hyponatremia and fluid overload that have developed as a result of SIADH. A 0.9% normal saline solution can be used once the serum sodium level has been raised nearer to normal range. A 0.45% or 0.33% normal saline solution is hypotonic and will only worsen the patient's fluid overload and hyponatremia.

The nurse is caring for a patient who has a serum magnesium level of 0.8 mEq/L. Which is the highest priority goal to include in the patient's plan of care? a. The patient will maintain urine output of at least 30 mL/hr. b. The patient will verbalize the importance of sufficient dietary intake of magnesium. c. The patient's oral mucous membranes will remain free of ulceration and pain. d. The patient will remain alert and oriented x3 with no confusion or seizure activity.

d. The patient will remain alert and oriented x3 with no confusion or seizure activity. A patient with low serum magnesium is at risk for neurologic symptoms including confusion, disorientation, and seizures. The highest priority goal for this patient is to avoid neurologic problems that could lead to injury. The other goals are applicable to the patient with low magnesium but are less important.

The nurse is caring for a patient who was brought to the ER after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see? a. pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg b. pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg c. pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg d. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg

d. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg The patient who overdosed on narcotic pain medication will be in respiratory acidosis as a result of respiratory suppression. Low pH of 7.27 and elevated PaCO2 are consistent with respiratory acidosis as insufficient carbon dioxide is removed from the blood. The low 60 mm Hg PaO2 is due to insufficient oxygen intake.

A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."

d. "Use a plastic bag to cover the extremity with the device." The nurse should ask the UAP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower with a vascular device. The nurse should disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the UAP.

While working in the prenatal clinic, you care for a very diverse group of patients. When planning interventions for these families, you realize that acceptance of the interventions will be most influenced by: a. Educational achievement. b. Income level. c. Subcultural group d. Individual beliefs.

d. Individual beliefs. The patient's beliefs are ultimately the key to acceptance of health care interventions. However, these beliefs may be influenced by factors such as educational level, income level, and ethnic background. Educational achievement, income level, and subcultural group all are important factors. However, the nurse must understand that a woman's concerns from her own point of view will have the most influence on her compliance.

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

d. Place a washcloth between the skin and tourniquet. To protect the client's skin, the nurse should place a washcloth or the client's gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the client's skin.

In what form do families tend to be most socially vulnerable? a. Married-blended family b. Extended family c. Nuclear family d. Single-parent family

d. Single-parent family The single-parent family tends to be vulnerable economically and socially, creating an unstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most socially vulnerable.

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

d. Stop the infusion of intravenous fluids. Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch

d. The client's left lower extremity is cool to the touch. Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess this perfusion problem.

The patient's family is important to the maternity nurse because: a. They pay the bills. b. The nurse will know which family member to avoid. c. The nurse will know which mothers will really care for their children. d. The family culture and structure will influence nursing care decisions.

d. The family culture and structure will influence nursing care decisions. Family structure and culture influence the health decisions of mothers.

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

d. Upper extremity swelling is noted. Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV should have one, but this does not take priority over the client whose arm is swollen.

A patient complains of insomnia while in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective Coping related to hospitalization c. Denial related to hospitalization d. High Risk for Insomnia related to hospitalization

A Anxiety related to hospitalization The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient's data do not support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.

A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. "What kinds of things do you do to reduce or cope with your stress?" b. "Tell me about your family history—do any relatives have problems with stress?" c. "Tell me about exercise—how far do you typically run when you go jogging?" d. "Stress can interfere with sleep. How much did you sleep last night?"

a. "What kinds of things do you do to reduce or cope with your stress?" The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home.

a. Ask if there is another family member who can help at home while the patient is in the hospital. The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

The nurse knows that which of the following medical conditions are most commonly associated with anxiety? Select all that apply: a. Cancer b. Chronic obstructive pulmonary disease c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism

a. Cancer b. Chronic obstructive pulmonary disease d. Dysrhythmias e. Encephalitis f. Hyperthyroidism A, B, D, E, and F are all associated with anxiety. Hypothyroidism is not associated with anxiety.

