4510 Exam 2

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Ask the client to extend the arms. Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be monitored?

Bone marrow biopsy Bone marrow aspiration or biopsy allows examination of blast cells and other hypercellular activity. Blood studies will not provide a definitive diagnosis of leukemia.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak because the bubbling should be intermittent. Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a primary health care provider's prescription.

The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process?

Diffusion Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?

Encourage the child's parents to stay with the child. Although the preschooler already may be spending some time away from parents at a day-care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH?

Fall CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

The nurse tells a client with leukemia who is receiving chemotherapy that allopurinol has been added to the medication list. When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent which problem?

Hyperuricemia Chemotherapy destroys cells, leading to the release of uric acid into the bloodstream. The client is then at risk of experiencing uric acid nephropathy, renal stones, and acute kidney injury. Allopurinol, an antigout medication, is used with chemotherapy to prevent or treat this complication of therapy. It also may be used in mouthwash following fluorouracil therapy to prevent stomatitis. Allopurinol is not used to treat nausea, diarrhea, or muscle spasms.

The nurse is monitoring a client with chronic lymphocytic leukemia (CLL). Which sign should the nurse specifically monitor for and report to the primary health care provider?

Lymphadenopathy CLL causes a slow increase in immature B cells. These cells infiltrate the bone marrow, lymph nodes, spleen, and liver. CLL eventually causes bone marrow failure; therefore, the client will have enlarged and swollen lymph nodes. Options 1 and 2 are clinical manifestations of acute leukemias. Option 3 is a clinical manifestation of hairy cell leukemia.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate?

Monitor for fluid and electrolyte imbalance. If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

The patient with advanced cirrhosis has: massive ascites, peripheral-dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. Which indicator is the most reliable for tracking overall fluid retention?

Performing daily weights with the same amount of clothing All of these measures should be performed for total care of the patient; however, weighing the patient every day is considered the single best indicator of fluid volume

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?" When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, along with hyperkalemia, a rapid irregular pulse, and dysrhythmias.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse?

"Enteral feedings maintain gut integrity and help prevent stress ulcers" Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective:The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma? Select all that apply.

"For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad," "I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt," "My weight has gone down a lot in the past month. I have no changes my diet or exercise regimen, but it has been nice," "Recently, my skin has been very itchy. I have had allergies in the past but this feels different," "Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets" Lymphoma is a form of cancer that begins in the body's lymphatic system (eg, lymph nodes, spleen) and is characterized by abnormal growth of lymphocytes. It is usually classified within two major subtypes, Hodgkin lymphoma and non-Hodgkin lymphoma (NHL), and is further identified by numerous subcategories. To be diagnosed with Hodgkin lymphoma, malignant Reed-Sternberg cells must be found in the lymphatic tissue. Furthermore, Hodgkin lymphoma tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node, often in the neck, underarm, or groin (Option 2). Clients may also present with or develop fever; significant, unexplainable, and/or unintentional weight loss (>10% of body weight); and/or drenching night sweats (ie, "B symptoms"); which typically associate with a poor prognosis (Options 1, 3, and 5). Additional indications are nonspecific (eg, itching, fatigue), although some clients are asymptomatic at the time of diagnosis (Option 4). It is critical that nurses are alert to potential symptoms of lymphoma because early identification and treatment improve the client's chance for complete remission. Educational objective:Lymphoma is a form of cancer beginning in the body's lymphatic tissues. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node. Additional manifestations include fever; significant, unintentional weight loss; night sweats; itching; and fatigue.

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

"I ate shellfish about 2 weeks ago at a local restaurant." Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?

"I can go back to work right away." To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective?

"I should avoid straining while having a bowel movement" Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications (eg, ascites, varices, encephalopathy) that will progressively intensify without lifestyle modifications. (Option 1) Alcoholism is one of the leading causes of cirrhosis. All clients with alcoholism should abstain from drinking to prevent further liver damage. (Option 2) Aspirin and ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) may cause gastrointestinal bleeding. Clients with esophageal varices or portal hypertension have an increased risk of bleeding and should avoid these medications. They should contact the health care provider regarding any pain or fever. (Option 4) Although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed. Educational objective:Clients with cirrhosis should eat a high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein intake is recommended. They should avoid hepatotoxic substances (eg, alcohol, acetaminophen) and medications (NSAIDs) that increase bleeding risk and reduce activities that increase intraabdominal pressure.

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? Select all that apply.

"I will use extra measures to protect my skin from sun exposure," "I will wash the treatment site with lukewarm water and mild soap," "I will wear soft, loose-fitting clothing" Clients receiving teletherapy (external beam radiation therapy) often experience significant effects to the skin of the treatment area. Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin. Key measures of skin care that clients receiving teletherapy should take include: Protect the skin from infection by not rubbing, scratching, or scrubbing (Option 2)Wear soft, loose-fitting clothingUse soft, cotton bed sheets and towelsPat skin dry after bathingAvoid applying bandages or tape to the treatment area Cleanse the skin daily by taking a lukewarm showerUse mild soap without fragrance or deodorantDo not wash off any radiation ink markings Use only creams or lotions approved by the health care provider (HCP)Avoid over-the-counter creams, oils, ointments, or powders unless specifically recommended by the HCP as they can worsen any irritation Shield the skin from the effects of the sun during and after treatmentAvoid tanning beds and sunbathingWear a broad-brimmed hat, long sleeves, and long pants when outsideUse a sunscreen that is SPF 30 or higher Avoid extremes in skin temperatureAvoid heating pads and ice packs (Option 1)Maintain a cool, humid environment for comfort Educational objective:The client receiving teletherapy is taught measures to implement to protect the skin from infection and promote healing. Recommended skin care measures include taking a lukewarm shower daily, avoiding rubbing or scratching the skin, using only approved lotions, shielding the skin from the effects of the sun, and avoiding extremes in temperature.

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

"I'm going to take aspirin for my headache as soon as I get home." Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response?

"I'm not sure that I understand. Would you please explain?" Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the primary health care provider for further information is a block to communication.

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

"If a transfusion reaction occurs, it will be important to collect a fresh urine sample to check for hemolyzed RBCs" The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4). (Options 1 and 2) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective: An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

"It will enter the right main bronchus if inserted too far." If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

"The flowers from your garden are beautiful, but should not be placed in the child's room at this time. Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The leukemic cells crowd out the health bone marrow stem cells causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). For a hospitalized neutropenic child, flowers or plants should not be kept in the room, because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which the child is susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count increases.

The RN is teaching an assistive personnel (AP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the AP about patients with darker skin?

"Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." Teach the AP that compared with light-skinned adults, adults with darker skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status. None of the other responses are correct.

The nurse is caring for a client diagnosed with cirrhosis of the liver with portal hypertension. The client vomited 500 mL bright red emesis and states that he is feeling lightheaded. In which priority order should the nurse perform these interventions? Arrange the actions in the order they should be performed. All options must be used.

1) Apply oxygen, 2) Ensure that 2 large-bore intravenous lines are present with an isotonic solution infusing 3) Check the client's blood pressure, 4) Ask the client if he is taking any nonsteroidal anti-inflammatory medications. The client has an upper gastrointestinal (GI) bleed. Upper GI bleeding is an emergency because it can lead to hypovolemic shock. The first intervention of those listed should be to apply oxygen in an attempt to maximize the amount of oxygen being delivered by the decreased number of red blood cells due to the bleeding. The next action should be to ensure that 2 large-bore intravenous (IV) lines are present and begin replacement of the intravascular fluid volume with an isotonic IV fluid. The nurse should then check the blood pressure. These are all actions to stabilize and assess the client's current condition. The last intervention is to ask the client about nonsteroidal anti-inflammatory medications. Although it is important to identify the cause of the bleeding and obtain a complete history of events leading up to the bleeding episode, this needs to be deferred until emergency care is initiated.

