adult health II final exam review

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have? pH 7.49, HCO3 24, PaCO2 30 pH 7.49, HCO3 30, PaCO2 40 pH 7.26, HCO3 24, PaCO2 46 pH 7.26, HCO3 14, PaCO2 30

pH 7.26, HCO3 14, PaCO2 30 AKI causes metabolic acidosis because the kidneys cannot adequately process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is low, the bicarbonate is low, and the PaCO2 is low or in the expected range, as in these results.

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make? "A low-protein diet reduces the risk for uremia." "A low-protein diet reduces the risk for edema." "A low -protein diet will reduce the risk for hyperkalemia." "A low-protein diet will increase the nitrogenous wastes in the blood."

"A low-protein diet reduces the risk for uremia." Urea is a waste product of protein breakdown and can accumulate in clients who have kidney failure, causing uremia

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?

"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.

A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide?

"Apply the ointment in a thin line into the conjunctival sac." The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication comes in contact with the surfaces of the eye when the child blinks. If applied to the globe of the eye, most of the medication will end up in the child's lashes when the child closes her eye.

A nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching? "Cranberry juice can lower cholesterol." "You may experience bloating." "Cranberry juice can cause bad breath." "Drinking cranberry juice daily can prevent recurrent urinary tract infections."

"Drinking cranberry juice daily can prevent recurrent urinary tract infections." The client can decrease the risk of having recurrent urinary tract infections by consuming cranberry juice daily, because cranberry juice contains proanthocyanidins a compound that prevent bacteria from adhering to the urinary tract mucosa.

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? "Do have a history of chronic alcohol abuse?" "Have you had a recent influenza infection?" "Have traveled overseas recently?" "Are you taking a multivitamin?"

"Have you had a recent influenza infection?" The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client's parent is the nurse's priority? "He takes a 2-hour nap every day after school." "He says he feels sick to his stomach after taking this medication." "He has so many new bruises on his body." "He says his mouth is always dry."

"He has so many new bruises on his body." When using the urgent vs non-urgent approach to client care, the nurse determines that the priority concern is frequent bruising because this is a manifestation of carbamazepine toxicity. Carbamazepine toxicity can cause bone marrow depression, including leukopenia, anemia, and thrombocytopenia. The parent should monitor the client for bruising, bleeding, and sore throat and have periodic blood work drawn to monitor for myelosuppression.

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? "I know that I will get a kidney transplant. I am a good candidate." "I can now eat whatever I want. The dialysis will remove it from my system." "I just can't believe that this dialysis is going to ruin my whole life." "I know that kidney disease runs in my family, but I can prevent it."

"I just can't believe that this dialysis is going to ruin my whole life." This statement is an example of anticipatory grief, which often manifests through anger and denial of the fear of an upcoming loss.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? "My eye really itches, but I'm trying not to rub it." "I need something for the pain in my eye. I can't stand it." "It's hard to see with a patch on one eye. I'm afraid of falling." "The bright light in this room is really bothering me."

"I need something for the pain in my eye. I can't stand it." Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

The nurse is discharging a client from the hospital who has a new prescription for furosemide. Which of the following client statements indicates an understanding of the teaching? "I should eat a diet low in potassium while taking this medication." "I should limit my fluid intake while taking this medication." "My blood pressure will increase while I am taking this medication." "I need to limit my sun exposure and wear sunscreen while on this medication."

"I need to limit my sun exposure and wear sunscreen while on this medication." Limiting sun exposure and wearing sunscreen are appropriate while taking furosemide due to the adverse effect of photosensitivity.

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? "I will wipe from the back to front with the cleansing cloth." "I should not collect a urine sample when I am menstruating." "I should let the urine cool to room temperature before sending it to the lab." "I need to urinate a small amount in the toilet before collecting the sample."

"I need to urinate a small amount in the toilet before collecting the sample." The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.

A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?

"I should increase my sodium intake." A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and control hypertension.

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? "I will need to wipe my perineal area from back to front after urination." "I will need to empty my bladder regularly and completely." "I will need to drink apple cider vinegar each day." "I need to drink 8 cups of liquid each day."

"I will need to wipe my perineal area from back to front after urination." Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

"I'll be glad when I can stop taking this medicine." Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? "Wear an eye patch on the right eye at all times." "Plan to relax in a hot tub spa each day." "Engage in a vigorous exercise program." "Implement a schedule to include periods of rest."

"Implement a schedule to include periods of rest." The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? "Incorporate nonverbal cues in the conversation." "Ask multiple choice questions as part of the conversation." "Use a higher-pitched tone of voice when speaking." "Use simple, child-like statements when speaking."

"Incorporate nonverbal cues in the conversation." Nonverbal cues enhance the client's ability to comprehend and use language.

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? "Rest in bed for at least 2 days." "Keep your head up and straight." "Deep breathe and cough four times a day." "Lie on the side of the surgery when in bed."

"Keep your head up and straight." Keeping the head straight and avoiding looking down prevents increasing intraocular pressure.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? "Insert a padded tongue blade into the client's mouth." "Restrain the client." "Place the client on his back." "Move objects away from the client."

"Move objects away from the client." The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? "Yes, you are free to move around as you wish." "No, you are on strict bedrest and must not be up." "Please ring for assistance when you wish to get out of bed." "We will have to get a prescription from your provider."

