AH HESI V1 Study Guide

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide?

"Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." RATIONALE: Anger is a common emotional reaction when confronted with the diagnosis of a STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.

The registered nurse (RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.)

1. Older females. 2. School-age female. 3. Older males. 4. Adolescent males. RATIONALE: Hypoestrogenism and alkalotic urine are other age-related factors put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI.All individuals regardless of gender and/or age are at risk if the following conditions exist: vesicoureteral reflux, neuromuscular conditions, like Parkinson's disease, previous brain attacks, or the use of anticholinergic medications can all cause incomplete bladder emptying which can create bacterial overgrowth. Fecal and urinary incontinence contributes to poor perineal hygiene and bacterial growth.

The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result?

140 mg/dl. RATIONALE: The two hour postprandial level should be less 140 mg/dl for a young adult client.

Which client should be further assessed for an ectopic pregnancy?

A 24-year-old with shoulder and lower abdominal quadrant pain. RATIONALE: A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding.

Which client is at highest risk for compromised psychological adjustment after a hysterectomy?

A 29-year-old woman whose uterus ruptured after giving birth to her first child. RATIONALE: The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities.

Which client should the nurse assess first?

A 55-year-old newly admitted client complaining of jaw pain and indigestion. RATIONALE: The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury.

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care?

Achieve a sense of control. RATIONALE: The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan.

When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority?

Acute pain related to movement of the stone. RATIONALE: The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement".

The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)?

Administer medications for pain relief, shortness of breath, and nausea. RATIONALE: Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects are within the scope of practice for the PN.

A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action should the nurse implement next?

Administer the medication. RATIONALE: Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity.

The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching?

Altered sexual response. RATIONALE: Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men.

The registered nurse (RN) is caring for a client with acute pancreatitis and reviews the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis?

Amylase. RATIONALE: An elevated amylase level is associated with acute pancreatitis.

A client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help. How should the nurse explain the action of a synchronous pacemaker?

An electrical stimulus is discharged when no ventricular response is sensed. RATIONALE: The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the client's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium, stimulating it to contract when no ventricular depolarization is sensed.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information?

An image that describes metastatic sites of cancer. RATIONALE: PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis.

Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol?

Anticoagulation therapy. RATIONALE: The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria.

The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. Which information should the nurse provide the UAP?

Apply the blood pressure cuff to the arm on the nonoperative side. RATIONALE: Postoperatively, the nurse should instruct the UAP that blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury due to compromised lymphatic drainage. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.

A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure?

Assess for signs of bleeding and hypovolemia. RATIONALE: Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy. Having the client placed at right lateral position, not the left side, applies pressure at the biopsy site.

The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action should the nurse include in the client's plan of care?

Assist the client in coping with hot flashes. RATIONALE: Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client describes feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented?

Assist the client to ambulate in the hall. RATIONALE: Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus is passed, and distention is minimized by implementing early and frequent ambulation.

A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time?

Check for a pulse deficit. RATIONALE: A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condition occurs with atrial fibrillation.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

Cherry red color to the mucous membranes. RATIONALE: The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.

A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing the client?

Decreased color perception. RATIONALE: Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a global loss of vision so gradual that the client may not be aware of it.

What is the primary nursing problem for a client with asymptomatic primary syphilis?

Deficient knowledge. RATIONALE: An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?

Determine the time the client last voided. RATIONALE: Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next.

A client who just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse says during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection?

Discuss retesting to verify the results, which will ensure continuing contact. RATIONALE: Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education, retesting encourages the client to maintain medical follow-up and management.

A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement?

Document the finding as the only action. RATIONALE: Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time.

The unlicensed assistive personnel (UAP) reports that an 87-year-old client who is sitting in a chair at the bedside has an oral temperature of 97.2°F (36.4°C). Which intervention should the nurse implement?

Document the temperature reading on the vital sign graphic sheet. RATIONALE: A subnormal oral temperature of 97.2°F (36.4°C) is a common finding in elderly clients, so the nurse should document the findings and continue with the plan of care.

Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy?

Drinks a six pack of beer every day. RATIONALE: Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poorglucose control. Nephropathy is exacerbated by poor blood glucose control.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include?

Dry, itchy skin changes may occur. RATIONALE: Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritus.

The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider?

Dyspnea. RATIONALE: A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately.

A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)?

Evaluate the client's ability to adjust the voltage to control pain. RATIONALE: The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement?

Evaluate the effectiveness of narcotic analgesics. RATIONALE: Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.

After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement?

Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. RATIONALE: Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side with a pillow or sandbag under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for several hours to decrease the risk of bleeding from the biopsy site.

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make?

Exposure to cold environmental temperatures. RATIONALE: TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.

The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. Which position should the nurse ask the client to demonstrate to assess for asterixis?

Extend the arm, dorsiflex the wrist, and extend the fingers. RATIONALE: Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist, causing rapid, nonrhythmic extension and flexion of the wrist while attempting to hold position.

The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. Which precaution should the nurse implement?

Gloves should be worn during direct contact with the client's skin. RATIONALE: The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on contact precautions.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome?

Heart palpitations. RATIONALE: Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis.

The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further?

Increase in abdominal fat deposits. RATIONALE: An increase in the abdominal girth is a risk factor for the development of metabolic syndrome. According to the American Heart Association, men with a waist size 40 inches or larger and women 35 inches or larger double their risk factor of developing CAD and increase their chances 5Xs of developing DMII.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately?

Increased abdominal pain with rebound tenderness. RATIONALE: Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately.

A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis?

Inflammation is reduced by inhibiting prostaglandin synthesis. RATIONALE: Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, work by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.

The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement?

Irrigate the catheter. RATIONALE: Obstruction urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information?

Low impact exercise like walking, swimming, and water aerobics. RATIONALE: Low impact exercises that do not put additional pressure and strain or cause further harm to damaged joints, such as walking or swimming, are most beneficial to clients with osteoarthritis.Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage.

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which conclusion regarding this lab data is accurate?

Low risk for prostate cancer. RATIONALE: Clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer.

The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm 3and a platelet countof 160,000/mm 3. Which intervention is the primary focus in the client's plan of care for the RN to implement?

Maintain strict protective precautions. RATIONALE: The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection.

A client is admitted for reports of chest pain and aching for the past 4 days. The results for serum creatinine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings?

Myocardial damage that occurred several days earlier is best validated by serum troponin levels RATIONALE: an elevated serum troponin has become the cardiac marker of choice for diagnosing an acute MI. An elevated troponin will become evident with 2 to 3 hours of an MI in comparison to the CK-MB and other cardiac enzymes that can take up to 6 to 9 hours after the MI occurence

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take?

Provide cheese and bread to eat. RATIONALE: Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.:

The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)?

Pulse change from 85 to160 beats/minute lasting more than 10 minutes. RATIONALE: The RRT should be called to intervene for a postoperative client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time period.

The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider?

Rebound abdominal tenderness over right lower quadrant. RATIONALE: Right lower quadrant (RLQ) rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider.

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client states that sleep is fine but that the spouse has moved into the spare bedroom to sleep after returning home. The client states, "I guess we will never have sex again after this." Which response is best for the nurse to provide?

Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. RATIONALE: Sexual intercourse after an MI has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if the client does not experience shortness of breath or chest discomfort doing the stairs then it should be okay to resume sexual activity.

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?

Slow capillary refill in the digits with absent distal pulse points. RATIONALE: A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.)

Smoking can decrease the quantity and quality of sperm The first semen analysis should be repeated to confirm sperm counts Cessation of smoking improves general health and fertility RATIONALE: The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Teach measures to avoid the Valsalva maneuver. RATIONALE: The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide?

The cell count of the tumor reduces by half with each dose. RATIONALE: Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose.

A male client with a prostatic stent is preparing for discharge. Which information is most important for the nurse to provide the client prior to discharge?

The client should not be catheterized through the stent for at least three months. RATIONALE: A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement.

The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement?

The development of resistant strains of TB are decreased with a combination of drugs. RATIONALE: Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy.

The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client?

There is a radical change in appearance as a result of this surgery. RATIONALE: Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client.

A client with Meniere's disease is incapacitated by vertigo and is lying in bed, grasping the side rails, and staring at the television. Which nursing intervention should the nurse implement?

Turn off the television and darken the room. RATIONALE: To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimulant or rotational movement, such as sudden head movements or position changes, should be minimized. To effectively manage the client's symptoms, darken the room by minimizing fluorescent lights, flickering television lights, and distracting sounds.

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess?

Upper chest subcutaneous emphysema. RATIONALE: Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube.

The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing?

Urine output of 40 mL/hour RATIONALE: A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing.

What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit?

Use a bag-valve-mask resuscitator while removing the client from the area. RATIONALE: A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source.

Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)?

Use an end-tital CO2 detector. RATIONALE: The end-tidal carbon dioxide detector indicates the prescence of CO2tidal by a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff?

Wash hands after caring for the client. RATIONALE: The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.

Which assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment?