A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used.

1) Place client in high Fowler's position 2) Perform oropharyngeal suctioning 3) Administer 100% oxygen by nonrebreather mask 4) Assess lung sounds 5) Notify the health care provider (HCP) Alzheimer disease is a neurological condition that increases the risk for aspiration and aspiration pneumonia, a common cause of death in clients with swallowing dysfunction. The nurse activates a rapid response because the client is in acute respiratory distress. While waiting for the team, the nurse should implement the following actions in order: Place in high Fowler's position - quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease risk of further aspiration Perform oropharyngeal suctioning - the priority is clearing the airway after the client has been placed in a position that prevents further aspiration Administer 100% oxygen by nonrebreather mask - corrects hypoxemia/hypoxia once the airway has been cleared to allow passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness). Assess lung sounds - determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in place (eg, oxygen) and the client has been stabilized. Notify the primary HCP - to report the situation and assessment data To provide more efficient care, any of these tasks can be delegated to a second RN. Educational objective:While waiting for the rapid response team to respond to an adult client with acute respiratory distress, the nurse implements the following actions: positioning; suctioning to clear the airway, administering high-concentration oxygen; assessing lung sounds; and notifying the HCP.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.

1) Verify the primary health care provider's (PHCP's) prescription for the blood transfusion, 2) Ensure that an informed consent has been signed, 3) Insert an 18- or 19-gauge intravenous catheter into the client, 4) Obtain the unit of blood from the blood bank, 5) Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity, 6) Hang the bag of blood. The nurse would first verify the PHCP's prescription for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions, and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, 2 registered nurses or 1 registered nurse and 1 licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion.

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L) Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 mm3 (150 to 400 × 109/L). When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L).

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority?

Cover the wound with petroleum gauze taped on three sides In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space. (Option 1) This client's tachycardia and hypotension are likely related to pneumothorax and should improve once the pneumothorax is resolved; administering fluids alone would not help if the pneumothorax continues to worsen. Fluids are given to treat blood loss hypotension, but this should not be the first step in this case. (Option 2) Supplemental oxygen should be applied as needed after covering the wound. If possible, correcting the underlying cause is always a priority over treating manifestations. (Option 3) After covering the wound, chest tube placement is usually performed to evacuate air and blood from the pleural cavity. The client may need more than one chest tube to evacuate both air (placed higher) and fluid or blood (placed lower). Educational objective:A sucking chest wound indicates a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as heart failure (lung crackles) is an adverse effect of daunorubicin. Bone marrow depression is also an adverse effect. Fever is a frequent side effect, and sores in the mouth and throat can occur occasionally. Nausea and vomiting is a frequent side effect associated with the medication that begins a few hours after administration and lasts 24 to 48 hours. Options 1, 2, and 3 are not adverse effects.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority?

Cut the tube with scissors A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2). (Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider. (Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced. (Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube. Educational objective:A balloon tamponade tube is used to compress bleeding esophageal varices. Tube displacement may result in airway obstruction. The nurse should keep scissors at the bedside so that the tube can be emergently cut and removed if respiratory distress develops due to tube displacement.

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F (38.1° C) orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care provider (PHCP). If the client has a temperature higher than 100° F (37.8° C), the unit of blood should not be hung until the primary PHCP is notified and has the opportunity to give further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCP's prescription to administer medications to the client.

Oral rifaximin has been prescribed for a client with portosystemic encephalopathy. The nurse reviews the primary health care provider's prescription and determines that this medication has been prescribed for which purpose?

Destroy normal bacteria found in the bowel. Rifaximin may be prescribed for the client with portosystemic encephalopathy. It is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. The remaining options are not accurate rationales for administration of this medication to this client.

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply.

Do you use intravenous (IV) illicit drugs? How much alcohol do you typically drink? What over-the-counter drugs do you take? ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high. Educational objective:ALT/AST are enzymes indicating liver injury. Besides the obvious viral hepatitis, it can result from excess chronic alcohol intake or some over-the-counter drugs, including acetaminophen.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

Dyspnea In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply.

Dyspnea, Pallor, Tachycardia A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin. (Option 1) Coarse crackles occur with fluid overload but not with anemia. (Option 4) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation. Educational objective:Cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of anemia.

The nurse is monitoring a client with leukemia who is receiving doxorubicin by intravenous infusion. The nurse should monitor for which finding that would indicate doxorubicin toxicity?

Electrocardiogram (ECG) changes Cardiotoxicity can occur with the use of doxorubicin. The medication can produce irreversible toxicity to the heart, including ECG changes and heart failure. Elevated values on renal function tests are not associated with the use of this medication. A red coloration of the urine may occur with the use of this medication, but this effect is harmless.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply.

Elevate the legs and feet when sitting, Increase fluid intake during exercise and hot weather, Report swelling or tenderness in the legs Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity (Options 1, 3, and 5). (Option 2) Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood. (Option 4) Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial. Educational objective:Clients with polycythemia vera are at risk of developing thrombosis and should be taught preventive measures (eg, elevating the legs when sitting) and symptoms to report. They should take measures to prevent dehydration, and avoid iron-rich foods and hot showers/baths.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply.

Elevated bilirubin levels, Jaundice, Clay-colored stools, Dark or tea-colored urine There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and claycolored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider?

Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 L to 2L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. The other options may be components of the plan of care but are not the priority in this client.

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

Enlarged lymph nodes Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

Enlarged lymph nodes Hodgkin's disease is a chronic progressive neoplastic disorder of the lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time?

Excessive body fluid volume The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis?

Fatigue Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas-small, dilated blood vessels-are commonly seen in cirrhosis of the liver.

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase?

Fatigue, anorexia, and nausea In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply.

Fever, Weight loss, Night sweats, Enlarged, painless lymph nodes Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms?

Hematocrit 21% (0.21) Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option 1) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option 3) The leukocyte count is decreased (normal, 4,000-11,000/mm3 [4.0-11.0 x 109/L]). Leukocytes play a role in protecting the body from disease. (Option 4) The platelet count is decreased (normal, 150,000-400,000/mm3 [150-400 x 109/L]). Platelets play a role in blood clotting. Educational objective: Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess?

Hepatitis B surface antigen (HBsAg) HBsAg is present in chronic carriers. Hepatitis B virus DNA indicates viral replication. A prolonged prothrombin time is caused by decreased absorption of vitamin K in the intestine with decreased production of prothrombin by the liver. Anti-HBs is a marker for the response to the vaccine and indicates immunity to hepatitis B.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication?

Hold if 3 soft stools occur in a day Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective:Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. Therapeutic effects are evident via laboratory results and improving mental status.

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)?

Impaired gas exchange ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option 1) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 3) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 4) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. Educational objective:ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority?

Impaired gas exchange related to ventilation-perfusion imbalance Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation. (Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival. Educational objective:Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival.

A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. Laboratory results PH 7.25 PO2 79 mm Hg (10.5 kPa) PaCO2 35 mm Hg (4.66 kPa) HCO3 12 mEq/L (12 mmol/L)

Increase in respiratory rate The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective:Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices. Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem?

Increases the oxygen flow A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option 1) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option 3) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option 4) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. Educational objective:A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition?

Infection Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.

The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem?

Infection Neutrophils arise from stem cells and complete the maturation process in the bone marrow. They belong to a class of leukocytes known as granulocytes because of the large number of granules present inside each cell. Neutrophils provide the first internal line of defense, via phagocytosis, against foreign invaders (especially bacteria) in blood and extracellular fluid. If the neutrophil count is low, the client is at risk for infection. The remaining options are not associated with the function of neutrophils.

The nurse analyzes the laboratory values of an adult with acute myelogenous leukemia (AML) who is receiving induction chemotherapy. The nurse notes that the platelet count is 19,500 mm (19.5 × 10 /L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care?