"Please ring for assistance when you wish to get out of bed." This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? "Take aspirin for discomfort." "Restrict lifting objects greater than 10 pounds." "Expect reduced vision for 48 hours after procedure." "Apply warm compresses for discomfort."

"Restrict lifting objects greater than 10 pounds." The nurse should instruct the client to restrict lifting objects greater than 10 lb to reduce the risk for increased intraocular pressure.

A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make? "So, it seems that you feel responsible for what happened to your mother." "Your mother will be fine. You shouldn't worry so much." "Why do you blame yourself? You could not have prevented the stroke." "You are not responsible for your mother's stroke, but many people in your situation feel this way."

"So, it seems that you feel responsible for what happened to your mother." This response demonstrates the therapeutic communication technique of reflecting. It directs feelings back to the son in a way that shows interest and caring and encourages further communication.

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? "Syncope episodes may occur when taking this medication." "This medication may cause tachycardia." "You should administer the medication each morning." "You will need to monitor for constipation."

"Syncope episodes may occur when taking this medication." The nurse should inform the family to monitor for syncope, which places the client at risk for falling.

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate? "This is where you live now." "This is a safer place for you to live." "Tell me what you like to cook for dinner." "Your family said there is no one to care for you at home."

"Tell me what you like to cook for dinner." Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease means that the client is experiencing later stages of the illness with moderately severe to severe cognitive decline. By asking the client to talk about what she likes to cook for dinner, the nurse is demonstrating validation therapy by asking the client to talk about the areas that concern her. The nurse could continue the conversation by discussing how much the client misses her home and partner. Validation therapy helps clients who have cognitive disorders discuss their feelings about past events and people.

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?

"The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." The main side effects are mild disorientation and confusion immediately after the treatment, a slight headache, and short-term memory problems.

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching? "The fluid from my abdomen will be clear or slightly yellow." "The catheter can become infected even with sterile precautions." "The microwave in my kitchen can warm the solution before I use it." "The volume of the output solution should be greater than the input solution."

"The microwave in my kitchen can warm the solution before I use it." It is dangerous to use a microwave to heat dialysate because microwaves heat unevenly, and the dialysate can be much hotter than it initially appears. It is recommended that dialysate be warmed using dry heat, such as a heating pad. Warming the dialysate in water is also discouraged as this can introduce non-sterile water into the ports of the dialysate bag.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? "Turn the screws on the device once each day." "The purpose of this device is to immobilize the cervical spine." "Apply talcum powder under the vest to limit friction." "The purpose of this device is to allow for neck movement during the healing process."

"The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make? "This test will tell your doctor how your kidneys are functioning." "You'll have to ask your doctor." "This test will tell if you have severe renal impairment or a disease." "We'll find out if any medications, such as steroids, are interfering with your kidney function."

"This test will tell your doctor how your kidneys are functioning." This response is appropriate because it answers the client's question simply rather than avoiding it.

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? "Bloodshot eyes on the day of surgery should be reported to the provider." "Warm compresses should be applied to the eye three times daily." "Photophobia is expected for 2 to 3 days." "Vision will be greatly improved on the day of surgery."

"Vision will be greatly improved on the day of surgery." Vision should be greatly improved on the day of surgery. This information should be included in the teaching.

A nurse is caring for an older adult client who had a cerebrovascular accident and has left-sided weakness. The client's partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the following responses should the nurse make? "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today." "Don't worry. Most clients like your partner start making progress after a few days of rest." "You will have to speak to the provider for that information. I can arrange that for you."

"We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." This response illustrates the therapeutic communication technique of giving information. It directly addresses the partner's concern and demonstrates that discharge and rehabilitation planning begin on admission.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? "Without treatment, glaucoma can cause blindness." "Double vision is a common symptom of glaucoma." "Glaucoma is caused by inadequate production of fluid within the eye." "Use of eye drops will improve vision over time."

"Without treatment, glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include? "You should avoid foods high in fiber." "You should expect redness at the catheter exit site." "You should anticipate pain the first week during the inflow of dialysate." "You should warm the dialysate in a microwave oven before instillation."

"You should anticipate pain the first week during the inflow of dialysate." Abdominal pain is expected during inflow of the dialysate during the first few weeks of therapy.

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your provider might prescribe anticholinergic medications." "You should limit fluids in the evening." "You should restrict your intake of caffeine." "You might require intermittent urinary catheterization." "You might require an anterior vaginal repair."

"Your provider might prescribe anticholinergic medications" is correct. Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" is correct. Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" is correct. The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant. "You might require intermittent urinary catheterization" is incorrect. Intermittent urinary catheterization is used as a treatment for reflex incontinence. "You might require an anterior vaginal repair" is incorrect. An anterior vaginal repair, or colporrhaphy, is a surgical procedure for the treatment of stress incontinence.

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1370 mL

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A change in the Glasgow Coma Scale score from 13 to 11 Diplopia A drop in heart rate from 76 to 70/min Ataxia

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A client who has diarrhea A client who is vomiting A client who is taking a thiazide diuretic A client who has salicylate intoxication

A client who has diarrhea Diarrhea can cause metabolic acidosis due to the loss of bicarbonate.

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? A lucid period followed by an immediate loss of consciousness A change in the level of consciousness that develops over 48 hr Neurologic deficits that increase up to 2 weeks post-injury Cognitive perception that decreases over several months post-injury

A lucid period followed by an immediate loss of consciousness The nurse should expect the client who has an epidural hematoma to have a lucid period followed by an immediate loss of consciousness, which is caused by arterial bleeding into the space between the dura and skull.