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.) a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes d. Age and height e. Temperature

a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age, height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be affected.

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is which of the following? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

a. Identifying the cause of fear Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau's sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

a. Test for skin tenting. b. Measure rate and character of pulse. f. Observe for flatness of neck veins when supine. ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

The nurse is making a home visit to a child who has a chronic disease. Which finding has the greatest implication for acid-base aspects of this patient's care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

a. Urine output is very small today. Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

When planning to evaluate a patient's satisfaction with a teaching activity, the most appropriate strategy would be to a. include a survey instrument. b. observe for level of skill mastery. c. present information more than one time. d. provide for a return demonstration.

a. include a survey instrument. A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience. Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.

a. put himself first. In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

Mr. Giuseppe is a 60-year-old Italian immigrant who presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is "If it ain't broke, don't try to fix it." Understanding that respect for traditions and fulfilling obligations is important in developing a nursing plan of care. Mr. Giuseppe's cultural orientation is towards a. short term. b. long term. c. leisurely term. d. noncommittal.

a. short term. Short-term cultural orientation is towards the present or past and emphasizes quick results. Long-term cultural orientation is towards the future and long-term rewards. Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to a. switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. alter the internal state by modifying electronic signals related to physiologic processes. c. replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. reduce catecholamine production and promote the production of additional beta-endorphins.

a. switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

a. "Avoid carrying your grandchild with the arm that has the central catheter." A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 - 19 mEq/L. Which assessment should 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. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W 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 (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

a. A 34-year-old on NPO status who is receiving intravenous D5W Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes e. A 76-year-old who is prescribed antacids Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide-based or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 - 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

a. Apply oxygen by mask or nasal cannula. The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the client's nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the client's arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 - 16 mEq/L. What action should the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.

a. Assess client's rate, rhythm, and depth of respiration. Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 - 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

a. Assess the airway. All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

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. Which action should 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 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 should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg ACE inhibitors will disrupt the renin-angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client's blood pressure.

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should 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 should assess the client's respiratory status first to ensure respirations are sufficient. The respiratory assessment should 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.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

a. Electrocardiogram changes d. Paralytic ileus e. Skeletal muscle weakness Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia - Flaccid paralysis with respiratory depression b. Hyperphosphatemia - Paresthesia with sensations of tingling and numbness c. Hyponatremia - Decreased level of consciousness d. Hypercalcemia - Positive Trousseau's and Chvostek's signs e. Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension

a. Hypokalemia - Flaccid paralysis with respiratory depression c. Hyponatremia - Decreased level of consciousness Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseau's and Chvostek's signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should 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

a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

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. Which manifestation should the nurse identify as an example of the client's compensation mechanism? 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 manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.

A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases pH = 7.28 PaO2 = 85 mm Hg PaCO2 = 55 mm Hg HCO3 - = 26 mEq/L Vital Signs: Pulse rate = 96 beats/min Blood pressure = 135/45 Respiratory rate = 6 breaths/min O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowler's position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

a. Notify the Rapid Response Team and provide ventilation support. The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client's respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the client's hypoxic drive, nor would it address the client's most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvostek's sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability

a. Positive Chvostek's sign e. Anxiety and irritability A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 - 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau's sign

a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseau's sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

A nurse is planning interventions that regulate acid-base balance to ensure the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs

a. Reduction in the function of hormones b. Fluid and electrolyte imbalances e. Increase in the effectiveness of many drugs Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing the effectiveness of many drugs.