Initiate bleeding precautions. If a client with leukemia is has a low platelet count usually less than 50,000 mm (50.0 × 10 /L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided.

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question?

Insert and maintain a nasogastric tube Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive gastrointestinal bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining, vomiting) and from mechanical injury (eg, chest trauma, consuming sharp/hard foods). In UGIB, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage (Option 3). (Option 1) Pantoprazole is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the gastric mucosa. (Option 2) Octreotide may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal venous pressure, which reduces bleeding. (Option 4) NPO status may be prescribed in cases of UGIB to prepare the client for invasive diagnostic or therapeutic procedures (eg, esophagogastroduodenoscopy, variceal ligation). Educational objective: Gastroesophageal varix rupture/hemorrhage is a potentially lethal complication of cirrhosis that may occur from increased portal venous pressure (eg, coughing) and mechanical injury (eg, nasogastric tube insertion). The nurse should question prescriptions for activities that increase the risk of such rupture.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside?

Intubation tray The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L) and a mean cell volume (MCV) of 70 fl. The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia The normal hemoglobin level for an adult female client is 12 to 16 g/dL (120 to 160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels, since iron is required for hemoglobin development in the red blood cells. Reduced amounts of hemoglobin in the red blood cells makes the size of the red blood cells smaller, which manifests as a low MCV.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective?

Kale salad with boiled eggs and dried fruit, a brownie, and orange juice Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: Diets low in iron (eg, vegetarian and low-protein diets) Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process. (Option 1) Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of iron. (Option 2) Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron. (Option 3) Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources. Furthermore, the tea will inhibit iron absorption. Educational objective:Clients with iron-deficiency anemia should be taught to eat iron-rich foods such as meats (eg, beef, lamb, liver, chicken, pork), shellfish (eg, oysters, clams, shrimp), eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal.

The nurse is preparing to administer prescribed medications to a client with hepatic encephalopathy. The nurse anticipates that the primary health care provider's prescriptions will include which medication?

Lactulose Lactulose is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH and aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Bisacodyl is a stimulant laxative. Magnesium hydroxide is a saline laxative. Psyllium hydrophilic mucilloid is a bulk laxative.

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

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

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply.

Lips, Conjunctiva, Mucous membranes Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse should assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and earlobes.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

Malaise Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids?

Meats Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.

Monitor the client's temperature, Use sterile technique when suctioning, Use the closed-system method of suctioning, Monitor sputum characteristics and amounts. Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decreases the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3 (2 x 109/L). Which client sign or symptom is the most concerning and requires immediate further nursing action?

New-onset confusion Thrombotic thrombocytopenic purpura (TTP) consists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm3 (10 x 109/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in level of consciousness is the most clinically significant finding requiring an emergency response. (Option 1) The head is very vascular, and a nosebleed can occur with low platelets. A nosebleed is treated with direct pressure and application of cold. In this client, potential intracranial bleeding is the priority. (Option 2) Easy bruising can occur as a result of low platelets. However, the bruise is "old," and potential intracranial bleeding is the priority. (Option 4) Blood in the urine can be a symptom of low platelets due to lack of clotting ability. Although this is concerning, alterations in level of consciousness is the priority. Educational objective:A priority assessment in a client with low platelets is any change in level of consciousness (eg, disorientation, lethargy, restlessness). This can indicate intracranial bleeding and increased intracranial pressure.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action?

Notify the primary health care provider (PHCP) that the client is rescinding the DNR prescription. COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the PHCP to reverse the DNR prescription on the chart. The PHCP also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the PHCP. Option 2 is incorrect because the PHCP should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions. Some states offer DNR Comfort Care and DNR Comfort Care Arrest protocols. Protocols in these instances list specific actions that health care providers will take when providing cardiopulmonary resuscitation.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply.

Obtain baseline vital signs, abdominal circumference, and weight, Place client in high Fowler position or as upright as possible, Request that the client empty the bladder Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic. Educational objective:Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins.

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? Select all that apply.

Offer small, frequent meals to prevent nausea, Promote rest periods between periods of activity, Teach the client not to share razors or toothbrushes with others, Teach the client to abstain from drinking alcohol Hepatitis (inflammation of the liver) is often caused by infection, toxins, or trauma (eg, drug use, viral hepatitis, acute poisoning), resulting in impairment of liver function (eg, bile production, detoxification of blood, metabolism). Nursing interventions for clients with acute viral hepatitis include: Rest Alternate periods of rest and activity to reduce metabolic demands and avoid fatigue (Option 2). Avoid hepatotoxins (eg, alcohol, acetaminophen) as they worsen injury to liver cells (Option 5). Medications (eg, appetite stimulants, antipruritics, analgesics, sedatives) metabolized in the liver should be used cautiously to allow hepatocytes to heal. Nutrition Encourage low fat, small, frequent meals to decrease nausea and promote intake in clients with anorexia. Anorexia is lowest in the morning; promote eating a larger breakfast (Option 1). Provide oral care and avoid extremes in food temperature to increase appetite. Promote water consumption (2500-3000 mL/day) and diets adequate in carbohydrates and calories. Infection control Hepatitis B is transmitted through sexual contact and infected blood (eg, drug use, accidental needle stick, perinatal mother-to-child infection). A condom should be used during sexual intercourse. Clients should not share razors or toothbrushes (Option 4). (Option 3) Diets high in fat should be avoided as liver bile production, which is needed for fat digestion, may be impaired. Encourage protein and carbohydrate intake to assist with liver healing. Educational objective:Nursing interventions for clients with acute viral hepatitis include the promotion of rest alternated with activity, avoidance of hepatotoxic substances (eg, alcohol), and adequate nutrition (adequate carbohydrates and protein intake; low fat; small, frequent meals).

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply.

Orthopnea and dyspnea, Petechiae and ecchymosis, Inguinal or umbilical hernia, Abdominal distention and tenderness Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention?

PaO2 49 mm Hg (6.5 kPa), PCO2 60 mm Hg (8.0 kPa) Normal adult ABG values at sea level are as follows: pH 7.35-7.45 PaO2 80-100 mm Hg (10.7-13.3 kPa) PaCO2 35-45 mm Hg (4.66-5.98) Bicarbonate (HCO3-) 22-26 mEq/L (22-26 mmol/L) O2 Saturation (SaO2) 95%-99% ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary. (Option 2) PaO2 64 mm Hg (8.5 kPa) indicates hypoxemia, and PaCO2 45 mm Hg (6.0 kPa) is within the normal range, but results do not meet the criteria for ARF. (Option 3) PaO2 70 mm Hg (9.3 kPa) indicates hypoxemia, and PaCO2 30 mm Hg (4.0 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. (Option 4) PaO2 86 mm Hg (11.5 kPa) is within normal range, and PaCO2 25 mm Hg (3.33 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. Educational objective:Type I hypoxemic failure is associated with an alteration in O2 transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type II hypercapnic, or ventilatory, failure is associated with CO2 retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa), PaCO2 ≥50 mm Hg (6.67 kPa), and pH ≤7.30.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note?

PaO2 49 mm Hg, PaCO2 52 mm Hg Respiratory failure is described as a PaO2 of 60 mm Hg or lower and a PaCO2 of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (PaCO2) from the client's baseline are considered diagnostic.

Which parameters indicate 'refractory hypoxemia' in acute respiratory distress syndrome (ARDS)?

PaO2 is low despite a high FiO2 Refractory hypoxemia is defined as a low PaO2, despite a high FiO2. For example an ARDS patient could be on 100% FiO2, but still only have a PaO2 of 45 mm Hg (in SLC). Refractory hypoxemia provides evidence of a severe gas exchange problem. No matter how much O2 we drive into the lung, very little diffuses across the alveolarcapillary membranes.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?

Palpating for peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?