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? Provide warming measures for the client. Hyperextend the client's neck. Flex the client's hip. Adjust the client's head of bed.

Adjust the client's head of bed. The nurse should adjust the client's head of bed to keep CPP greater than 70 mm Hg.

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take? Administer the medication at 100 mg/min. Administer a saline solution after injection. Hold the injection if seizure activity is present. Dilute the medication with dextrose 5% in water

Administer a saline solution after injection. The nurse should flush the injection site with a saline solution after the injection of phenytoin to reduce and prevent venous irritation.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? Administer antibiotics when available. Reduce environmental stimuli. Document intake and output. Maintain seizure precautions.

Administer antibiotics when available. The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness.

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

Administer antibiotics. Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillins and erythromycin.

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?

Administer pain medication. Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need for comfort. Therefore, the first action the nurse should take is to administer pain medication to relieve the client's flank pain.

A nurse is preparing to administer phenytoin 50 mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take?

Administer the medication over 1 min. The nurse should administer phenytoin slowly, no faster than 50 mg/min.

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? Administer the medications by touching the tip of the dropper to the sclera of the eye. Hold pressure on the conjunctiva sac for 2 min following application of drops. Administer the medications 5 min apart. It is not necessary to remove contact lenses before administering medications.

Administer the medications 5 min apart. The nurse should instruct the client that, if more than one ophthalmic medication is to be administered, they should be given 5 min apart.

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? Initiating an IV potassium infusion. Encouraging the client to eat bananas. Administering sodium polystyrene sulfonate. Administering a potassium-sparing diuretic.

Administering sodium polystyrene sulfonate. The nurse should expect to administer sodium polystyrene sulfonate, which ab

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

Alcohol increases the chance of phenytoin toxicity. The nurse should include in the home instructions that alcohol alters the blood level of phenytoin.

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

Alcohol use disorder The nurse should identify that a substance use disorder is a contraindication for kidney transplant.

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? Obtain a culture of the specimen using sterile swabs. Allow the drainage to drip onto a sterile gauze pad. Suction the nose gently with a bulb syringe. Insert sterile packing into the nares.

Allow the drainage to drip onto a sterile gauze pad. The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness Alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? Recommend that the partner place the client in a long-term care facility. Suggest that the partner see a counselor to help him cope with his exhaustion. Ask the partner to talk about his difficulties in caring for the client. Tell the partner to call a family meeting to get help.

Ask the partner to talk about his difficulties in caring for the client. The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Assess the client's airway patency is correct. The nurse should continually assess the client's airway during a seizure.Place a tongue depressor in the client's mouth is incorrect. Placing something in the client's mouth can cause injury.Remove objects from the client's bed is correct. The nurse should remove objects that can cause injury to the client during a seizure.Place the client in a side-lying position is correct. The client should be positioned side-lying to prevent aspiration of secretions or vomit.Restrain the client is incorrect. Restraining the client can cause injury.

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?

Assist the client to the correct room. Assisting the client to the correct room protects both clients. It helps reorient the client who is unable to find her own room, and it protects the other client from an invasion of her personal space.

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Auscultate the site for a bruit. The nurse should auscultate the AV graft site for the presence of a bruit or palpate the site for a thrill every 4 hr to assess for blood flow.

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Sleep on the abdomen to facilitate wound healing. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Bend at the waist to pick objects up from the floor. Notify the surgeon if white drainage develops on the eyelids.

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery.

A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis. Which of the following is an expected finding for this client?

BUN 100 mg/dL The kidneys normally eliminate urea by the process of filtration and tubular secretion. Therefore, BUN is a measure of kidney function. The client's BUN is level is above the expected reference range and is an indication of poor kidney function.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech

Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils. Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion. Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension. Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing.

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? Kernig's sign Nuchal rigidity Brudzinski's sign Bradykinesia

Brudzinski's sign This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.

A nurse is teaching a client who has chronic kidney disease term-2about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching?

CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires. CAPD's advantages include fewer dietary and fluid restrictions as compared to hemodialysis.

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? Obtain the telephone number of the client's provider. Find a location for the client to sit. Call emergency services. Drive the client to the nearest emergency department.

Call emergency services. The client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center.

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? Cardiac dysrhythmias Hypoglycemia Seizures Neurogenic shock

Cardiac dysrhythmias This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? Replace the catheter every 3 days. Check the catheter tubing for kinks or twisting. Irrigate the catheter once each shift. Clean the perineal area with an antiseptic solution daily.

Check the catheter tubing for kinks or twisting. The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Check the patency of the client's airway. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is checking the patency of the client's airway.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? Testing visual acuity Observing for facial symmetry Eliciting the gag reflex Checking the pupillary response to light

Checking the pupillary response to light Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

Cheddar cheese The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?

Complete a neurological check. Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? Urinary retention Low back pain Incontinence Confusion

Confusion Confusion is a clinical finding of UTIs specifically associated with older adult clients.

A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? Potassium levels are increased in clients who have polyuria. Specific gravity is decreased in clients who have hypovolemia. BUN is decreased in clients who have dehydration. Creatinine levels are increased in clients who have acute kidney injury.

