ATI Adult Medical Surgical

A client questions the nurse concerning the usual course of multiple sclerosis (MS). Which of the following is an appropriate response by the nurse? "Each client is different; we cannot predict what will happen." "I can see that you are worried, but it's too soon to predict what will happen." "Acute episodes are usually followed by remissions, which may last varying lengths of time." "It's too early to think about the future; let's focus on the present and take one day at a time."

"Acute episodes are usually followed by remissions, which may last varying lengths of time." The client has asked the nurse an information-seeking question. The nurse provides factual information while giving the client some realistic hope.

A client who works in carpentry is seen by the triage nurse. The client complains of severe right eye pain with a gritty sensation. When obtaining a history from this client, which question has the highest priority? "Do you have any allergies?" "What were you working with at the time the manifestations occurred?" "Were you wearing goggles or glasses at your job?" "Did you flush your eye out at work?"

"Did you flush your eye out at work?" The first action to decrease additional risk of injury is to flush out the eye as soon as possible after entry by a foreign body. If this was not done at the worksite, it needs to be done immediately.

A nurse is reinforcing teaching to a client recently diagnosed with systemic lupus erythematosus (SLE). Which statement made by the client indicates to the nurse an accurate understanding of the home management of SLE? "I will need to take prednisone when I am having an exacerbation of the disease." "I'm thankful this condition only affects the skin because I will just need to stay out of the sun." "A warm shower for 10 to 15 minutes every evening will really help to loosen up my joints." "A mild fever is common with SLE and usually does not require medical intervention."

"I will need to take prednisone when I am having an exacerbation of the disease." SLE is an autoimmune disorder characterized by flares or exacerbations with periodic remissions. It affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. Prednisone (Deltasone) is the medication most commonly given to decrease the body's inflammatory response and subsequently decrease pain in affected joints/organs/tissues and fatigue. Long-term therapy with corticosteroids pose significant side effects so clients are usually weaned off these medications when the exacerbation has subsided.

A client is diagnosed with endocarditis following rheumatic heart disease. Which comment made by the client indicates to the nurse that she understands discharge teaching in relation to endocarditis? "I will force fluids to prevent dehydration." "I will notify my doctor before I have invasive surgery or dental procedures." "I will stay on a low-protein and low-potassium diet." "I will wear a mask when I go out into crowds."

"I will notify my doctor before I have invasive surgery or dental procedures." Preventing a reoccurrence of rheumatic endocarditis is the goal of notifying the provider prior to invasive surgical or dental procedures. The client will need prophylactic antibiotic therapy prior to any invasive procedure that can result in risk for a streptococcal infection.

A client is experiencing stomatitis as a result of chemotherapy and radiation therapy. Which statement made by the client indicates to the nurse that reinforcement of teaching is necessary? "I will use a soft toothbrush or toothette for oral care." "I will use lemon and glycerine swabs after meals." "I will remove my dentures except while eating." "I will rinse my mouth frequently with hydrogen peroxide."

"I will use lemon and glycerine swabs after meals." This statement indicates that further teaching is necessary. Lemon and glycerin swabs promote drying and are irritating to mucous membranes. The client should not use lemon and glycerin swabs for oral care if she already has inflamed tissues inside the mouth.

When a nurse brings a hospitalized client with AIDS (acquired immune deficiency syndrome) the morning dose of zalcitabine (Hivid), the client states, "I have this awful burning sensation in my fingers and toes. They are numb and tingling." What response by the nurse is appropriate at this time? "I'll just give you half of the prescribed dose this morning." "Take the medication. It should begin to help the manifestations caused by AIDS soon." "I'll hold the medication and notify your provider immediately." "Let me know when the feelings subside, and I'll bring the medication back."

"I'll hold the medication and notify your provider immediately." Zalcitabine may cause peripheral neuropathy, characterized by numbness, tingling, burning, or pain of the extremities. This is also a common problem with didanosine (Videx), an antiviral agent used to treat clients with AIDS. If zalcitabine is not discontinued promptly when the client begins to show manifestations of peripheral neuropathy, it may become progressive and irreversible. Even if zalcitabine is discontinued promptly, the peripheral neuropathy may not be completely reversible. If, after discontinuing the medication, the manifestations improve, then zalcitabine may be reintroduced at half the previously prescribed dose.

A middle-adult assistive personnel (AP) is assigned to give a bath to a client with herpes zoster (shingles). The AP asks if this disease is contagious because there is an isolation sign on the client's door. Which response by the nurse would be appropriate at this time? "Adults have a natural immunity from casual exposure to children who have had chickenpox." "You should have immunity from the varicella vaccination you received as an infant." "You cannot get shingles if you have had chickenpox." "If you have had chickenpox, then you can care for this client without concern."

"If you have had chickenpox, then you can care for this client without concern." Varicella zoster is the causative agent of both chickenpox and herpes zoster. The virus that causes herpes zoster can only be passed on to others who have not had chicken pox and then they will develop chicken pox not herpes zoster. Herpes zoster is much less contagious than chicken pox. Clients with herpes zoster can transmit the virus if blisters are broken, so contact precautions should be taken by care providers who have not had chicken pox.

In preparation for a sigmoid colon resection, the nurse is reinforcing information about the colostomy that will be performed. Which statement by the client will require further clarification? "Because most of my colon is still intact and functioning, my stool will be formed." "My stoma will appear large at first, but it will shrink over the next few weeks." "My colostomy will begin to function 2 to 4 days after surgery." "My diet will have to change dramatically."

"My diet will have to change dramatically." This statement would need further clarification. Most clients require no change in their diet patterns: foods that were not well tolerated prior to surgery (gas-producing foods) will probably continue to be poorly tolerated after surgery. Clients are instructed to try foods and evaluate their effect upon the GI tract. TEST-TAKING STRATEGY: Whenever you are confronted with a question that asks for "further clarification" the CORRECT answer will be the INCORRECT choice.

A client has just received a cardiac pacemaker. Which statement by the client demonstrates to the nurse an understanding of the pacemaker's purpose? "The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular." "I don't have to take my antihypertensive medications since my pacemaker will regulate my body's blood flow." "Having a pacemaker means that I will never have a heart attack." "I cannot stand in front of our new microwave oven when it is on."