Pasta with sauce Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.

Pathological fracture, Urinalysis positive for Bence Jones protein, Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) Multiple myeloma is a B cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with multiple myeloma may experience pathological fractures, hypercalcemia, anemia, recurrent infections, and renal failure. In addition, Bence Jones proteinuria is a finding. A serum calcium level of 8.6 mg/dL (2.15 mmol/L) and a hemoglobin level of 15.5 g/dL (155 mmol/L) are normal values. A serum creatinine level of 2.0 mg/dL (176.6 mcmol/L) is elevated indicating a renal problem.

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.

Pathological fracture, Urinalysis positive for Bence Jones protein, Serum creatinine level of 2.0mg/dL Multiple myeloma is a B cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with multiple myeloma may experience pathological fractures, hypercalcemia, anemia, recurrent infections and renal failure. In addition, Bence Jones protienuria is a diagnostic finding. A serum calcium level of 6.6 mg/dL (hypocalcemia) and an elevated hematocrit are not expected. A serum creatinine level of 2.0 mg/dL is elevated indicating a renal problem.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note?

Peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note?

Peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

Pitting edema Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites (Option 4). (Options 1, 2, and 3) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism. Educational objective:Serum albumin plays an important role in maintaining intravascular oncotic pressure. Very low levels of albumin result in fluid leak from the vessels into the interstitial tissue and can lead to pitting edema of the lower extremities, periorbital edema, and ascites.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply.

Place client in semi-Fowler position, Provide alternating air pressure mattress, Use music to provide a distraction In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective:The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown.

The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm3 (2 × 109/L), the platelet count is 150,000 mm3 (150 × 109/L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate?

Place the client on neutropenic precautions. The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. This includes protective isolation techniques to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops below 90,000 to 100,000 mm3 (90 to 100 × 109/L) or per primary health care provider prescription or agency policy. The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal clotting time is 8 to 15 minutes, and the normal ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). Removing the rectal thermometer from the client's room would be done if bleeding precautions were initiated. There is no useful reason to eliminate all protein from the diet.

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP?

Positive, purulent sputum culture VAP is the second most common health care-associated infection (HAI) in the United States and is associated with increased mortality, hospital cost, and length of stay. Because it is a nosocomial infection, signs and symptoms associated with VAP usually present within ≥2-3 days after initiation of mechanical ventilation (MV). Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (12,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray. (Option 1) Blood-tinged sputum may occur but is not the best indicator of VAP. (Option 2) Positive blood cultures may identify the microorganism causing the infection but are not the best indicator of VAP. Positive blood cultures could be from another source of infection. (Option 4) Rhonchi and crackles are adventitious lung sounds associated with pneumonia but can be present in pulmonary edema or just from increased mucous secretions. They are not the best indicator of VAP. Educational objective:VAP is an HAI that usually occurs within ≥2-3 days after the initiation of mechanical ventilation. Characteristic manifestations of VAP include purulent secretions, positive sputum culture, leukocytosis, elevated temperature, and new or progressive pulmonary infiltrates on chest x-ray.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?

Presence of asterixis Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nurse is providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient with acute myelogenous leukemia (AML). Which action by the new RN requires that the nurse intervene immediately?

Priming the transfusion set using 5% dextrose. Normal saline (0.9% NaCl), and isotonic solution, should be used when priming the IV tubing. Dextrose in an IV solution is metabolized quickly, leaving a hypotonic solution (pure water), which can cause hemolysis of the red blood cells.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet?

Protein Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply.

Provide the client with a soft toothbrush, Instruct the client to use an electric razor, Monitor all secretions for frank or occult blood Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

Rapid, shallow respirations An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

A client with pneumonia is transferred from the medical unit to the intensive care unit due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the health care provider (HCP)? Click on the exhibit button for additional information. Progress notes: 1845 Productive cough of large amount of tan mucus, scattered rhonchi, and crackles in bases. Arterial blood gas (ABG) results: PaCO2 35 mm Hg, PaO2 90 mm Hg on nasal oxygen at 6L/min. Temperature 101.1 F (38.3 C). On vancomycin for 2 days.______________RN 1945 Repeat ABG: PaCO2 33 mm Hg, PaO2 89 mm Hg on 50% oxygen via face mask.______________RN 2045 Repeat ABG: PaCO2 32 mm Hg, PaO2 86 mm Hg on 100% oxygen via total rebreather mask.______________RN

Refractory hypoxemia Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema. The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP. (Options 1 and 3) Cough with mucus production and scattered rhonchi and crackles are expected findings in a client with pneumonia. (Option 4) Temperature is an expected finding in a client with pneumonia who is receiving antibiotic therapy. The white blood cell count can still be elevated after 2 days of antibiotic therapy. Educational objective:Refractory hypoxemia is the inability to improve oxygenation with increases in oxygen concentration. It is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high mortality rate.

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene?

Removing the inner cannula and cleaning using standard infection control precautions When tracheostomy care is performed, a sterile field is set up and a sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so a sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis The normal pH is 7.35 to 7.45. Normal PaCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and PaCO2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas?

Respiratory acidosis and hypoventilation The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory acidosis. Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression (eg, opioids, benzodiazepines, alcohol, sedating antihistamines). (Option 1) Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating. (Option 2) Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating. (Option 4) Hypoxia, anxiety, and pain are common causes of respiratory alkalosis, which is due to alveolar hyperventilation (rapid breathing). Educational objective:Over-sedation, sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

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

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?

Respiratory rate of 8 breaths/min For patients with chronic emphysema (and any other form of COPD), the stimulus to breathe is a low serum/blood oxygen level (the normal stimulus to breathe is a high CO2 level). This patient's oxygen flow is too high which is the likely cause of the low respiratory rate. If the nurse does not intervene the patient is at risk for respiratory arrest.

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.

Restrict visitors who might have a respiratory illness, Use strict aseptic technique for all procedures, Ensure that anyone entering the child's room wears a mask A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room.

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time?

Rib fractures are often the result of blunt thoracic trauma (eg, motor vehicle collision). In the absence of significant internal injuries (eg, pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques (Option 1). (Options 2 and 3) Interventions focused on removing secretions to improve gas exchange (eg, ambulation, coughing, incentive spirometry) are appropriate after the client's pain is controlled. (Option 4) Rib fractures are very painful. Shallow breathing and reports of pain on inspiration are expected findings that do not require immediate notification of the health care provider. Educational objective:Client management for rib fractures focuses on pain control followed by pulmonary hygiene techniques (eg, coughing, deep breathing, incentive spirometry). Without adequate pain control, breathing can become shallow, which may lead to buildup of secretions, atelectasis, and pneumonia.

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation?

Right lateral Pneumonia is a lung infection resulting in decreased gas exchange in the affected lung lobes. The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. This ventilation-to-perfusion (V/Q) mismatch, or pulmonary shunt, may result in hypoxia and respiratory distress. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood (Option 2). (Option 1) Left lateral positioning will worsen hypoxia by decreasing blood flow to the unaffected (ie, right) lung. (Options 3 and 4) Positioning in supine or Trendelenburg position does not promote increased perfusion to the unaffected lung, which is needed to improve hypoxia. Educational objective:Pneumonia (ie, infection of the lungs) causes decreased gas exchange in the affected lung lobes, which can lead to hypoxia and respiratory distress. Clients with unilateral pneumonia should be positioned with the unaffected (ie, good) lung down to improve perfusion and oxygenation.

The clinic nurse prepares instructions for a client diagnosed with leukemia who developed stomatitis after the administration of a course of antineoplastic medications. The nurse should provide the client with which instruction?