Creatinine levels are increased in clients who have acute kidney injury. Increased creatinine levels are associated with renal failure.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? Nephrosclerosis Uremia Diverticulitis Cystitis

Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Daily weight Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Decreased level of consciousness Tachypnea Bilateral weakness of extremities Hypotension

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

Dehydration Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Dehydration Diabetes insipidus causes excessive excretion of dilute urine, resulting in dehydration.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? Bargaining Denial Depression Anger

Denial During the denial stage of Kübler-Ross's stages of grieving, the client acts as though nothing has happened and might refuse to believe or understand that a loss has occurred.

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? Developing a respiratory infection Taking too much prescribed medication Diet high in protein Not exercising enough

Developing a respiratory infection The most common triggers of myasthenic crises are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures.

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?

Diabetes mellitus Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications?

Dialysis disequilibrium Dialysis disequilibrium syndrome can develop during or after hemodialysis. The syndrome is caused by the rapid decrease in fluid volume and BUN levels during dialysis. The change in urea levels can cause cerebral edema and increased intracranial pressure. Manifestations include headache, nausea, vomiting, restlessness, seizures, and coma.

A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin. Which of the following adverse effects should the nurse include in the teaching?

Dizziness. Lightheadedness or dizziness is likely with the first several doses. Clients should be taught to rise slowly and carefully from lying or sitting positions until the sensation disappears.

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? Urge incontinence Dribbling of urine Weight gain Rectal distention

Dribbling of urine Dribbling of urine, or overflow incontinence, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hr. between catheterizations.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day. Take 3,000 mg of vitamin C daily. Restrict calcium intake to one serving per day. Eat 12 oz of animal protein daily.

Drink 3 L of fluid every day. The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? Apply pressure to the bridge of the nose after administration. Wipe the eye from the outer canthus to the inner canthus before instillation. Drop prescribed amount of medication into the conjunctival sac. Protect the distal portion of the eyedropper using clean technique.

Drop prescribed amount of medication into the conjunctival sac. With the dominant hand resting on client's forehead, hold filled medication eyedropper or ophthalmic solution approximately 1 - 2 cm above conjunctival sac. Instill prescribed number of medication drops into the conjunctival sac. After instilling the drops, ask the client to close his eye gently. If the client is to receive more than one eye medication to the same eye, wait at least 5 min before administering the next medication.

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? Elevate the head of the bed to 30°. Notify the provider for drainage greater than 80 mL/8hr. Place the client in a flat, lateral position. Provide passive range-of-motion exercises to the neck.

Elevate the head of the bed to 30°. The client who has surgery to treat a supratentorial brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of the bed to 30° assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Elevate the head of the bed. The nurse should elevate the head of the bed 30° to 45° to promote reduction of intracranial pressure, while monitoring for changes in blood pressure.

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing interventions should the nurse implement?

Encourage exhaling through mouth during defecation. The nurse should encourage the client to exhale through her mouth when defecating to decrease strain.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? Apply cold compress to the client's flank area. Restrict protein intake to 2 servings per day. Discourage ambulation. Encourage intake of at least 3 L of fluids per day.

Encourage intake of at least 3 L of fluids per day. The nurse should encourage the client to consume at least 3,000 mL of fluids per day to dilute the urine, increase hydrostatic pressure behind the stone, and move the calculi down the urinary tract.

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take? Provide a low-sodium diet. Administer sumatriptan. Place in high-Fowler's position. Encourage oral fluids.

Encourage oral fluids. A lumbar puncture (LP) is a diagnostic test of the cerebral spinal fluid. During an LP, a needle is inserted through the dura mater that surrounds the spinal cord. Cerebral spinal fluid (CSF) is aspirated and sent to a lab for diagnostic testing. The most common complication following an LP is a spinal headache. This is caused by leakage of CSF from the puncture hole in the dura mater and subsequent tension on the brain. A spinal headache usually occurs within 12 to 24 hr following an LP. Treatment for a spinal headache includes placing the client in a flat position to decrease tension on the brain and increasing the client's fluid intake to replace CSF volume.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? Encourage brief exercise before meals to promote appetite. Place food in the affected side of the mouth. Encourage the client to take small bites. Place the client with the head reclined back to facilitate swallowing.

Encourage the client to take small bites. The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? Evaluate the client's neurological status. Perform a complete blood count. Check the client's temperature. Administer an oral analgesic.

Evaluate the client's neurological status. Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hr.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? Hypocalcemia BMI less than 25 Family history Diuretic use

Family history Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer? Danazol Finasteride Fluoxymesterone Methyltestosterone

Finasteride Finasteride, a 5-alpha-reductase inhibitor, is used in the treatment of BPH to prevent the conversion of testosterone and to decrease prostate size.

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?

Furosemide Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion. Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP.

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Headache, restlessness Headache and restlessness are manifestations of disequilibrium syndrome, which occurs during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between fluid and blood that occurs.. This condition can cause cerebral edema leading to seizures and coma, and a PRN dose of the anticonvulsant phenytoin should be administered.