"The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular." Maintaining a regular heartbeat at a predetermined rate is the primary purpose of a cardiac pacemaker.

Hemodialysis and Peritoneal Dialysis: Assessment of an arteriovenous fistula

- Alert nurse of signs of disequilibrium syndrome such as nausea and headache - Check for thrill or bruit - Eat well balanced meals that include foods high in folate (beans, green vegetables) and increase protein

Cardiovascular Diagnostic and Therapeutic Procedures: PICC care

- Apply an initial dressing of gauze and replace with transparent dressing within 24 hours - An initial x-ray should be taken to ensure proper placement

Meningitis: Assessing for client findings

- Constant Headache -Stiff neck - Photophobia - Fever and chills - Nausea and vomiting - Altered LOC - Positive Kernigs and Brudzinski's signs

Pain Management: use of non pharmacological methods of pain relief

- Cutaneous (skin) stimulation- TENS, heat, cold, therapeutic touch and massage - Distraction (deep breathing, ambulation, visitors, TV and music) - Relaxation (meditation, yoga and progressive muscle relaxation -Imagery (focus on pleasant thoughts) - Elevation of extremities to promote venous return

Heart Failure and Pulmonary Edema: Recognizing manifestations of left sided heart failure

- Dyspnea, Orthopnea (SOB while laying down), nocturnal dyspnea - Fatigue - Displaced apical pulse (hypertrophy) - S3 heart sound (gallop) - Pulmonary congestion - Frothy sputum - Altered mental status - Decrease in urine output

Stroke: Caring for a client who has left sided hemiplegia (155)

- Observe extremities for injury - Apply an arm sling if client is unable to care for the affected extremity - Ensure foot rest is on wheel chair and ankle brace is on the affected foot - Instruct client to dress the affected side first

Diabetes Mellitus Management: teaching about self administration of insulin

- Rotate injection sites - Inject at a 90 degree angle. Aspiration is not necessary - Advise client to eat at regular intervals, avoid alcohol intake and adjust insulin to exercise and diet to avoid hypoglycemia - When mixing insulin's, draw up the shorter acting insulin into the syringe first and then the longer acting insulin.

Parkinsons disease: Expected findings

- Stooped posture - Slow, Shuffling gait - Slow speech - Tremors - Muscle rigidity - Bradykinesia/ Akinesia -Autonomic Symptoms - Difficulty chewing and swallowing - Drooling - Dysarthria - Difficulty with ADL's - Mood swings - Dementia

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Adminiser oxygen via a nonrebreather mask. -Initiate IV therapy with a large bore catheter -Insert NG tube -Administer ranitidine

Cardiovascular Diagnostic and Therapeutic Procedures: Teaching about a PICC

-Advise client not to immerse arm in water, to cover dressing site to avoid water exposure -Avoid BP in the arm with PICC

Pulmonary Embolism: Planning care for a client who is receiving enoxaparin

-Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma) -Monitor bleeding times (PT, aPTT and INR) -Monitor for side effects such as thrombocytopenia, anemia and hemmorhage

Fractures and immobilization devices: Prevent complications (787)

-Assess neurovascular status of the affected body part for every hour for 24 hours and Q4 hours after that - Maintain body alignment - avoid lifting or removing weights -Monitor pain level - Monitor for signs of infection - Support nutrition

Cardiovascular Diagnostic and Therapeutic Procedures: Caring for a client who has a PICC

-Assessing site every 8 hours. Note redness, swelling, drainage, tenderness and condition of dressing -Change tube and positive pressure cap per facility protocol -Using 10mL or larger syringe to flush the line -Cleanse with alcohol for 3 seconds before accessing it -Use transparent dressing

Cancer disorders: client teaching following partial glossectomy

-Client need for alternate communication following surgery -head of bed elevated to reduce edema -report leakage of fluid from the suture line or swallowing difficulty -thicken liquids -frequent oral hygiene

TB: Discharge teaching about TB

-Continue medication therapy for its full duration of 6-12 months -continue with follow-up care for 1 year -Sputum samples every 2-4 weeks, no longer contagious after 3 neg samples -proper hand hygiene -wear N95

Neurologic Diagnostic Procedures: Preparing for a lumbar puncture

-Instruct client to void before procedure and have them stretch over an overbed table if sitting is preferred - Monitor the puncture site for several hours to ensure the site clots and to decrease the risk of post lumbar puncture headaches

Meningitis: Planning interventions for care (53)

-Isolate client as soon as meningitis is expected -Implement fever reduction measures -report to public health department -Bed rest with HOB 30 degrees -Provide quiet environment and minimize exposure to bright light -Avoid coughing and sneezing which increased ICP -Maintain safety and seizure precautions

Cardiovascular and Hematologic Disorders: teaching client about food interaction with Warfarin

-Kale, spinach -Brussels sprouts -collard greens, mustard greens -green tea -grapefruit juice, alcohol

Pulmonary Embolism: Risk factors for DVT (258)

-Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) -Long bone fractures -Advanced age

Antibiotics affecting protein synthesis: Adverse effects of gentamicin

-Ototoxicity: cochlear damage (hearing loss) and vestibular damage (loss of balance). -Nephrotoxicity (proteinuria, elevated BUN, creatinine levels). -Hypersensitivity ( rash, pruritis, parathesia of hands and feet, and urticaria).

Rheumatoid Arthritis: Reviewing Laboratory Values

-Positive Anti- cyclic citrullinated peptide -RF Antibody (Diagnostic level for RA is 1:40-1:60) expected reference range 1:20 - Elevated ESR 20-40 mild inflammation 40-70 moderate 70-150 severe - Positive C-reactive protein - Positive ANA titier - Elevated WBC's

Hemodialysis and Peritoneal Dialysis: Intervening for decreased dialysate flow rate

-Reposition client -milk tubing -check tubing for kinks or closed clamps -Tell client to avoid constipation by taking stool softeners and consuming a diet high in fiber

Acute Kidney injury and chronic kidney disease: Evaluating teaching about nutrition

-Restrict dietary intake of potassium, phosphate and magnesium during oliguric phase -K and Na is regulated according to stage of kidney injury - high protein diet to replace the high rate of protein breakdown due to the stress from the illness. Possible TPN

Head Injury: indications of increased intracranial pressure

-Severe headache - Deteriorating LOC - Dilated, pinpoint or asymmetric pupils - Alteration in breathing pattern - Abnormal posturing - cerebrospinal fluid leakage

Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection (743)

-Urethral trauma -Urinary retention - Bleeding - Infection

TB: Priority action for a client in the emergency department (249)

-Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists

Nutrition Assessment: Caring for a client with pancreatitis

-increased serum glucose -reduce pancreatic stimulation through NPO; NG tube is inserted to suction gastric contents -snacks high in calories in order to maintain weight

A nurse is reviewing the medication history of a client who is to undergo allergy testing. The nurse should instruct the client to discontinue which of the following medications before the testing?