Rinse the mouth with a diluted solution of baking soda or saline. Stomatitis (ulceration in the mouth) can result from the administration of antineoplastic medications. The client should be instructed to examine the mouth daily and report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with a diluted solution of baking soda or saline. Food and fluid are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet that includes milkshakes and ice cream. Instruct the client to avoid spicy foods and foods with hard crusts or edges. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth, particularly with a stiff-bristled toothbrush, and flossing when stomatitis is severe.

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question?

Spironolactone 25 mg PO every 12 hours Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. (Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias. (Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus. Educational objective:Tumor lysis syndrome is an oncologic emergency that results in hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia. Treatment includes aggressive hydration, correction of electrolyte abnormalities (eg, loop diuretics, phosphate binders), and hypouricemic agents (eg, allopurinol).

When assessing a patient who required emergency surgery and multiple blood transfusions three days ago, the nurse funds that the patient looks anxious and has labored respirations at the rate of 38/min. The oxygen saturation is 90% at 6 L/min via nasal cannula. Which action is most appropriate?

Switch the patient to a nonrebreather mask at 95-100% FiO2 and call the health care provider to discuss the patient status. The patient's history and symptoms suggest the development of acute respiratory distress syndrome, which will likely require endotracheal intubation and mechanical ventilation. The health care provider must be notified so that appropriate interventions can take place. Application of a nonrebreather can deliver a high FiO2 (up to 95-100%).

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply.

Teaching the child effective hand-washing techniques, Instructing the parents to avoid administering medications unless prescribed, Providing a well-balanced diet. Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home-schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the PHCP. Provision of a low-fat, well balanced diet is recommended. Parents are cautioned about administering any medication to the child. because normal doses of many medications may become dangerous owing tho the liver's inability to detoxify and excrete them. Hand washing is the most effective measure for control of hepatitis in any setting, and effective hand washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease?

The disease occurs most often in those older than 75 years of age. Hodgkin's lymphoma is a cancer that can occur at any age but appears to peak in 2 different age groups: in teens and young adults and in adults in their 50s and 60s. The remaining options are characteristics of this disease.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated?

The fecal pH is acidic Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

The nurse obtains the following data about a patient admitted with multiple myeloma. Which information requires the most rapid action by the nurse?

The patient reports new-onset leg numbness and weakness. The leg numbness may indicate vertebral compression fractures resulting in compression of spinal nerves. This change must evaluated and treated immediately by the health care provider to prevent further loss of function.

Which of the following diets would place a client at the highest risk for macrocytic anemia?

Vegan Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate. (Option 1) Lacto-ovo-vegetarian — eggs, milk, and milk products are included, but no meat is consumed. (Option 2) Lacto-vegetarian — milk and milk products are included in the diet; eggs and meats are excluded. (Option 3) Macrobiotic — whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective:Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12 deficiency and the resulting macrocytic anemia.

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective?

Vital signs remain within the client's normal parameters Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). (Options 1 and 3) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option 2) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion. Educational objective:Clients undergoing paracentesis to alleviate symptoms related to ascites are at risk for hypotension due to changes in abdominal pressure. IV albumin increases intravascular fluid volume and may be used to prevent hypotension associated with paracentesis.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension?

Abdominal distention With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

Administer prescribed analgesic medication for incisional pain Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options 2, 3, and 4) These are appropriate interventions but will be more effective if pain is managed first. Educational objective:The nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises.

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply.

Administering medications via metered-dose inhaler (MDI), Checking oxygen saturation using pulse oximetry, Auscultating breath sounds The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, or evaluating a patient's abilities requires additional education and skills within the scope of practice of the professional RN.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?

Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. The remaining options are incorrect.

The patient has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. Which laboratory result will the nurse check first to see if the medication is having the desired effect?

Ammonia level The healthy liver breaks down ammonia, but in liver disease, the ammonia accumulates, and serum levels increase. Lactulose helps by enhancing intestinal excretion of ammonia.

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply.

Ammonia, Bilirubin, Prothrombin time Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium). Educational objective:The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH?

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

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

Apply cool, moist washcloths to the affected areas, Keep the fingernails trimmed short to minimize skin scratching, Use skin protectant or moisturizing cream over unbroken skin, Wear cotton gloves or long-sleeved clothing to avoid scratching A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options 2 and 5). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options 1 and 4). Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option 3) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided. Educational objective:A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long-sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths also help. Cholestyramine increases the excretion of bile salts through feces, thereby decreasing itching.

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status?

Arterial blood gases Arterial blood gas (ABG) assessment parameters provide objective data about the efficiency of gas exchange in the lungs and effectively evaluate the following: Acid-base balance (pH, HCO3) Oxygenation status (PaO2, partial pressure of oxygen in the arterial blood) Tissue oxygenation (SaO2, percentage of available hemoglobin saturated with oxygen) Ventilation (PaCO2, partial pressure of carbon dioxide in the arterial blood) Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). The adequacy of oxygenation and ventilation in a client with respiratory failure is best evaluated through ABG analysis. (Option 2) Chest x-ray is used to determine structural abnormality (eg, enlarged heart, fractured ribs), presence of air, fluid, infiltrates, lesions, and response to treatment. It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option 3) Decreased serum hematocrit and hemoglobin levels can affect the carrying capacity and delivery of oxygen to the tissues. They do not provide objective data about a client's gas exchange, oxygenation, and ventilation status. (Option 4) The serum lactate level provides information about anaerobic tissue metabolism (perfusion). It does not provide objective data about a client's gas exchange, oxygenation, and ventilation status. Educational objective:Respiratory failure can occur when oxygenation is inadequate (hypoxemic failure) and/or when ventilation is inadequate (hypercapnic failure). Arterial blood gas analysis provides objective data about the efficiency of gas exchange in the lungs.

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings? Select all that apply. Laboratory results: Albumin 1.5 g/dL (15 g/L) Ammonia 112 mcg/dL (80 µmol/L)INR1.9 Bilirubin 22 mg/dL (376 µmol/L) Platelets 55,000/mm3 (55 × 109/L)

Ascites, Bruising, Itching, Lethargy Laboratory abnormalities seen in liver dysfunction Low serum albumin [3.5-5.0 g/dL(35-50 g/L]); Fluid overload: edema, ascites, weight gain. High serum ammonia (15-45 mcg/dL[11-32 µmol/L]); Hepatic encephalopathy: confusion, lethargy, asterixis, coma. Elevated INR/prolonged PT (INR: 0.75-1.25, PT: 11-16 sec); Bruising, bleeding. Increased bilirubin level (0.2-1.2 mg/dL [3-21 µmol/L]); Jaundice, scleral icterus, itching. Low platelets (thrombocytopenia) (150,000-400,000/mm3 [150-400 × 109/L]); Petechiae, spontaneous bleeding. Cirrhosis of the liver occurs when chronic liver disease (eg, hepatitis C infection) causes scar tissue and nodules, which can decrease liver function and lead to liver failure. Clients with end-stage liver disease may experience exacerbations requiring hospitalization and acute intervention. Numerous laboratory abnormalities occur in the setting of liver failure and correlate with assessment findings (eg, high serum ammonia resulting in hepatic encephalopathy) (Options 1, 2, 4, and 5). (Option 3) Lactulose, an osmotic laxative, decreases serum ammonia levels by causing ammonia to be excreted through stool. The desired therapeutic effect is the production of 2 or 3 soft bowel movements each day; therefore, clients receiving lactulose should not exhibit constipation. Educational objective:Laboratory abnormalities common in liver failure include low serum albumin (causes ascites), elevated INR (increases risk for bruising and bleeding), elevated serum ammonia (causes lethargy and confusion), and increased bilirubin (causes jaundice and itching).

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply.

Ask if the client knows what day it is, Ask the client to extend the arms Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis. Educational objective:HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs during suctioning. Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

Assess the client's hand movements with the arms extended, Compare current mental status findings with those from previous shifts, Contact the health care provider to request a blood draw for ammonia level Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. (Option 4) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option 5) Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen. Educational objective:Hepatic encephalopathy is a serious complication of end-stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis; coma and death can occur if this condition remains untreated. Pharmacologic treatments include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge.