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child? b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."

b. "How do you feel about what is going on right now?" Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. "Baking soda is an effective inexpensive antacid." b. "I shall take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions." e. "Fasting is a great way to lose weight rapidly."

b. "I shall take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions." Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. "To prevent another problem, I should eat less sodium during diarrhea." b. "My blood became too acid because I lost some base in the diarrhea fluid." c. "Diarrhea removes fluid from the body, so I should drink more ice water." d. "I should try to slow my breathing so my acids and bases will be balanced."

b. "My blood became too acid because I lost some base in the diarrhea fluid." Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should 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 (Calcimar).

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 diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate? a. "It is probably just coincidental that your blood sugar is high when you are ill." b. "Stressors such as illness cause the release of hormones that increase blood sugar." c. "Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times." d. "Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level."

b. "Stressors such as illness cause the release of hormones that increase blood sugar." The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

b. Discuss how divorce support groups could increase coping and social support. High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships are known to affect a person's coping effectiveness negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases

b. Level of consciousness Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek's sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer

b. Positive Chvostek's sign in patient with acute pancreatitis Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.

A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

b. The medication may take up to 12 weeks to become effective. Efficacy may take at least 8 to 12 weeks. The other options are not realistic.

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet

b. Tingling of fingertips d. Numbness around mouth e. Cramping in feet Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland

b. Tumor that secretes excessive antidiuretic hormone (ADH) ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

The home health nurse has an acute immunodeficiency syndrome (AIDS) patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau's sign e. Flat neck veins when upright f. Decreased patellar reflexes

b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau's sign Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

Strategies to include in a teaching plan for an adult who has repeatedly not followed the written discharge instructions would include a. individualized handout. b. instructional videos. c. Internet resources. d. self-help books.

b. instructional videos. An instructional video would provide a visual/auditory approach for discharge instructions. Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making.

b. prompt further to elicit additional questions or concerns. When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."

b. "I will eat three well-balanced meals and a snack daily." Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates the client correctly understood the teaching? a. "I must drink a quart 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 PM 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 daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

A nurse is planning care for a client who is anxious and irritable. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 - 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been experiencing any vomiting?" e. "Are you experiencing any shortness of breath?"

b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" This client's symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a client's personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 - 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

b. Anxiety-induced hyperventilation The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) 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 fluid loss.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler's position

b. Apply oxygen by mask or nasal cannula. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler's position will not address the client's problem.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 - 22 mEq/L. Which clinical situation should the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

b. Bronchial obstruction related to aspiration of a hot dog Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line.

b. Ensure an x-ray is completed to confirm placement. A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek's sign

b. Kussmaul respirations The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis - Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis - Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease

b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Re-position the client into the Trendelenburg position.

b. Prepare to assist with chest tube insertion. An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

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

b. Serum potassium level of 5.4 mEq/L e. Blood osmolality of 250 mOsm/L 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 nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 - 16 mEq/L. Which provider order should the nurse expect to receive? a. Furosemide (Lasix) 40 mg intravenous push b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation d. Indwelling urinary catheter

b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W This client's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate should be replaced to help restore this client's acid-base balance. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client's pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this client.

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this client's care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

c. Have training sessions to help the staff understand their new responsibilities. Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

c. Identifying a confidant to share feelings Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

c. Increased risk for suicide Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

c. Oliguric renal disease When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

c. Slow and deepen breathing via use of a positive, repeated word. The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58

c. Urine output 8 mL/hr Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.

The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable spasms, trembling, and shouting. It is important to identify manifestation of illness in order to effectively treat a patient. The nurse identifies this as a culture-bound syndrome called a. shenjing sharo. b. loco de la cabeza. c. ataque de nervios. d. neuroasthenia.

c. ataque de nervios. Ataque de nervios is a Latin-Caribbean culture-bound syndrome that usually occurs in response to a specific stressor and is characterized by dissociation or trance-like states, crying, uncontrollable spasms, trembling, or shouting. Shenjeng sharo refers to "weakness of nerves" in Chinese culture; it is caused by a decrease in vital energy that reduces the function of the internal organ systems and lowers resistance to disease. Loco de la cabeza is a Spanish phrase meaning crazy in the mind and not necessarily manifested by physical symptoms. Neuroasthenia is an Asian term characterized by extreme fatigue after mental effort and bodily weakness of persistent duration.

Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.

c. fixed gender roles. In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

Barriers to patient education the nurse considers in implementing a teaching plan include a. family resources. b. high school education. c. hunger and pain. d. need perceived by patient.

c. hunger and pain. A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient's educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements. c. increasing global diversity. d. litigious society.

c. increasing global diversity. Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

The most appropriate resources to include when planning to provide patient education related to a goal in the psychomotor domain would be a. diagnosis-related support groups. b. Internet resources. c. manikin practice sessions. d. self-directed learning modules.

c. manikin practice sessions. A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3- high b. pH low, PaCO2 low, HCO3- low c. pH low, PaCO2 high, HCO3- high d. pH low, PaCO2 high, HCO3- normal

c. pH low, PaCO2 high, HCO3- high Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3-. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond? a. "Potatoes and avocados can be substituted for fruit." b. "If you cook the fruit, the amount of potassium will be lower." c. "Berries, cherries, apples, and peaches are low in potassium." d. "You are correct. Fruit is very high in potassium."

c. "Berries, cherries, apples, and peaches are low in potassium." Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

c. "I take sodium bicarbonate after every meal to prevent heartburn." Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching? a. "Weigh yourself every morning and every night." b. "Check your radial pulse twice a day." c. "Read food labels to determine sodium content." d. "Bake or grill the meat rather than frying it."

c. "Read food labels to determine sodium content." Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

A nurse teaches clients at a community center about risks for 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 receiving hypertonic 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.

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g 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 high serum potassium level and cardiac changes should 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 should be administered with dextrose to prevent hypoglycemia. Kayexalate 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 prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

After administering 40 mEq of potassium chloride, a nurse evaluates the client's response. Which manifestations 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 treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. "Is there a place that I can dispose of my unused morphine pills?" b. "I want to lose at least 20 pounds without getting sick this time." c. "I think I have asthma because I cough when dogs are near." d. "I ran out of money and am cutting my insulin dose in half."

d. "I ran out of money and am cutting my insulin dose in half." Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response? a. "Why not start by learning to meditate? That technique will cover everything." b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety." c. "Reading about stress and how to manage it might be a good place to start." d. "Let's talk about what is going on in your life and then look at possible options."

d. "Let's talk about what is going on in your life and then look at possible options." In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. "This tool will let us compare your stress to other patients in the hospital." b. "This tool is short because it only measures the negative stressors you are experiencing." c. "You will need to ask your parents about stressors you had as a child to complete this tool." d. "This tool will help assess recent positive and negative events you are experiencing."

d. "This tool will help assess recent positive and negative events you are experiencing." Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill

d. Cultural desire, self-awareness, cultural knowledge, and cultural skill The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness

d. Decreased level of consciousness Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

d. Institute fall precautions due to potential postural hypotension and weak leg muscles. Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management.

d. Plan to reinforce and repeat teaching about diabetes management. Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.

A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery d. Relaxation breathing

d. Relaxation breathing Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

d. The patient has recently lost her spouse and needed to move in with her daughter. The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due to working, but this should not directly affect the patient.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. addresses group needs. b. follows formalized plans. c. has standardized content. d. often occurs one-to-one.

d. often occurs one-to-one. Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

The nurse educator would identify a need for further teaching when the student lists the types of learning as a. affective. b. cognitive. c. psychomotor. d. self-directed.

d. self-directed. Self-directed is one approach to learning but is not considered a type or domain of learning. Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include a. adherence. b. developmental level. c. motivation. d. technology.

d. technology. The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should 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 liter 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 should 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 liter 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.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

d. Decreased orthostatic light-headedness and dizziness The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates 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 should 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 often high in sodium.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should 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 diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse

d. Presence of an ulnar pulse An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.