...

Acid base imbalance: Interpreting ABG results

1) Look at pH <7.35 acidosis >7.45 Alkalosis 2) PaCo2 and HCO3 <35 or >45 PaCO2 is respiratory <22 or >26 is metabolic

A nurse is providing dietary teaching to a client who is post-operative following a thyroidectomy with removal of the parathyroid glands the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet

12 almonds because they are the best source of calcium to recommend because they contain 36 milligrams of calcium removal of the parathyroid glands which regulate calcium in the body can result in hypocalcemia

A nurse is caring for a client who has a new prescription for tpn the client is to receive 2,000 kcalories per day the t-pn solution has 500 kcalories per liter the IV pump should be set at how many milliliters per hour

167 milliliters per hour

A nurse is preparing to administer amikacin 500 mg by intermittent IV bolus to a client. Available is amikacin mg in dextrose 5% in water (D5W) 200 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

400 mL/hr

A nurse on a medical-surgical unit is receiving change of shift report on four clients which of the following clients should the nurse identify as having the greatest risk for developing an infection

A client who has COPD and is receiving steroid therapy because of decreased oxygenation and increased mucus production additionally taking a steroid medication increases the client's risk for infection by suppressing the immune system and masking the presence of an infection

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A.) Throat

Emergency Nursing principles and management: Priority action for abdominal trauma (9)

ABCDE (Airway, breathing, circulation, disability and exposure)

Respiratory Failure: Manifestations of Acute respiratory failure

ABG values: Room air, PaO2 <60 and SaO2 <90 PaO2 >50 in conjunction with a pH less than 7.30 - lack of perfusion to the capillary bed

A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while receiving a blood transfusion which of the following medications should the nurse administer

Acetaminophen to reduce fever and decreased the manifestation of the febrile reaction manifestations of a febrile reaction include tachycardia fever hypotension and chills the nurse should discontinue the transfusion and return the blood bag and tubing to the blood bank

Hypertension: Action for hypertensive crisis

Administer IV anti-hypertensives therapies, such as nitroprusside, nicardipine and labetaolol Monitor BP every 5-15 minutes Assess neurological status Monitor Cardiac status

A nurse is caring for a client who is receiving tpn a new bag is not available when the current infusion is nearly completed which of the following actions should the nurse take

Administer dextrose 10% in water until the new bag arrives. Tpn Solutions have a high concentration of dextrose therefore if a t-pn solution is temporarily unavailable the nurse administer dextrose 10% or 20% and water to avoid a precipitous drop in the client's blood glucose level

A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first?

Administer morphine

A client who had a traumatic amputation of the arm at the elbow is reporting pain in the hand of the amputated limb. The client has dressing changes prescribed twice daily, hydrocodone (Vicodin) and gabapentin (Neurontin) PRN, and cefuroxime sodium (Ceftin) 750 mg 3 times daily IV. Which of the following actions by the nurse is appropriate? Administer prescribed dose of gabapentin (Neurontin). Administer prescribed dose of hydrocodone (Vicodin). Contact the provider for a change in the antibiotic prescribed. Increase the frequency of the dressing changes.

Administer prescribed dose of gabapentin (Neurontin). This client is experiencing phantom limb pain. Even though amputated limbs are no longer attached to the body, a client can feel pain in the amputated limb, especially after a traumatic amputation. Opiates are not effective for this type of pain. Beta-blockers, antispasmodics and anticonvulsants such as gabapentin, are more effective for treating this type of pain.

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Administer the medication at the same time each day. The nurse administer the medication to the client at the same time each day to maintain consistent serum levels

Immunizations: Recommended vaccinations for older adult clients (943)

Adults age 50 or older: -Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine -Hepatitis A - Hepatitis B - Meningococcal Vaccine

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints.

Emergency Nursing principles and management: Emergency Illness management (9)

Always assess airway, breathing and circulation FIRST

Arthoplasty: Pain control

Analgesics - opiods (epidural, PCA, IV, Oral) NSAIDS Continuous peripheral nerve block Ice or cold therapy to reduce swelling Head of bed slightly elevated and the affected leg in a neutral position. place a pillow or abduction device between the legs when turning to the unaffectedNe side

A nurse is caring for a client in acute renal failure. Which of the following manifestations should the nurse expect the client to exhibit? Anuria Polyphagia Weight loss Bradycardia

Anuria Anuria (no urine output) occurs during acute renal failure.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site

A nurse is preparing to administer an intramuscular injection. The most important action by the nurse to prevent direct injection of the medication into the venous system is to do which of the following? Aspirate the syringe after insertion of needle. Insert the needle at a 45º angle. Use the Z track method of injection. Inject the medication slowly.

Aspirate the syringe after insertion of needle. The syringe is aspirated by pulling back on the plunger to determine if any blood enters the syringe. If blood returns, the medication will enter the venous system if it is injected. Many intramuscular medications are not safe for intravenous administration.

Inflammatory Disorders: Assessing a client who has a friction rub

Assess lung sounds in all fields Friction rub occurs from -Pericarditis -Myocarditis -Rheumatic endocarditis

Electrolyte imbalance: Priority assessment for hypokalemia

Assessing for a patent and open airway

Hepatitis and Cirrhosis: Client positioning following a biopsy

Assist the client into a supine position with the upper right quadrant of the abdomen exposed

Medications affecting coagulation: Heparin Contraindications

Avoid NSAIDS while on heparin

A client has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do which of the following? Avoid intramuscular injections (IM). Administer oxygen via nasal cannula. Maintain a no visitors policy. Provide meticulous oral hygiene every 3 to 4 hr.