A nurse in an emergency department is admitting a client. Vital Signs 1700: Temperature 36.7° C (98° F) Heart rate 108/min Respiratory rate 24/min Blood pressure 96/55 mm Hg Oxygen saturation 95% on room air 1800: Temperature 36.7° C (98° F) Heart rate 118/min Respiratory rate 24/min Blood pressure 90/55 mm Hg Oxygen saturation 95% on room air Nurses notes 1700: Client reports several episodes of lower gastrointestinal bleeding GI over the past 2 days when having a bowel movement. States last episode was bright red. Reports history of hemorrhoids. Oriented to person, place, and time. Reports weakness and fatigue, dizziness with ambulation. Describes rectal pain as 7 on a 0 to 10 scale. Sinus tachycardia, no dysrhythmias noted on ECG; S1 S2 heart sounds heard on auscultation; peripheral pulses palpable. Respirations even, unlabored, chest clear on auscultation. Bowel sounds present x 4 quadrants. Denies abdominal pain. States urinating without difficulty. Provider updated, prescriptions received. 1745: Client reports another episode of GI bleeding, bright red blood when having a bowel movement. Ataxia noted when ambulating back to stretcher. Client states, "I'm very dizzy." Past Medical History: Osteoarthritis Frequent headaches Hemorrhoids Home Medications: Naproxen 500 mg 2 tablets daily PO PRN arthritis pain/headaches Aspirin 325 mg 2 tablets daily PO PRN arthritis pain/headaches Provider's Prescriptions 1730: NPO Hold naproxen and aspirin CBC now IV infusion of 5% dextrose in lactated Ringer's solution, 500 mL bolus now over 2 hr Diagnostic Results 1800: Hemoglobin 10 g/dL (Female 12 - 16 g/dL) Hct 30% (Female 37 - 47%) Total WBC 8,500/mm3 (5,000 to 10,000/mm3) Platelet count 149,000/mm3 (150,000 to 400,000/mm3) Which of the following 3 assessment from the clint's medical record require immediate follow-up? Select the 3 findings that require immediate follow-up. WBC count Heart rate Hct and hgb Neurological assessment Cardiac rhythm Urinary assessment

Heart rate is correct. The client is experiencing tachycardia with an increasing heart rate. This is an outcome of the lower GI bleeding that is occurring and requires immediate follow-up with the provider. Hgb and hct is correct. The client's H & H is below the expected reference range and is an outcome of the lower GI bleeding that is occurring and requires immediate follow-up with the provider. Neurological assessment is correct. The client is continuing to experience GI bleeding which is impacting the client's neurological status and requires immediate follow-up with the provider. WBC is incorrect. The client's WBC count is within the expected reference range and does not require immediate follow-up. Cardiac rhythm is incorrect. While the client is experiencing tachycardia, there are no dysrhythmias associated with the GI bleeding, so this does not require immediate follow-up. Urinary assessment is incorrect. There are currently no indications that the GI bleeding is affecting the client's urinary function, so this does not require immediate follow-up.

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? Diarrhea Hematuria Increased thirst Impaired taste

Hematuria Clients who sustain a fracture to the pelvis and symphysis pubis should be monitored for manifestation of internal bleeding, such as blood in the urine and stool.

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac. The nurse should hold the bottle of ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above the lower conjunctival sac.

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect? Hyperkalemia Hypernatremia Hypercalcemia Hypophosphatemia

Hyperkalemia AKI is a loss of renal function that results in a failure to maintain homeostasis. Fluid and electrolyte balance, as well as acid-base balance, are disrupted. The nurse should expect the client to have hyperkalemia due to protein breakdown and the subsequent release of intracellular potassium in to the circulation. The kidneys' inability to filter and excrete potassium results in hyperkalemia.

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Hyperkalemia The nurse should expect the client to have an increase in the serum concentration of potassium during the oliguric phase. Potassium can rise to a life-threatening level during this phase and should be monitored closely.

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

Hypokalemia If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia, which features manifestations of muscle weakness and cardiac arrhythmia.

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?

Hyporeflexia The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and hyperreflexia.

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord.Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles.Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input.Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus.Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? Administer pain medication. Darken the client's room and close the door. Increase fluid intake. Elevate the head of the bed to 30º.

Increase fluid intake. The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? Decreased urine specific gravity Decreased Hgb Increased BUN Increased urine ketones

Increased BUN Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss.

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? Brisk pupillary reaction to light. Increased sleeping Tachycardia Depressed fontanels

Increased sleeping Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

Intracranial pressure (ICP) 18 mm Hg This client's ICP level is above the expected reference range of 10 to 15 mm Hg. ICP increases with suctioning, coughing, sneezing, straining, and frequent positioning.

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? Turn the television on at all times. Hang abstract pictures on the walls. Keep familiar personal items at the bedside. Encourage bright glaring lighting in the room.

Keep familiar personal items at the bedside. The client who is confused should have familiar personal items at the bedside in the same place at all times in order to lessen confusion.

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning from the emergency. No one else should have access to or administer medications the nurse has prepared. Securing them and returning later to finishing preparing and administering them decreases the risk of medication errors.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Loosen restrictive clothing is correct. Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained. Insert a bite stick into the client's mouth is incorrect. A bite stick or padded tongue blade can cause an obstruction in the client's airway or further injury if teeth are broken as a result of the jaw clamping down on the bite stick. Place the client into a supine position is incorrect. If it is possible to do without causing injury to the client, the nurse should assist the client who is having a seizure into a lateral position. This position assists with the drainage of saliva and mucus, preventing aspiration, and allows the tongue to fall forward, preventing airway obstruction. Place a pillow under the client's head is correct. The nurse should place a pillow or rolled blanket under the client's head to protect the head from injury. Apply restraints is incorrect. The nurse should not restrict movement of a client who is having a seizure. Instead, the nurse should guide the client's movements to prevent injury and, if possible, assist the client into a lateral position.

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take? Elevate the head of bed to 45°. Maintain the client on absolute bed rest. Administer a cleansing enema. Place the client in a room near the nurses' station.