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement?

Assess the client's motivation to make the necessary self-care changes before and after the transplant The client may not be an appropriate transplant candidate due to his alcohol use. However, additional facts are needed to determine the true situation as the only information obtained came from the client's spouse. The nurse should assess the client's drinking habits and motivation to stop drinking before and after the transplant by speaking with the client directly. In addition, a transplant requires many other self-care regimens. The nurse should be alert for indicators of the client's ability to take prescribed medications, follow dietary restrictions, and attend medical appointments. The information obtained from this assessment should be communicated to the interdisciplinary team members responsible for determining transplant eligibility. (Option 1) Transplant and hospice care are options for the client with end-stage liver disease; palliative specialists can assist with identifying the goals of care and facilitating decision-making. However, this does not directly address the concern of the client's spouse. At this time, further assessment is necessary before appropriate interventions can be planned. (Option 3) At this point, it is unclear whether the client is motivated to quit drinking (the nurse has only heard from the spouse). Therefore, it is premature to plan for this type of intervention. The client will need to stay sober not just prior to the surgery, but for a lifetime if the transplant occurs. Any discussion between the client's family and the medical team should be based on this understanding. (Option 4) If the nurse is concerned about transplant eligibility due to the spouse's statement, then this should be communicated to the client's interdisciplinary team after further assessment. At this point, it is premature to involve the nurse manager. Educational objective: The client with end-stage organ failure must be motivated and able to engage in complex self-care regimens before and after solid organ transplant. Concerns about the client's motivation to engage in necessary self-care requirements (eg, alcohol abstinence) require further assessment.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?

Assess the symptoms reported by the UAP Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability. (Option 1) Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention. (Option 3) Diuretics (eg, spironolactone, furosemide) are prescribed for clients with ascites. If the client is hypotensive or hypovolemic, the nurse can hold the prescribed diuretics, but this should not be the nurse's first intervention. (Option 4) The nurse can instruct the UAP to assist the client back to bed if this is an appropriate action after assessing the client, but this should not be the nurse's first intervention. Educational objective:A client who is experiencing lightheadedness and unsteady gait following paracentesis requires immediate assessment because these manifestations can signal hypovolemia with hypotension, which can lead to hemodynamic instability and hypovolemic shock.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action?

Assist the client in expressing feelings. The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply.

Blood, Semen, Vaginal secretions Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through unprotected sexual intercourse and intravenous illicit drug use (Options 1, 3, and 5). Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B. (Option 2) The transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and improper food handling. Therefore, this infection is seen primarily in developing countries. Hepatitis B is not transmitted through feces. (Option 4) Urine is not known to be a mode of transmission for any form of hepatitis. Educational objective:The transmission of hepatitis B occurs through parenteral or sexual contact with body fluids such as blood, semen, or vaginal secretions (mnemonic: B for body fluids).

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action?

Call the rapid response team The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT. (Option 1) The client's restlessness and confusion are likely secondary to low oxygenation. Anxiety will cause hyperventilation, which will only exacerbate the situation. However, administering anti-anxiety medication is not the priority over obtaining help quickly. In addition, the client's oxygenation could deteriorate depending on the prescribed anti-anxiety medication, which could depress respirations. (Option 2) The health care provider who performed the surgery must be notified of the client's deteriorating condition; however, this should be done after calling the RRT. Stabilizing the client is the priority. (Option 4) The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed. This position maintains the airway and ensures that the client does not choke on vomit. Educational objective:When a client is demonstrating clinical deterioration, the nurse's priority is to prevent full respiratory or cardiac arrest by calling the rapid response team.

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply.

Check secretions for frank or occult blood, Encourage fluid intake to avoid constipation, Provide oral sponges or a soft toothbrush for oral care Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option 4) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy. Educational objective:The immediate postoperative priority goal for a client with a newly placed tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway.

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply.

Chest pain during inhalation, Diminished breath sounds, Dyspnea A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options 1 and 3). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option 2). (Option 4) Fluid outside the lung interrupts the transmission of sound, resulting in decreased fremitus and dullness with percussion in pleural effusion. Percussion is hyperresonant in clients with pneumothorax. (Option 5) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion. Educational objective:A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.

The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition?

Cirrhosis of the liver The normal albumin level ranges from 3.5 to 5 g/dL (35 to 50 g/L). The albumin level is decreased in many conditions, such as acute infection, ascites, alcoholism, burns, and cirrhosis. The remaining options identify conditions in which the albumin level is increased.

The nurse receives the handoff of care report on four clients. Which client should the nurse see first?

Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless. Acute respiratory failure (ARF) is a life-threatening impairment of the lungs' ability to oxygenate blood and excrete carbon dioxide (CO2). ARF may occur from exacerbation of chronic (eg, chronic obstructive pulmonary disease, asthma) or acute (eg, pneumonia, pulmonary edema) illnesses. Nurses assessing for signs of ARF should consider both respiratory and neurological manifestations. Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom that may occur because of the brain's sensitivity to inadequate oxygenation and alterations in acid-base balance from retained CO2(Option 4). Additional signs and symptoms may include paresthesias, dyspnea, tachypnea, and hypoxemia. (Option 1) Clients recovering from recent pneumonectomy (ie, surgical removal of part or all of the lung) often experience considerable pain, which may cause respiratory distress if not adequately controlled. A client with tachypnea and severe pain should be seen promptly but only after addressing potential ARF. (Option 2) Crackles, absent or diminished breath sounds over the affected lobe, and slightly decreased oxygen saturation are expected findings in pleural effusion, in which fluid collects in the space surrounding the lung. (Option 3) Low-grade fever may occur following surgery (due to the release of inflammatory cytokines) or from postoperative atelectasis. The client should be encouraged to ambulate and deep-breathe. Educational objective: Acute respiratory failure is a life-threatening impairment of lung function that inhibits gas exchange. Common symptoms include altered mental status (eg, confusion, agitation, somnolence), paresthesias, dyspnea, tachypnea, and hypoxemia, all of which should be addressed immediately.

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first?

Client with severe acute pancreatitis who has inspiratory crackles at the lung bases Clients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed further for progression. (Option 1) Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing), this is not the priority assessment. (Option 2) Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. The sound originates from air moving through large airways (bronchi) filled with mucus secretions and are expected in clients with chronic bronchitis. Although they require treatment (eg, medication, mobilization of secretions), this is not the priority assessment. (Option 3) The lung under the pleural effusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged. Educational objective:Clients with acute pancreatitis are at high risk for developing acute respiratory distress syndrome.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

Collapse of alveoli and decreased compliance Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

Which finding suggests to the nurse that a client with bleeding esophageal varices is experiencing a side or adverse effect of vasopressin therapy?

Complaints of chest pain Vasopressin therapy causes vasoconstriction, and side and adverse effects include myocardial ischemia, which may be evident by the client's complaints of chest pain. Elevated temperature, bounding peripheral pulses, and a BUN of 20 mg/dL (7.1 mmol/L) are not adverse effects. Vasopressin therapy can cause hypothermia. Because vasopressin has potent vasoconstrictive effects on the peripheral arterioles, weak versus bounding pulses may be found. The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L).

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask?

"Do you abuse alcohol?" Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem?

"Have you enjoyed having visitors?" Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement?

"I can resume a full activity level within 1 week." The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply.

"I may continue to use an electric shaver," "I will not blow my nose if I get a cold," "I should use a soft-bristled toothbrush to avoid mouth trauma" Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia should be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction?

"I will take acetaminophen if I get a headache." Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure for a liver biopsy. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure." The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

"I'm going to take aspirin for my headache as soon as I get home." During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.

The nurse is caring for a patient with cirrhosis and portal hypertension. Which statement by the patient is cause for greatest concern?