Avoid intramuscular injections (IM). The platelet count is dangerously low indicating thrombocytopenia (decreased platelet count). Any invasive procedure, such as an IM injection, can precipitate hemorrhage that may be difficult to stop. Bleeding precautions are necessary for this client.

A nurse is in a provider's office is providing teaching to a client who has a urinary tract infection and a new prescription for ciprofloxacin. Which of the following instructions should the nurse include

Avoid taking magnesium containing antacids with this medication. The nurse should instruct the client to take Ciprofloxacin either two hours before or 6 hours after taking an antacid but not to take Ciprofloxacin with an antacid because magnesium containing antacids decrease the absorption of Ciprofloxacin

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabes that contain separate categories of data.) Blood Pressure Prescribed medications Oxygen saturation BUN

BUN

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

BUN 34 mg/dL

A nurse is caring for a client who has a new diagnosis of hyperthyroidism which of the following is the priority assessment finding that the nurse should report to the provider

Blood pressure of 170 over 80 because using the Urgent vs. Non-urgent approach to client care the nurse determines that the priority funding is a systolic blood pressure of 170 which indicates that the client is at risk for thyroid storm

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia

A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity?

Bradycardia

A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect?

Bruit heard over the middle upper abdomen.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion.

Bubbling in the water-seal chamber has ceased.

A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color

C.) depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium

A nurse is providing teaching to a client who has hypothyroidism and is receiving Levothyroxine the nurse should instruct the client that which of the following could interfere with the absorption of the medication

Calcium supplements

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? Select all that apply.

Calf pain, numbness in the arms and intense headache. Calf pain is an indication of DVT and the client should report this finding to the provider immediately. Numbness in the arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement therapy and an intense headache can indicate a cerebrovascular accident.

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy when removing the dressing with the nurse notes that a large part of the bowel is protruding through the abdomen which of the following actions should the nurse take first

Call for help because evidence based practice indicates that the nurse should first stay with the client and call for assistance the client will require emergency surgery and is at risk for shock therefore the nurse should attain immediate assistance

A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour.

A nurse is assisting in admitting a client to the burn treatment center following the client's rescue from a house fire. Which observation takes the highest priority? Characteristics of the cough and sputum Estimation of burn injury Extent of edema formation Level of pain

Characteristics of the cough and sputum A client burned in a house fire has likely suffered a smoke inhalation injury as well. Consequently, observations of the client's respiratory status are of the highest priority. A productive cough with sooty sputum indicates smoke inhalation. Clients with smoke inhalation injury are at high risk for respiratory compromise and frequently require ventilatory assistance. TEST-TAKING STRATEGY: When confronted with a priority-setting data collection question in which all four options appear plausible, you should always think of you're ABCs: Airway, Breathing, Circulation. Observations should always follow that order. If a respiratory observation that is appropriate for the client is listed, it is likely to be the correct answer.

A nurse is caring for a client who is receiving plasmapheresis through a venous access site. Which of the following actions should the nurse take?

Check electrolyte levels before and after therapy. Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor the clients electrolyte levels before and after therapy.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer. According to evidence based practice the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the clients medication administration record.

A nurse making rounds finds a client in the waiting room who is confused, has clammy skin, and his hands are tremoring. The nurse should do which of the following? Check the client's blood glucose using a glucometer. Check the client's oxygen level using a pulse oximeter. Call a code blue. Implement seizure precautions.

Check the client's blood glucose using a glucometer. These are manifestations of hypoglycemia that are consistent with diabetes and a blood glucose level should be done to validate this suspicion. This client needs to be assessed for the presence of ketones in the urine, a blood sugar, and arterial blood gases to determine the degree of acidosis and elevation of the blood sugar.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall during the assessment the client states last week I crashed my car because my vision suddenly became blurry which of the following actions is the nurses priority

Check the clients neurologic status because the first action you should take is to assess the client

Head injury: Identification of altered respiratory patterns

Cheyne stokes respirations central neurogenic hyperventilation apnea

Asthma: Identifying pathophysiology

Chronic inflammatory disorder of the airways -Mucosal edema - Bronchoconstriction - Excessive mucus production - Dyspnea - Chest tightness - Anxiety/Stress -Wheezing -Coughing - Poor O2

A nurse is providing teaching to a female client who has a history of urinary tract infections which of the following information should the nurse include in the teaching

Clean the perineum from front to back after voiding or defecating to avoid introducing bacteria to the urethra

A client is brought to the emergency department following a fall. The nurse, suspecting a basilar skull fracture, should check the client for which of the following signs specific to a basilar skull fracture? A depressed fracture of the forehead Clear fluid coming from the nares Black-and-blue discoloration around the eyes A superficial hematoma on the skull

Clear fluid coming from the nares Clear fluid coming from the nares is associated with a basal skull fracture.

Hyperthyroidism: Caring for a client following a thyroidectomy

Client in high fowlers position, support head and neck with pillow and avoid neck extension check surgical site for excessive bleeding have trach supplies immediately available Hypocalcemia can occur

GI therapeutic procedures: Shortage of TPN Solution

Clients receiving TPN frequently need supplemental regular insulin. Keep dextrose 10% in water at the bedside in case the solution runs out. this minimizes the risk of hypoglycemia

A nurse asks a client who is diagnosed with asthma about the pathophysiology of the disorder. Further reinforcement of teaching is indicated when the client states that the cause of airway obstruction is due to which of the following? Edema of the bronchial membranes Collapse of the alveoli Constriction of the bronchioles Excessive production of mucus

Collapse of the alveoli Alveolar collapse does not contribute to an acute asthma attack. TEST-TAKING STRATEGY: Whenever you are confronted with a negative-response question like this, the CORRECT answer will be the INCORRECT choice.

Fractures and immobilization devices: Assessing for compartment syndrome (795)

Compartment Syndrome assessment: Pain Paralysis Paresthesia Pallor Pulselessness Intense pain with movement numbness, burning and tingling are early signs

A nurse is planning care for a client who is post-operative following a laparotomy and has a closed suction drain which of the following actions should the nurse take to manage the drain

Compress the drain Reservoir after emptying because it creates a vacuum that draws fluid out of the room through the drain and into the reservoir

Diabetes mellitus management: Recognizing Hypoglycemia

Confusion Shaking (tremors) Hunger Diaphoresis Tachycardia

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect

Constipation. A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism resulting and slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid and take to reduce the risk of constipation

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

Consume at least 30 g of fiber daily

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the primary care provider to clarify the prescription

Hemodynamic Shock: Priority intervention for hypovolemic shock

Continuously monitor airway and vital signs Administer fluids (0.9% NaCl or Lactated Ringers) Have resuscitation equipment available

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider?