Wheezing becomes louder. RATIONALE: In an acute asthma attack, air flow may be so significantly restricted that breath sounds and wheezing are diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive.

A client in the preoperative holding area receives a prescription for midazolam IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement?

Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. RATIONALE: Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered.

The nurse is completing the health assessment of a 79-year-old client who denies any significant health problems. Which finding requires the most immediate follow-up assessment?

Yellowish discoloration of the sclerae. RATIONALE: In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment.

Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.)

pH 6 Sugar negative Bilirubin negative Specific gravity 1.015. RATIONALE: A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated.

A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardia infarction?

Oral contraceptives. RATIONALE: Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or stroke.

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide?

"Get involved with a support group. I will give you some names." RATIONALE: A support group provides a safe haven for the couple to share their feelings and experience, gain insight from others dealing with the same experience, and assure the couple that they are not alone in their situation.

A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed?

"I know I will miss having sexual intercourse with my husband." RATIONALE: Further teaching is needed in response to the client's misunderstanding of not being able to have sexual intercourse after a hysterectomy.

The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis?

"I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." RATIONALE: Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.

A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which explanation by the nurse accurately describes the client's fracture?

A fracture that bends or splinters part of the bone. RATIONALE: An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)?

Obtain a prescription for an adjusted dose of insulin. RATIONALE: Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.

A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching the client, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women?

African American women. RATIONALE: Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000).

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscope. What nursing interventions should be implemented in the immediate post-procedural period?

Allow the client nothing by mouth until the gag reflex returns RATIONALE: the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions.

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

Auscultation. RATIONALE: Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create inaccurate assessment of bowel sounds heard during auscultation.

The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies?

Avoid allergy medications that contain pseudoephedrine or phenylephrine. RATIONALE: OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.

A client with a recent history of blood in the stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.)

Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. RATIONALE: Preoperative preparation for proctosigmoidoscopy includes a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.

A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse?

Bluish periumbilical skin discoloration. RATIONALE: Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury.

Which instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home?

Catheterize every 3 to 4 hours. RATIONALE: The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home.

The nurse is caring for a client who is receiving chemotherapy for non-Hodgkin's lymphoma. Laboratory results reveal a platelet count of 10,000/mL. Which action should the nurse implement?

Check stools for occult blood. RATIONALE: Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds. Awarded 1.0 points out of 1.0 possible points.

A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse?

Chest x-ray indicating a mediastinal shift. RATIONALE: Immediate action is required for findings of a mediastinal shift, which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax.

A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the registered nurse (RN) what she should expect as a common treatment. What recommended plan of care should the nurse provide the client?

Cholecystectomy via laparoscopy. RATIONALE: The nurse should explain to the client that gall bladder surgical removal is most often recommended via laparoscopic excision.

A male client comes into the clinic with a history of penile discharge with painful, burning unrination. Which action should the nurse implement?

Collect a culture of the penile discharge. RATIONALE: Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge todetermine thecause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema?

Compress the flank and upper buttocks. RATIONALE: Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present.

Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis?

Cough brought on by swallowing. RATIONALE: A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately.

A client is recently diagnosed with systemic lupus erythematosus (SLE) and the registered nurse (RN) is assessing for common complications. Which symptom should the RN instruct the client to report immediately?

Fever related to infection. RATIONALE: Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately.

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider?

Fingerstick glucose of 300 mg/dl. RATIONALE: Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth.

A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. Which assessment finding is most important for the nurse to identify?

Flushed skin and headache. RATIONALE: The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing.

A client with osteoarthritis receives a prescription for naproxen. Which potential side effect should the nurse discuss with the client about this medication?

Gastrointestinal disturbance. RATIONALE: Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this medication be taken with food to avoid gastrointestinal upset.

The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. Which action should the nurse implement?

Give IV fluids with electrolytes RATIONALE: When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration.

A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next?

Give a sublingual nitroglycerin tablet. RATIONALE: After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation.

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract?

Have intercourse or masturbate at least twice a week. RATIONALE: The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids.

A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse (RN) identify in the client's history?

Heart failure (HF). RATIONALE: Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema.

The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply).

Hematemesis Gastric pain on an empty stomach Intolerance of spicy foods RATIONALE: Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan that increases the risk for cervical cancer?

Human papillomavirus. RATIONALE: According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.

A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the registered nurse (RN) which medication should she use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain?

Ibuprofen. RATIONALE: Ibuprofen, a nonsteroidal antiinflammatory drug (NSAID) provides the most effective relief for primary dysmenorrhea because it has antiprostaglandin properties.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing diagnosis for this client?