Maintain the client on absolute bed rest. The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? Gradual onset of several hours Manifestations preceded by a severe headache Maintains consciousness History of neurologic deficits lasting less than 1 hr

Manifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25% Cushing's Triad is an indication that the client is experiencing increased intracranial pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? Albumin 25% Dextran 70 Hydroxyethyl glucose Mannitol 25%

Mannitol 25% The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? Place the client in protective isolation. Minimize environmental stimuli. Elevate the head of the client's bed 45°. Limit the client's ambulation to once a day.

Minimize environmental stimuli. A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.

A nurse is caring for a client who has a bacterial infection and is receiving gentamicin. Which of the following actions should the nurse take to minimize the risk of an adverse effect of the medication?

Monitor the serum medication levels. A disadvantage of gentamicin, an aminoglycoside, is the association with nephrotoxicity and ototoxicity, both of which are a result of elevated trough levels. Monitoring the serum medication levels is an important action to minimize the risk of an adverse effect of gentamicin.

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurses' station. This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger. A positive Tensilon test is indicated by a 4 to 5 min period of improved muscle tone and strength.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Nausea and vomiting Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take? Provide the client with water to test the gag reflex. Perform carotid massage. Notify emergency management services. Drive the client to the nearest medical facility.

Notify emergency management services. The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse should call the emergency management services.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? Obtain IV access. Keep the lights on when the client is sleeping. Place the client's bed in the high position. Keep a padded tongue blade available at the client's bedside.

Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

Oliguria The nurse should identify little to no urine output as possible manifestations of kidney rejection.

A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? Trendelenburg Semi-Fowler's Prone On the unoperated side

On the unoperated side The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? Stress incontinence Urge incontinence Overflow incontinence Reflex incontinence

Overflow incontinence These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Perforated tympanic membrane The client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test. The nurse should perform a Romberg's test to check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? Place suction equipment at the client's bedside. Apply an eye patch to the client's right eye. Avoid the use of warm water to wash the client's face. Provide range-of-motion exercises to the client's neck and shoulders.

Place suction equipment at the client's bedside. Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Administer a nitrate antihypertensive. Assess the client for bladder distention. Place the client in a high-Fowler's position. Obtain the client's heart rate.

Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side. The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? Extension of the arms Pronation of the hands Plantar flexion of the legs External rotation of the lower extremities

Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tract

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying. This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is developing a plan of care for a client who is postoperative following a pneumatic retinopexy to repair a detached retina. Which of the following interventions should the nurse include in the plan?

Position the client prone. The client is positioned on the abdomen if oil or gas is placed in the eye during the surgery. This position allows the injected bubble to float into position overlying the area of detachment and provide consistent pressure to reattach the retina.

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

Potassium Potassium levels are reduced by the process of diffusion during dialysis.

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

Potassium 2.9 mEq/L Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Prepare the client for mechanical ventilation. The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.) Protein Calcium Calories Phosphorous Sodium

Protein is correct. A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein. Phosphorous is correct. A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys. Sodium is correct. A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention. Calcium is incorrect. A client who has CKD is at risk for hypocalcemia due to an alteration in the conversion of vitamin D by the kidneys. Calories is incorrect. A client who has CKD requires adequate calories to meet metabolic needs.

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? Post a written schedule of daily activities. Use an overhead loudspeaker to announce events. Provide a consistent daily routine. Allow the client to choose free-time activities.

Provide a consistent daily routine. A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed. Furnish restraints at the bedside is incorrect. The nurse should not plan to restrain a client during a seizure, as this can cause harm to the client's muscles and limbs.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Provide client supervision. Limit client physical activity. Speak loudly to the client. Leave the television on continuously.

Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.) Provide oral fluids. Monitor for nausea. Maintain fetal position. Check level of consciousness. Check sensation in the toes.

Provide oral fluids is correct. Adequate hydration will decrease the risk of a spinal headache. Spinal headaches occur when cerebral spinal fluid (CSF) is decreased suddenly. Adequate hydration will aid in the replacement of CSF. Monitor for nausea is correct. Nausea and vomiting might occur with an increase in intracranial pressure or meningitis. If the client develops persistent nausea or vomiting, the nurse should monitor for other manifestations and report the findings to the provider. Additional findings to report include change in vital signs, headache, change in level of consciousness, nuchal rigidity, drainage, redness, or swelling at the puncture site. Check level of consciousness is correct. A change in the client's level of consciousness (LOC) might indicate meningitis or a loss of cerebral spinal fluid (CSF). Check sensation in the toes is correct. A lumbar puncture could cause injury to the spinal cord. The nurse should monitor the client's neurological status in both lower extremities. Sensation to touch and position should be checked, as well as the ability to flex toes and move the feet. The neurological exam should be modified to maintain the client in a flat, still position. A neurological deficit should be reported. Maintain fetal position is incorrect. Following a lumbar puncture (LP), the client should be kept flat and still, often in a prone position. This helps decrease leakage of cerebral spinal fluid (CSF) from the LP site. The fetal position is used during the LP procedure, not after.

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? Report of discomfort during dialysate inflow Blood-tinged dialysate outflow Dialysate leakage during inflow Purulent dialysate outflow

Purulent dialysate outflow Peritonitis is an inflammation of the peritoneum and a major complication of peritoneal dialysis. Manifestations of peritonitis include cloudy dialysate outflow, fever, nausea, and vomiting. If untreated, the client can become severely ill, progressing to bacterial septicemia and hypovolemic shock. Peritonitis can be prevented with meticulous site care. The nurse and client should wear a mask when accessing the catheter. Strict aseptic technique should be used when connecting and disconnecting the catheter.