Crackles heard on auscultation

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Disease process Laboratory findings Current medications Family history

Current medications

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish and ureterostomy. Which of the following statements should the nurse include in the teaching

Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma. The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to minimize irritation of the skin from exposure to urine

A client in a community clinic tests positive on a Mantoux skin test but does not demonstrate active lesions on a chest x-ray. When assisting with the development of the plan of care for this client, the nurse should reinforce that isoniazid (INH) therapy will have to be taken for which of the following time frames? For the rest of the client's life Until the client has a negative sputum sample Daily for approximately 1 year Until the client has a non-reactive Mantoux

Daily for approximately 1 year INH prophylaxis is taken for approximately 9 months to 1 year. However, in that time frame, noncompliance is a major problem and has contributed to the development of multiple medication-resistant strains of TB. The client will need to be monitored carefully to ensure compliance for the duration of the treatment period.

Cushing Disease/ Syndrome: Priority Actions

Daily weights Monitor I&O assess for hypervolemia monitor for skin breakdown

A nurse is developing a teaching plan for a client who has gout. Which of the following recommendations should the nurse include?

Decrease intake of purine meats

A nurse is assessing a client who has hypokalemia which of the following manifestations should the nurse expect

Decreased peristalsis due to a decrease in gastrointestinal smooth muscle contraction

A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment?

Decreased sodium

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment?

Decreased viral load

A client is diagnosed with active pulmonary tuberculosis and begins a treatment regimen of rifampin (Rifadin) and ethambutol (Myambutol). The nurse should reinforce with the client the need to report which of the following adverse effects to the provider? Red-orange discoloration of body fluids Anorexia Headaches Decreased visual acuity

Decreased visual acuity The most commonly reported adverse reaction to therapeutic doses of ethambutol is visual disturbance. This side effect will likely necessitate termination of ethambutol therapy because irreversible blindness can result.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy which of the following actions should the nurse take

Demonstrate ways to deep breathe and cough to prevent respiratory complications

Posterior Pituitary Disorders: Medications to treat diabetes insipidus

Desmopressin acetate (DDAVP) - Notify weight gain >2 lbs in 24 hours Cabamazepine (Tegretol) -Notify sore throat, fever or bleeding Vasopressin (Pitressin) - Notify headache or confusion

A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath. Which of the following actions is the priority for the nurse to perform prior to administering oxygen?

Determine if the client has a history of COPD. According to evidence based practice the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic hypercarbia in a client who has COPD

A client with type 1 diabetes mellitus has a capillary blood glucose reading of 48 mg/dL. Which of the following should the nurse expect to find? Kussmaul respirations Diaphoresis Decreased skin turgor Ketonuria

Diaphoresis Hypoglycemia is a complication that occurs in clients with insulin-dependent diabetes mellitus. Hypoglycemia develops when the client's blood glucose level is below 70 mg/dL and can occur secondary to a precipitous decrease in blood glucose that is still within the expected reference range. Common symptoms of hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion.

A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take?

Dispose of the medication

A nurse is assessing a client's hydration status. Which of the following findings indicated fluid volume overload.

Distended neck veins

A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker the nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take

Document that depolarization has occurred. When a pacing stimulus is delivered to The ventricle a spike appears on the ECG Rhythm strip this bike should be followed by a QRS complex which indicates pacemaker capture or depolarization

A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output?

Dopamine

A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse the reason for having two chest tubes. The nurse's response is based on the knowledge that the lower chest tube is placed to do which of the following? Remove air from the pleural space. Create access for irrigating the chest cavity. Evacuate secretions from the bronchioles and alveoli. Drain blood and fluid from the pleural space.

Drain blood and fluid from the pleural space. Blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity. For this reason, the lower chest tube is the one that primarily drains blood and fluid.

A nurse is caring for a client who underwent a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). The client's bladder is continuously irrigated with saline via a three-way catheter PRN. Which of the following findings should be reported immediately to the provider? An output less than the input coming from the catheter Report of bladder spasms Drainage that resembles ketchup coming from the catheter A report of feeling a strong urge to urinate

Drainage that resembles ketchup coming from the catheter Drainage that resembles ketchup coming from the catheter indicates arterial bleeding which should be reported to the surgeon.

A nurse is providing teaching to a client who has a new prescription for psyllium which of the following information should the nurse include in the teaching

Drink 240 milliliters of water after Administration

Seizures and Epilepsy: Seizure precautions

During a seizure: Position client on the floor and provide a patent airway, turn client to side and loosen restrictive clothing

A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place the priority on which of the following findings

Dysphasia because it indicates that the client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity

A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism.

Dyspnea

A nurse is completing the evening observations on a client in balanced skeletal traction admitted the previous evening for a fractured left femur. Which observation should the nurse report to the charge nurse? Swelling and bruising of the thigh Report of leg pain and at the pin site Dyspnea and chest petechiae Report of muscle spasms in the affected leg

Dyspnea and chest petechiae Dyspnea and chest petechiae are unexpected findings, suggestive of a fat embolus, which must be reported to the charge nurse. Clients with fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 24 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The charge nurse should be notified of this assessment immediately as the client may rapidly progress into acute respiratory failure and shock.

A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. The nurse should monitor for which of the following that is a manifestation of left sided heart failure? Swelling of the fingers and hands Jugular neck vein distension 3+ ankle edema Dyspnea with a cough that is worse at night

Dyspnea with a cough that is worse at night Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided heart failure causes blood to back up in the heart and lungs with decreased distribution of blood throughout the body.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect?

Elevated bilirubin level

A nurse is planning care for a client who is scheduled for a thoracentesis which of the following interventions should the nurse include in the plan

Encourage the client to take deep breaths after the procedure to read expand the lung

Supportive therapy provided by the nurse for a client during a sickle cell crisis would include which of the following? Scheduling frequent walks Applying cold compresses to painful joints Administering NSAIDs Encouraging the client to drink a lot of fluids

Encouraging the client to drink a lot of fluids Dehydration increases the viscosity of the blood which in turn increases sickling. Encouraging fluid intake to promote hydration is an appropriate action.