Impaired comfort. RATIONALE: In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection, which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "impaired comfort."

A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first?

Instill the first dose of nystatin vaginally per applicator. RATIONALE: Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms.

The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client?

It is slow to leave the stomach. RATIONALE: This type of diet is slowly digested and is slow to leave the stomach, thereby the possibility of dumping syndrome is reduced as a result of its density from proteins and fats, and the reduction of fluids.

A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect?

Leave the cream on the skin for 1 to 2 hours before the procedure RATIONALE: Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.

In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning?

Left lateral, supine, brief periods on the right side, and prone. RATIONALE: After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side is recommended because it prevents impaired circulation and reduces pain. The prone position helps prevent flexion contractures of the hips and prepares the client for optimal functioning and ambulating.

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique?

Maintains correct spinal alignment to protect the surgical area. RATIONALE: Log rolling technique maintains the spine in a straight superior-inferior plane and aligns the spine without movement while protecting the surgical area. This is particularly important when the procedure involves bone grafts that may take several weeks for the bone to fuse.

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete?

Measure the blood pressure. RATIONALE: Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured.

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome?

Metastatic cancer. RATIONALE: Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava.

The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different?

Method of insertion. RATIONALE: The best explanation of how a percutaneous endoscopic gastrostomy (PEG) tube differs from a gastrostomy tube (GT) is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used as it does not require general anesthesia and is less invasive. Insertion is performed with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall. It is held in place by a tiny plastic device called a "bumper" that holds the g-tube in place with a small water-filled balloon securing it against the abdominal wall.

While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement?

Monitor infusing IV fluids and any replacement blood products RATIONALE: Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products.

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.)

Nail polish Hearing aid Contact Lenses Partial Dentures RATIONALE: The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place.

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis?

New onset of coughing. RATIONALE: A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough, tachycardia, and an increased shallow respiration rate.

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan?

Nothing by mouth is allowed for 6 to 8 hours before the study. RATIONALE: The client should be NPO, to include smoking or chewing gum for at least 6 hours before the UGI study.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first?

Notify the client's healthcare provider. RATIONALE: Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider.

A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement?

Notify the healthcare provider. RATIONALE: Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication.

During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement?

Notify the surgeon RATIONALE: The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately.

The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, which action should the nurse implement?

Observe the client for coughing colored sputum after drinking a small amount of colored water. RATIONALE: To evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then the client should be observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water.

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate?

Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. RATIONALE: Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.

The nurse obtains a client's history that includes right mastectomy and radiation therapy for breast cancer 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy?

Pathologic fracture of two ribs on the right chest. RATIONALE: The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.

A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis?

Perform weight resistance exercises. RATIONALE: Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises is most important in the prevention of osteoporosis in postmenopausal clients.

The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding would indicate to the nurse that the client is at risk for diabetes insipidus (DI)?

Polydipsia. RATIONALE: A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst.

The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube?

Prepare the client for chest x-ray at the bedside. RATIONALE: A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?

Prevent the formation of effusion fluid. RATIONALE: Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid.

The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing?

Promotes CO 2 elimination. RATIONALE: Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to occur.

During the initial outbreak of genital herpes simplex in a female client, what should be the nurse's primary focus in planning care?

Promotion of comfort RATIONALE: The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority.

The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.)

Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head RATIONALE: Part of a client's s/p mastectomy teaching plan should include reporting evidence of inflammation at the incision site or the affected arm, and to avoid lifting or reaching above their head.

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?

Respiratory effort. RATIONALE: Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively.

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client?

Return to pre-illness weight. RATIONALE: MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan?

Risk for infection RATIONALE: A wound healing by secondary intention is an open wound that is at risk for infection and the location of the wound near the anal area increases the risk for infection even more so.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

Serosanguineous nasal drainage. RATIONALE: Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage?

Serum troponin. RATIONALE: Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB.

The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately?

Severe muscle pain. RATIONALE: A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching.

A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client?

The registered nurse (RN) case-manager for the unit with 1 year's experience. RATIONALE: The RN case-manager is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care.

Which method elicits the most accurate information during a physical assessment of an older client?

Use reliable assessment tools for older adults. RATIONALE: Specific assessment tools designed for an older adult consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. Examples of these tools include the Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), and skin breakdown risk (Braden Scale).

The nurse is assessing a client admitted from the emergency department with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.)

Vagal stimulation. Decreased duodenal inhibition Hypersecretion of hydrochloric acid. An increased number of parietal cells. RATIONALE: Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.