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away Pushing away a painful stimulus is an expected response.

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum laboratory values? Potassium Phosphate Creatinine RBC

RBC Serum RBCs are decreased in clients who have chronic glomerulonephritis due to the decreased production of erythropoietin, the factor that stimulates production of erythrocytes.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? Apply restraints. Administer opioids. Darken the room. Reduce stimuli.

Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? Provide a nonskid mat to alleviate plate movement. Encourage the client to use his right hand when feeding himself. Remind the client to look for food on the left side of the tray. Encourage the use of the wide grip utensils.

Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? Intracranial pressure Serum electrolytes Temperature Respiratory status

Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Restrict head movement. The client should restrict head and eye movement to prevent further detachment prior to surgery.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen A rigid, boardlike abdomen is a manifestation of peritonitis.

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? Loss of consciousness lasting 30 to 60 min Glasgow Coma Scale score of 11 Nuchal rigidity Sensitivity to light

Sensitivity to light The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise.

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI)?

Serum creatinine 1.8 mg/dL The nurse should identify the client who has had an MI is at increased risk for the development of AKI due to decreased perfusion of the kidneys. An indication that the client is at risk for developing AKI is a creatinine level that is 1.5 times greater than the expected reference range. In an older female client, the expected reference range for creatinine is 0.5 - 1.2 mg/dL; therefore, a creatinine level of 1.8 mg/dL indicates the client has an increased risk for AKI.

A nurse is reviewing laboratory findings for four clients. Which of the following clients has manifestations of acute kidney injury?

Serum creatinine 6 mg/dL This finding is above the expected reference range. The expected reference range for creatinine is 0.5 mg/dL to 1.3 mg/dL depending on the client's gender and age. An elevated serum creatinine is a manifestation of impaired kidney function, such as with acute kidney injury.

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

Serum creatinine 7 mg/dL A serum creatinine of 7 mg/dL is a critical value that indicates serious impairment of renal function. Clients who have chronic glomerulonephritis usually develop the disease over 20 to 30 years. Gradual changes occur in the kidney resulting in atrophy and a decreased number of functioning nephrons.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Severe headache Bradycardia Blurred vision Oriented to person, place, and year

Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply). Slurred speech Bone pain Bradypnea. Pruritus Hypotension

Slurred speech is correct. Slurred speech is an expected finding of ESKD. Bone pain is correct. Bone pain is an expected finding of ESKD. Pruritus is correct. Pruritus is an expected finding of ESKD. Bradypnea is incorrect. Tachypnea, rather than bradypnea, is an expected finding of ESKD. Hypotension is incorrect. Hypertension, rather than hypotension, is an expected finding of EKRD.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? Edematous bruise on forehead Small drops of clear fluid in left ear Pupils are 4 mm and reactive to light Glasgow Coma Scale (GCS) score of 12

Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? Lactulose Sevelamer Sodium polystyrene Darbepoetin alfa

Sodium polystyrene (Kayexalate) Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? Speak to the client about one idea at a time. Ask the client to multi-task. Limit questions to yes and no answers. Focus on a single form of communication.

Speak to the client about one idea at a time. The nurse should speak using sentences that contain one clear thought or idea for better communication and understanding.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth. The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client's airway, breathing, and circulation is the highest priority.

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? Rotate assignment of daily caregivers. Provide an activity schedule that changes from day to day. Limit time for the client to perform activities. Talk the client through tasks one step at a time.

Talk the client through tasks one step at a time. The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. Suction the nostril. Notify the physician. Ask the client to blow his nose.

Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? The client has a 5 lb weight gain since yesterday. Flattened neck veins Oxygen saturation 93% Return of skin to previous position when the client's shin is palpated

The client has a 5 lb weight gain since yesterday. The nurse should identify that a gain of 2 lb per day is stable. A gain of more than 2 lb per day or 5 lb per week is an indication of fluid overload.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? The partner has placed locks at the top of the doors leading to the outside. The partner has hired a house cleaner. The partner has lost 20 lb in the past 2 months. The partner redirects the client when the client is frustrated.

The partner has lost 20 lb in the past 2 months. A large weight loss by the caregiver is an indication of caregiver role strain.

A nurse is caring for a client who has severe right wrist pain. Nurses' Notes 1200: Client has severe right wrist pain after a fall. Past medical history: Anemia, osteoporosis, and congestive heart failure Current Medications: Ferrous sulfate 325 mg PO daily, alendronate 70 mg PO once/week, furosemide 40 mg PO QD18 g IV started in the client's left antecubital0.9% sodium chloride IV infusion initiated at 150 mL/hr per provider's prescription 1315: Client requested pain medication. Rates pain as an 8 on a 0 to 10 pain scale. Client given 4 mg of IV morphine per provider's prescription. Following administration, the client became lethargic and respirations decreased to 6/min.Naloxone IV was administered per provider's prescription. Client is still lethargic at this time, but respirations have increased. Provider notified. Vital Signs 1200: Temperature 36.9°C (98.4° F) Apical Pulse 88/min Respiratory rate 20/minBlood pressure 118/78 mm Hg Pulse oximetry 97% on room air 1315: Temperature 37.2°C (99° F)Apical Pulse 76/min Respiratory rate 10/min and shallow Blood pressure 110/70 mm Hg Pulse oximetry 91% on room air Diagnostic Results 1230: Right wrist x-ray: non-displaced distal radius fracture