A nurses in an acute care facility is caring for a client who is at risk for seizures which of the following precautions should the nurse implement

Ensure that the client has a patent IV in the event that the client requires medication to stop seizure activity

A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies?

Enzyme immunoassay (EIA)

Dosage calculations: Calculating IV infusion rate

Ex: nurse is preparing to administer dextrose 5% in water 500 mL IV to infuse over 4 hours. The nurse should set the IV infusion pump to deliver how many mL/hr> -Volume (mL)/Time (hr) = X -500 mL/5hr = 125 mL/hr

A provider is planning to remove a client's chest tube. Which instruction should the nurse give the client to ensure understanding regarding the removal procedure? Breathe in through pursed lips. Take a deep breath and hold it. Exhale and bear down gently. Take shallow, rapid breaths.

Exhale and bear down gently. A gentle Valsalva maneuver is recommended to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

A nurse is reviewing the medical record of a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect?

Facial butterfly rash. A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks and nose and can disappear during times of remission.

A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing

Fractures and Immobilization devices: Assessing for complications (795)

Fat embolism: Dyspnea, chest pain and decreased oxygen saturation Decreased mental acuity Respiratory distress Tachycardia Tachypnea Fever Osteomyelitis: Constant bone pain Edema Fever Possible elevated sedimentation rate

Chest tube insertion and monitoring: Maintaining drainage system

First Chamber: Drainage collection Second Chamber: Water seal Third Chamber: Suction control Position client in semi-fowlers to high-fowlers position to promote optimal lung expansion - Tidaling with movement is expected in the water seal chamber - Cessation of tidaling in the water seal chamber signals lung reexpansion - Continuous bubbling in the water seal chamber (air leak finding)

A nurse is teaching an older adult client about osteoporosis prevention the nurse should instruct the client that which of the following medications can increase her risk for developing osteoporosis

Fludrocortisone due to an increase in bone resorption by osteoclasts it can also reduce intestinal absorption of calcium

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC?

Flush the PICC line with 10 mL NS before and after medication administration.

A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction?

Flushing

A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? Select all that apply.

Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet and increase fluid intake. Smoking cessation is an important lifestyle modification to prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.

Arthroplasty: Preventing complications following hip arthoplasty

Follow position restrictions to avoid dislocation - use elevated seating - straight chairs with arms - abduction pillow or a pillow between client legs - externally rotate toes

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

Ginkgo biloba can cause an increased risk for bleeding.

A nurse is caring for a client who has dka which of the following findings should indicate to the nurse at the client's condition is improving

Glucose of 272 because a glucose reading less than 300 indicates Improvement in the client's status

And your sis reading teaching to a client who has hypertension and a new prescription for Verapamil. Which of the following juices should the nurse instruct the client to avoid

Grapefruit because it inhibits the hepatic metabolism of the medication and then place the current client at risk for toxicity

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching?

Grilled chicken breast

A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

HGB of 8. The nursery report and HGB level of 8 which is below the expected reference range and as an indicator of postoperative hemorrhage or anemia.

A nurse is assessing a client who has peripheral artery disease which of the following findings should the nurse expect

Hair loss on the lower legs the nurse should expect a client who is Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth

When reinforcing health teaching to a group of clients, it is important for the nurse to emphasize that melanoma is characterized by lesions that have which of the following appearances? Are predominantly one solid color Are symmetrical in shape Are less than 6 mm in diameter Have an irregular border

Have an irregular border Using the ABCD mnemonic, a melanotic skin lesion may exhibit one or more of the following characteristics; asymmetry of the shape, border irregularity, color that varies within the lesion, and a diameter that is 6 mm or greater.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

Heart rate 52/min

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit

Heart rate of 110 per minute

A nurse is caring for a client who presents to a clinic for a one-week follow-up visit after hospitalization for heart failure based on the information in the clients chart which of the following findings should the nurse report to the provider

Heart rate of 55 per minute is a significant drop from the clients Baseline of 74 permanent and it can indicate the development of digoxin toxicity

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?

Hemodialysis is sometimes needed following surgery.

A nurse is providing teaching to a client who has asthma about the use of a metered dose inhaler the nurse should identify that which of the following client actions indicates an understanding of the teaching

Holding breath for 10 seconds after inhaling so that the medication can move deep into the Airways

A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis

Hyperkalemia as a result of kidney failure because kidney failure results in decreased excretion of potassium

Fluid Imbalances: Clinical manifestations of Dehydration

Hyperthermia tachycardia thready pulse hypotension decreased CVP tachypneic hypoxia dizziness syncope confusion thirst decreased cap refill

Fluid imbalances: Assessment findings

Hypo: Increased Hct Increased urine specific gravity increased serum sodium Hyper: Decreased Hct Normal sodium decreased electrolytes, BUN and creatinine Respiratory alkalosis

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia

Electrolyte Imabalances: Increasing the risk for digoxin toxicity

Hypokalemia and client receiving digoxin increases the risk for digoxin toxicity

A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock?

Hypotension

COPD: Expected ABG results

Hypoxemia (decreased PaO2, less than 80) Hypercarbia (increased PaO2, greater than 45) Respiratory acidosis, metabolic alkalosis compensation

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching question mark

I am dieting to lose weight. Excess weight cut creates increased abdominal pressure that can result in stress incontinence.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

I am taking this medication to increase my energy level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When the medication is effective the client should have a decreasing fatigue and an improvement and activity tolerance.

A nurse is providing instructions to a client who has Type 2 diabetes mellitus and a new prescription for metformin which of the following statements by the client indicates an understanding of the teaching

I should take this medication with a meal to improve absorption and to minimize gastrointestinal distress

A nurse is providing discharge instructions to a client who has laryngeal cancer and received is receiving radiation treatment which of the following statements by the client indicates an understanding of the teaching

I will avoid direct exposure to the Sun because the client should avoid exposure of irradiated skin areas to the Sun for at least one year after completing radiation therapy skin in the radiation path is especially sensitive to sun damage

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching?