"I'm very constipated and have been straining during bowel movements." Portal hypertension increases pressure in the venous system and contributes to the development of esophageal varices, which are very fragile. Straining increases thoracic or abdominal pressure, which can cause a sudden rupture of fragile blood vessels with massive hemorrhage. The patient could have fluid accumulation in the abdomen (ascites) that may be mild and hard to detect or severe enough to cause orthopnea. Patients will compensate for orthopnea by assuming a more upright position. This symptom warrants additional investigation. Dependent peripheral edema can also be observed but is less urgent.

The nurse is caring for a client with a diagnosis of lung cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L) The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation?

A shunt unit exists. When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication?

Acetaminophen Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (i.e., ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session?

Activity should be limited to prevent fatigue. Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action?

Administer 100% oxygen using a non-rebeather mask with flow rate of 15 L/min. The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective: The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO.

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education?

Applies suction when inserting the catheter into the airway Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). (Option 1) Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote comfort in clients receiving MV. (Option 3) Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. (Option 4) It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency. Educational objective:To minimize removal of oxygen and mucosal trauma, suction should be applied only when removing the catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg, hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, preoxygenating with 100% oxygen, and limiting suction time to 10-15 seconds.

A client in the intensive care unit with acute respiratory distress syndrome (ARDS) is intubated and connected to a mechanical ventilator. Which actions will the nurse use to decrease the risk for developing ventilator-associated pneumonia? Select all that apply.

Avoiding sedating the patient when possible, Keep the head of the bed elevated at least 30 degrees, Assist the patient with mobilization and exercises several times daily, Provide oral care with several times daily with antibacterial solution Current evidence-based recommendations for prevention of VAP includes frequent and effective oral care with chlorhexadine solution. Intubation and mechanical ventilation can increase the amount of bacteria colonization in the oral cavity and the endotracheal tube serves as a direct route for bacteria to colonize the lungs. For more info see this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706660/ (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706660/)

Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications?

Decrease in aspartate aminotransferase (AST) Complications from viral hepatitis include bleeding tendencies with increasing prothrombin time values and abnormalities of liver function. Clients also can develop encephalopathy. A characteristic sign of encephalopathy is asterixis. Serum transaminase levels such as AST decrease, and vitamin K becomes absorbed as liver cells heal and regenerate.

The nurse is teaching a group of day-care workers about how to avoid transmission of hepatitis A in day-care settings. What is the single most effective measure to emphasize?

Hand hygiene should be performed often to prevent and control the spread of infection. Hand washing is the most important aspect to emphasize. Addressing fecal incontinence and sharing of personal items may be recommended when the disease is in an infectious stage. Immunizations are recommended, but this would be emphasized to parents rather than day-care workers

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices. Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information.

Insert a new tracheostomy tube using the bedside obturator A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma. (Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply. Educational objective:Accidental dislodgment of a tracheostomy tube is a medical emergency. With a mature tracheostomy, an attempt to insert a new tracheostomy tube with the bedside obturator is indicated. If a tube cannot be reinserted, the stoma is covered with a sterile, occlusive dressing. Ventilation is provided with a bag-valve mask over the nose/mouth.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply.

Jaundice, Clay-colored stools, Elevated bilirubin levels, Dark or tea-colored urine There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply.

Leukopenia, Elevated liver enzymes, Elevated serum bilirubin level, Elevated serum erythrocyte sedimentation rate (ESR) Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESRs. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply.

Monitor daily weight, Measure abdominal girth, Monitor respiratory status, Assist the client with care as needed Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

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

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which assessment finding should the nurse expect to note?

Periods of apnea followed by deep rapid breathing Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. The descriptions in the remaining options are incorrect.

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following?

Phlebotomy Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary. (Option 1) A blood transfusion is contraindicated in a client with PV because this would have the opposite of the desired effect, further increasing the RBC count and clotting. (Option 2) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration. (Option 4) Steroid injections are not typically used to treat PV. Educational objective:A client with polycythemia vera requires periodic therapeutic phlebotomy treatments to reduce the RBC count and risk of blood clotting associated with increased blood viscosity.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food?

Pork Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse should check which diagnostic test noted in the client's record to determine the stage of the disease?

Positron emission topography (PET) scan Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue. It is characterized by painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Diagnostic testing for this disorder includes blood studies, excisional lymph node biopsy, bone marrow examination, and radiographic studies. These tests are used for evaluation purpose but are not definitive. PET scan with or without computed tomography is used to diagnose and determine the stage of the disease.

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider?

Potassium 3.0 mEq/L (3.0 mmol/L) Liver Dysfunction & Laboratory Abnormalities Protein Synthesis >>> Low serum albumin Detoxification of ammonia >>> Hgh serum pneumonia Coagulation factor production >>> Elevated INR, prolonged PT Hepatic cell damage >>> Elevated AST/ALT The client with cirrhosis is at risk of hepatic encephalopathy. Hypokalemia, high protein intake, gastrointestinal bleeding, constipation, hypovolemia, and infection can precipitate hepatic encephalopathy. Use of furosemide can cause hypokalemia, which must be corrected immediately to prevent the precipitation of hepatic encephalopathy and dangerous arrhythmias. (Option 1) A low albumin level of 2.5 g/dL (25 g/L) is common in liver failure due to decreased protein synthesis. The lower limit for serum albumin is 3.5 g/dL (35 g/L) and there is no treatment to correct it. Albumin infusion is only temporary and is used to produce good diuresis when used in combination with furosemide. (Option 2) INR is elevated in this client but is not dangerously high. The INR in a healthy person who is not on warfarin should be close to 1. Elevated prothrombin time and INR are common with liver disease or cirrhosis. Intervention is indicated if there is evidence of bleeding. (Option 4) This client's serum sodium is lower than the normal lower limit of 135 mEq/L (135 mmol/L), likely from dilutional hyponatremia from excess water retention. However, it is not significantly low and poses little risk to the client at this point. Educational objective: Lab abnormalities common in liver failure include low albumin, elevated INR, and elevated liver function tests. A low serum potassium can increase the risk of hepatic encephalopathy and should be reported to the health care provider. Elevated serum ammonia confirms the hepatic encephalopathy diagnosis.

A client with cirrhosis is being treated for hypernatremia. On reviewing the laboratory values for the client, the nurse determines that treatment is effective if which laboratory result is noted?

Serum sodium value of 145 mEq/L (145 mmol/L) Laboratory data reflective of hypernatremia include a serum sodium value greater than 148 mEq/L (148 mmol/L), serum osmolality greater than 295 mOsm/kg (295 mmol/kg), and urine specific gravity greater than 1.030 when the kidneys are functioning normally. The increase in the urine specific gravity is a result of the compensatory attempt by the kidneys to conserve water. Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). The serum sodium level of 145 mEq/L (145 mmol/L) is the only normal value, indicating that treatment is effective.

When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply.

Suction the oral cavity whenever needed, Practice frequent oral hygiene, including teeth brushing, Wear gloves when suctioning or handling the endotracheal tube. Measures to prevent VAP include removing subglottic secretions every 2 hours and whenever needed; frequent oral hygiene, which includes teeth brushing; hand hygiene before and after each client contact; and application of gloves after hand washing and before suctioning. Topical antibiotics have no effect. Ventilator circuit tubing does not need to be changed every 2 hours; depending on agency policy, tubing is changed every 24 or 48 hours. Head of the bed elevation is maintained at a minimum of 30 degrees; a supine position can lead to aspiration.

The nurse is caring for a client who is receiving asparaginase. The nurse should monitor the client for improvement of which condition?

Acute lymphocytic leukemia Asparaginase is indicated for the treatment of acute lymphocytic leukemia. Lung cancer, breast cancer, and metastatic prostate cancer are treated with other antineoplastic agents.