The client is at risk for developing __________ and __________. Respiratory acidosis is correct. An adverse reaction to morphine sulfate is respiratory depression. The client's respiratory rate has decreased from 20 to 10/min and are now shallow. Respiratory acidosis occurs when there is impaired respiratory function causing reduced oxygen and carbon dioxide exchange, leads to carbon dioxide retention. Hypervolemia is correct. The client is at risk for hypervolemia because of their history of congestive heart failure and the rate at which the IV solution is running at. Osteomyelitis is incorrect. The client is not at risk for developing osteomyelitis, which can occur in clients who have compound or surgically repaired fractures. Metabolic alkalosis is incorrect. The client is at risk for metabolic alkalosis at this time. Instead the client is at risk for another acid/base imbalance. Phlebitis is incorrect. There is no evidence to suggest that the client is at risk for phlebitis at this time.

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?

The medication should be applied on a regular schedule for the rest of the client's life. Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or decrease its production, or both. The client must continue the eye drops on an uninterrupted basis for life to maintain intraocular pressure at an acceptable level.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?

Urine output is less than 400 mL per 24 hr. Inadequate urinary output is associated with the oliguric phase of acute kidney injury. The minimum amount of urine needed to rid the body of metabolic waste products is 400 mL. Therefore, a client who is producing less than 400 mL of output in 24 hr is manifesting acute kidney injury.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? Sodium 165 mEq/L Potassium 5.2 mEq/L Urine specific gravity 1.020 Hct 62%

Urine specific gravity 1.020 In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the treatment is effective.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? Instruct the client to cough and deep breathe. Place the client in a supine position. Place a warming blanket on the client. Use log rolling to reposition the client.

Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?

Vertigo The nurse should expect a client who has an acoustic neuroma, a benign tumor of cranial nerve VIII, to manifest mild to moderate vertigo as time progresses.

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange? Monitor vital signs every 2 hr during the procedure. Warm the dialysate solution prior to instillation. Place the drainage bag above the level of the client's abdomen. Maintain the client in a left lateral position during dialysis.

Warm the dialysate solution prior to instillation. Pain during inflow of the dialysate is a common adverse effect when clients begin peritoneal dialysis. Warming the solution decreases discomfort.

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? Hyperactive reflexes Extreme thirst Weak, irregular pulse Hyperactive bowel sounds

Weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse is preparing to obtain a daily weight from a client who has chronic kidney disease. Which of the following actions should the nurse implement?

Weigh the client after he has voided. The nurse should have the client void before obtaining a daily weight.

A nurse is caring for a client. Nurses' Notes Hospital Day 1 1700: Client admitted to the medical surgical unit for reports of right leg swelling and pain. Area of redness and swelling noted to right thigh with small white pustule in center. Area is warm and tender to touch. Area marked with an indelible marker. Morphine and first dose of cefuroxime administered in the emergency department. Client is resting comfortably. 0800: Client alert and oriented to person, place, and time. Reports right leg pain interrupted sleeping; rates pain as 8 on 0 to 10 scale. Lungs clear bilaterally, respirations unlabored. Heart rhythm regular. Abdomen soft and non-distended, bowel sounds present all 4 quadrants. 0815: Client reports feeling lightheaded and dizzy. Vomited 300 mL emesis. Vital Signs 0800: Temperature 37.1 ˚C (98.8 ˚F) Heart rate 48/min Respiratory rate 14/min Blood pressure 122/84 mm Hg 0815: Heart rate 42/min Respiratory rate 10/min Blood pressure 108/62 mm Hg Provider Prescriptions Admission: Cefuroxime 250 mg po q12h (0800, 1600) Lovastatin 20 mg po qd with dinner (1800) Pantoprazole 40 mg po qd (0800) Morphine 30 mg po q4h prn for pain Propranolol 40 mg po bid, hold for apical pulse < 50/min (0800, 1600) Medication Administration Record Admission: 1800: Administered lovastatin 20 mg po 2100: Administered morphine 30 mg po Hospital Day 2 Medication Administration Record: 0800: Administered cefuroxime 250 mg po Administered pantoprazole 40 mg po administered propranolol 40 mg po Administered morphine 30 mg I The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report? Propranolol Cefuroxime Morphine Lovastatin Pantoprazole

When taking action, the nurse should identify that the 0800 administration of morphine and propanol were medication errors and require immediate intervention, provider notification, and documentation of the situation on an incident report. The client received 30 mg morphine via IV, however, the provider order is for the administration of 30 mg morphine PO, which indicates the medication was given via the wrong route. In addition, the usual starting dose for morphine given IV is 4 to 10 mg, which constitutes an overdose of medication. The nurse should assess the client for respiratory depression, notify the provider, and document the situation in an incident report. The client also received propranolol, which had a parameter to hold for apical pulse < 50/min. At the time of administration, the client's heart rate was 48/min. This constitutes a medication error and should be reported to the provider and documented in an incident report The nurse should continue to monitor the client's heart rate and blood pressure frequently until the vital signs return to baseline.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? pulse and blood pressure findings behavioral indicators and effect scheduled treatments and client illness a self-report pain rating scale

a self-report pain rating scale Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client's self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.