I will count my heart beats before taking this medication.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

I will eat more high-fiber foods. The client should eat high-fiber foods to help prevent constipation which is a common adverse effect of oral iron supplements.

A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the following statements by the newly licensed nurse indicates an understanding of the teaching

I will leave assessment equipment in the room to use on this client the nurse should follow contact precautions and use dedicated equipment when assessing the client to prevent cross-contamination with other clients

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

I will monitor my blood pressure while taking this medication.

A nurse is providing teaching to a client who has Type 1 diabetes mellitus and a new prescription for insulin lispro which of the following statements by the client indicates an understanding of the teaching

I will need to take this bro in addition to my other prescribed insulin because it is a rapid-acting insulin that the client can use in conjunction with an intermediate or long-acting insulin

A nurse is providing teaching to a client who has AIDS which of the following statements by the client indicates an understanding of the teaching

I will take my temperature once a day a client who has AIDS is immunocompromised and is at risk for infection the client should take his temperature daily to identify a temperature greater than 100 degrees which is an early manifestation of an infection

A nurse is providing discharge teaching to a client who is to self administer heparin subcutaneously. Which of the following responses by the client indicates an understanding of the teaching

I will use an electric razor to shave. Heparin is an anticoagulant that places the client at risk for bleeding therefore the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

I will use my hands rather than a washcloth to clean the radiation area.

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands teaching?

I will wear clean graduated compression stockings everyday. The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?

INR 2.5

A nurse in an emergency department is caring for a client who has full thickness Burns over 20% of his total body surface area after ensuring a patent Airway and administering oxygen which of the following items should the nurse prepared to administer first

IV fluids to provide circulatory support

Electrolyte imbalances: Treatment of hypokalemia

IV potassium supplement Never administer IV bolus Encourage foods high in K

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

Cancer treatment options: Protective Isolation (999)

If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless be needs to leave for a diagnostic procedure, in case of transport place a mask on him - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production

Which client problem should receive highest priority when a client is admitted with an acute exacerbation of rheumatoid arthritis? Difficulty with hygiene and grooming Impaired physical mobility Body-image disturbance Anxiety

Impaired physical mobility When setting priorities for nursing care, physiological needs should be addressed first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as hygiene and grooming.

A nurse is caring for a client who has a positive culture for Clostridium difficile which of the following actions should the nurse take

Implement contact precautions for the client because direct contact is the mode of transmission

A nurse is caring for a client who recently had a stroke of the right hemisphere which of the following manifestations should the nurse expect

Impulsive behavior

A nurse is providing teaching to a client who has irritable bowel syndrome which of the following instructions should the nurse include in teaching

Increase fiber intake to at least 30 grams per day to produce bulky soft stools and establish regular bowel patterns

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake

A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock?

Increased heart rate

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions

A nurse is reviewing the laboratory results of a client who has a new diagnosis of acute leukemia which of the following findings should the nurse identify as an expected finding

Increased white blood cell count do to overproduction of white blood cells by the bone marrow

Blood and blood product transfusions: Administering Fresh Frozen Plasma

Initiate a large bore IV access: 20 gauge needle Complete transfusion withing 2-4 hours time frame If reaction occurs: -Stop transfusion immediately - Initiate 0.9% NaCl in a separate line - Save blood bag and blood tubing

A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions

A nurse is planning care for a client who was having a modified radical mastectomy of the right breast which of the following interventions should the nurse include in the plan of care

Instruct the client that the drain is removed when there is 25 milliliters of output or less over a 24-hour period the drain will remain in place for one to three weeks after surgery and we've removed when there is 25 milliliters of output or less in a 24-hour period

A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for him.

A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte disturbance associated with this diagnosis, the nurse should observe the client for evidence of which of the following? Elevated blood pressure Involuntary muscle spasms Cold intolerance Weight loss

Involuntary muscle spasms A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels), which may cause tetany. Involuntary muscle spasms are a common symptom associated with hypothyroidism.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

Irrigate the indwelling urinary catheter

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

It's like a curtain closed over my eye.

A nurse is planning acre for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client's room

A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the nurse should instruct the client to do which of the following? Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures. Keep moist heat on the ankle to prevent muscle spasm. Keep the foot in a dependent position to aide circulation to the foot. Keep ice on the ankle to prevent edema.

Keep ice on the ankle to prevent edema. Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse transmission will also be reduced, resulting in analgesia to the injured area and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min per application.

a nurse is caring for a client who had an open thoracotomy with chest tube insertion which of the following actions should the nurse take

Keep the chest tube collection chamber below the level of the lungs

A client is returning from surgery with a radium implant for the treatment of endometrial cancer. In planning this client's care, which action would be consistent with the client's diagnosis? Talking with the client about ways to deal with alopecia Encouraging the client to do active range of motion exercises Keeping forceps and lead container in room Restricting all visitors while the implant is in place

Keeping forceps and lead container in room Forceps and a lead container should be kept in the room for use if the implant slips out of the client.

IV therapy: Medication administration

Know -Right Patient -Right drug -Right Dose -Right Time -Right Route

A nurse is caring for a client with arteriosclerosis. When reviewing the client's chart, which of the following factors should the nurse realize is associated with the development of arteriosclerosis? Cholesterol level is 195 mg. HDL serum levels are elevated. LDL serum levels are elevated. Cholesterol level is 135 mg.

LDL serum levels are elevated. Elevated LDLs increases a client's risk for arteriosclerosis. The high lipoproteins should be HIGH and the low should be LOW, and the very low should be VERY LOW.

A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take?

Leave a stethoscope in the room for blood pressure monitoring.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?

Listen with the client on his left side. When providing nursing care the nurse should first use the least invasive intervention. Therefore after auscultating a murmur the first action the nurse should take is to place the client on his left side and listen to his heart again.

Heart failure and pulmonary edema: treatment of cardiomyopathy

Loop Diuretics (Lasix) Afterload reducing agents: Ace Inhibitors (Enalapril) Inotropic agents: Digoxin Beta Blockers: Metoprolol Vasodilators: Nitroglycerine

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

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

Low urine specific gravity

A client who had a craniotomy is sitting in a chair with the nurse present in the room. While the client is sitting, he begins to experience a grand mal seizure. At this time, the most important nursing intervention is which of the following? Provide oxygen. Turn the client onto his side. Provide privacy. Lower the client to the floor.