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply.

Consume multiple small meals throughout the day, Allow the client to select foods that are most appealing, Eliminate fatty foods from the meal trays until nausea subsides Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?

Increased uric acid level Hyperuricemia is especially common following treatment for leukemias and lymphomas, because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.The nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase. The nurse should notify the primary health care provider if monitoring reveals which finding?

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client?

Low arterial PaO2 The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3 (200 × 109/L). The nurse should prepare to implement which action based on this finding?

Remove the rectal thermometer from the client's room. When the client's platelet count is low, the client is at risk for bleeding. Options 1, 3, and 4 relate to the risk for infection. Rectal temperatures should not be taken on a client who is at risk for bleeding because the thermometer could cause an alteration in the delicate rectal membranes and lead to bleeding.

A 2-year-old child with respiratory syncytial virus (RSV) has a respiratory rate of 44 breaths/minute, nasal flaring, and abdominal breathing. Upon examination the child is cyanotic with a SpO2 of 80%. The nurse knows that the child is at risk for which complication?

Respiratory arrest

The adult client with hepatic encephalopathy has a serum ammonia level of 200 mcg/dL (120 mcmol/L) and receives treatment with lactulose. The nurse determines that the client had the best and most realistic response if the serum ammonia level changed to which value after medication administration?

90 mcg/dL (54 mcmol/L) The normal serum ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). In the client with hepatic encephalopathy, the ammonia level is not likely to drop below normal, nor is it likely to drop into the low-normal range. A level of 90 mcg/dL (54 mcmol/L) is slightly above normal and represents the most realistic response of the medication. The nurse should also monitor the client for signs and symptoms that indicate improvement in the condition.

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level?

Decreased The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but are not the priority in this client.

A hospitalized client is receiving chemotherapy. Based on today's blood laboratory results, what action should the nurse take? Laboratory results White blood cell count 1,400/mm3 (1.4x109/L) Absolute neutrophil count 500/mm3 (0.5x109/L) Hemoglobin 10.5 g/dL (105 g/L) Platelets 150,000/mm3 (150x109/L) Serum potassium 3.4 mEq/L (3.4 mmol/L)

Place a mask on the client The normal range for a WBC count is 4,000-11,000/mm3 (4.0-11.0×109/L). Clients with neutropenia (a reduction in WBCs) are predisposed to infection. The absolute neutrophil count (ANC) is determined by multiplying the total WBC count by the percentage of neutrophils. Neutropenia is an ANC below 1,000/mm3 (1.0×109/L). An ANC below 500/mm3 (0.5×109/L) is defined as severe neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression from the chemotherapy. The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA (high-efficiency particulate air) filtration (or positive pressure air flow). Until the room can be readied, the client should be protected with a mask and separated from infectious clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. In addition, no infectious health care providers (eg, with colds) should care for the client. (Option 1) Thrombocytopenia (low platelets) can result from bone marrow suppression caused by chemotherapy. This client's platelets are at the low end of the normal range (150,000-400,000/mm3 [150-400× 109/L]). Spontaneous or surgical bleeding from thrombocytopenia rarely occurs with a platelet count of >50,000/mm3 (50 × 109/L). (Option 2) This client's potassium level is slightly low (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Low potassium, if it affects the cardiac tracing, causes flattened T waves. Peaked or tented T waves on a cardiac tracing are related to hyperkalemia. (Option 3) Epoetin alfa (human recombinant erythropoietin) is a hematopoietic growth factor. The erythropoietin is produced in the kidney and stimulates bone marrow production of red blood cells (RBCs), a process called erythropoiesis. Epoetin alfa is used to stimulate RBC production but is not typically prescribed unless the client has symptomatic anemia with hemoglobin of <10 g/dL (100 g/L). Educational objective:Neutropenia (ANC <1,000/mm3 [1.0×109/L]) and severe neutropenia (ANC <500/mm3 [0.5 × 109/L]) result in immunosuppression and require protective (reverse) precautions to be taken first. Place the client in a private room with HEPA filtration. Ensure that the client avoids raw fruits/vegetables, standing water, and undercooked meat.

The nurse monitors the client for which condition as a complication of polycythemia vera?

Thrombosis Polycythemia vera is a disorder of the bone marrow. It results in excessive production of white blood cells, red blood cells, and platelets. Clients with polycythemia vera are also more likely to form blood clots that can cause thrombi, strokes, myocardial infarctions, and abnormal bleeding. Clients with polycythemia vera are hypertensive; therefore, hypotension is incorrect. Cardiomyopathy and pulmonary edema are not concerns with this disorder.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, PaCO2 50 mm Hg Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The result is hypercapnea (CO2 retention). The normal pH is 7.35 to 7.45. The normal PaCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased because the PaCO2 is elevated.

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

"I ate shellfish about 2 weeks ago at a local restaurant." Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners.

A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion?

Ammonia level of 98 mcg/dL (60 mcmol/L) The normal serum ammonia level ranges from 10 to 80 mcg/dL (6 to 47 mcmol/L). High levels of ammonia can result in encephalopathy and coma. The other blood levels are not related to hepatic encephalopathy and are also normal values.

The assistive personnel (AP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min is reporting nasal discomfort. What intervention should the nurse suggest to the AP to improve the patient's comfort?

Apply a water-soluble jelly to the nares When the oxygen flow rate > 4 L/min, the mucous membranes can become dried out. To address this issue, the AP can apply a watersolube jelly to the nares to help humidify the incoming air.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication?

Bleeding Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes.

A client with portosystemic encephalopathy is receiving oral lactulose daily. The nurse should check which item to determine that this medication has been effective?

Blood ammonia level Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portosystemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, blood pressure, or serum potassium level.

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing?

Mediastinal flutter The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage.

A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action?

Notify the primary health care provider (PHCP). Respiratory failure is defined as a PaO2 of 60 mm Hg or lower. The nurse should notify the PHCP for further prescriptions. Common causes of hypoxemic respiratory failure are pneumonia, pulmonary embolism, and shock. This client should be receiving oxygen. Repeating the arterial blood gases and maintaining continuous pulse oximetry do nothing to correct the problem.

The nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase. The nurse should notify the primary health care provider if monitoring reveals which finding?

Prolonged blood clotting times Asparaginase can cause severe adverse effects; however, they often are different from those of other antineoplastic medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Signs and symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast with most antineoplastic medications, asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration.

Which clinical consequence is not associated with pulmonary edema in acute respiratory distress syndrome (ARDS)?

Respiratory alkalosis When pulmonary edema accumulates at the alveolar-capillary membrane, the distance over which O2 (and CO2) must diffuse increases. This increased diffusion distance is directly correlated to decreased gas exchange, resulting in hypercapnea. Hypercapnea (increased CO2) results in a respiratory acidosis, not alkalosis. Respiratory alkalosis generally results from hyperventilation and blowing off CO2.

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?

Uric acid level Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.

Which of the following patients is at risk for developing of acute respiratory distress syndrome (ARDS)? Select all that apply.

24 year-old make with quadriplegia male who aspirated gastric fluids when he was lying down in bed, 40 year-old female who sustained severe pulmonary contusions from chest trauma in a motor vehicle collision, 84 year-old female with bacterial pneumonia in both lungs Aspiration of gastric content with HCl and pepsin can cause severe damage to lung tissue. This damage will stimulate an inflammatory response. In addition, an individual with quadriplegia will be unable to use many of their accessory breathing muscles and may be prone to atelectasis due to low inspiratory volumes. Physical trauma from severe chest injuries can cause injury to alveoli and capillaries that can be the starting point for ARDS. Cell injury will activate an inflammatory response that can quickly spread throughout the lungs. Bacterial pneumonia in both lungs can develop into ARDS, especially in older adults. The infection will stimulate an inflammatory response that can spread throughout the lung.