Lower the client to the floor. When a client begins to have a seizure while sitting or standing, the nurse should gently lower the client to the floor to protect the client from injury; therefore, this intervention has the highest priority.

Respiratory management and mechanical ventilation: caring for a client who has an ET tube

Maintain a patent airway -assess the position and placement of tube - Suction oral and tracheal secretions to maintain tube patency - Soft wrist restraints - Maintain cuff pressure below 20mm Hg

Burns: Priority action during resuscitation phase

Maintain airway and ventilation rapid fluid resuscitation (0.9% NaCl or LR's)

Heart failure and pulmonary edema: Dietary teaching about sodium restriction

Maintain fluid and sodium restriction Increase dietary intake of potassium

Pain management: Interventions to promote postoperative recovery

Managing acute severe pain with short term around the clock administration of opiods parental route is best for immediate short term relief

Acute kidney injury and chronic kidney disease: Metabolic changes associated with chronic kidney disease

Metabolic acidosis

Diabetes Mellitus Management: Sick Day Management

Monitor blood glucose every 3-4 hours Continue to take insulin or oral hypoglycemia agents consume 4oz sugar free liquid every 30 minutes meet carb needs with soft foods Test urine for ketones

Anemias: Administering Epoetin Alfa

Monitor for an increase in blood pressure Monitor Hgb and Hct twice a week

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care?

Monitor the client for confusion

Diabetes Mellitus Management: Evaluating Glycemic Control

Monitor with HbA1c expected reference range is 4-6% acceptable target for clients with diabetes 6.5-8% indicator of average blood glucose for the past 120 days

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

My joints ache because I have Lyme disease.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking Feverfew to prevent her headaches the nurse should identify that which of the following client medications interact with Feverfew

Naproxen because they both impaired platelet aggregation and place the client at risk for bleeding

Gastrointestinal Therapeutic Procedures: Ostomy complications

Necrosis: pale pink or bluish/purple in color intestinal obstruction: abdominal pain, absent bowel sounds, distention, n/v

GI therapeutic procedures: D/C TPN therapy

Never abruptly stop TPN, gradually decrease (10%) to allow body adjustment. Monitor vital signs q 4-8 hours

Angina and MI: Client teaching about nitroglycerin

Nitrogylcerin prevents coronary artery vasospasm and reduces preload and afterload. Used to treat angina and help with BP. - Place nitro under tongue to dissolve - Take up to two more doses of nitro at 5-min intervals - Stop activity and rest Headache is a common side effect Orthostatic hypotension

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Nonrebreather mask

A nurse is caring for a client who has an arteriovenous fistula for dialysis which of the following requires intervention by the nurse

Numb fingers distal to the fistula it indicates impaired circulation and requires intervention

Disorders of the eye: Age related macular degeneration

Number 1 cause of vision loss in people <60 Dry Macular Degeneration: Smokers HTN Female Short body stature Family History Diet lacking carotene and Vitamin A - Lack of depth perception - Distorted objects - Blurred vision - Loss of central vision - Blindness

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs

Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood pressure of 204/102 mm Hg. The client is also incontinent of urine. When contributing to the client's plan of care, which nursing action would be appropriate? Offer the client a bedpan every 2 hr. Place an adult diaper on the client and check every 2 hr. Request a prescription for an indwelling urinary catheter from the client's provider. Ambulate the client to the bathroom every 4 hr.

Offer the client a bedpan every 2 hr. The effects of a TIA are usually temporary, and the nurse should try to help the client regain bladder control. This option helps the client regain bladder control, uses an appropriate time interval (2 hr) for bladder training, and keeps the client safe by maintaining bed rest.

Disorders of the eye: Indications of Glaucoma

Open Angle - Headache - Mild eye pain - loss of peripheral vision - decreased acommodation - Elevated IOP (>21) Angle- Closure - Rapid onset of elevated IOP - Decreased or blurred vision - Halos around lights - non reactive pupils - severe pain and nausea - photophobia

An assistive personnel (AP) discovers a fire in the utility room. Which action by the AP would require the nurse to intervene? Turning off electrical equipment Moving clients who are in the immediate area of the fire Opening the doors and windows to let the smoke out Activating the nearest fire alarm

Opening the doors and windows to let the smoke out Opening doors and windows makes the fire worse by providing more oxygen. Doors and windows should be shut.

A nurse is caring for a client who has a prescription for Enalapril the nurse should identify which of the following findings as an adverse effect of the medication

Orthostatic hypotension because dilation of arteries and veins causes orthostatic hypotension which is an adverse effect of Enalapril

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

Paco2 of 56. A client who has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area and lungs for gas exchange and causes the paco2 to increase above the expected reference range.

Rheumatoid Arthritis: Client teaching about early indications

Pain at rest with movement Morning stiffness fatigue joint swelling warmth and erythema

A nurse is assessing for compartment syndrome in a client who has a short leg cast which of the following findings should the nurse identify as a manifestation of this condition

Pain that increases with passive movement because compartment syndrome results from a decrease in blood flow in the extremities because of a decrease in the muscle compartment size due to a cast that is too tight

Anemias: Manifestations of anemia

Pallor Fatigue irritability dypnea sensitivity to cold tachycardia bright red tongue (vit b12 deficiency)

a nurse is caring for a client who is experiencing supraventricular tachycardia upon assessing the client the nurse observes the following findings heart rate 200 per minute blood pressure 78 over 40 and respiratory rate 30 per minute which of the following actions should the nurse take

Perform synchronized cardioversion

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip. (Click on the audio button to listen to the clip.) Murmur S4 Pericardial friction rub Ventricular gallop

Pericardial friction rub

A nurse is providing medication teaching to a group of clients who have seizure disorders which of the following information should the nurse include about phenytoin

Phenytoin decreases the effectiveness of oral contraceptives because it stimulates the synthesis of hepatic enzymes which can decrease the activity of other medications including oral contraceptives

Which nursing action is appropriate when trying to control epistaxis? Have the client learn forward and gently blow clots from the nose. Instruct client to sit with head hyperextended. Apply ice compresses to the client's forehead and the back of the neck. Pinch the soft portion of the nares for 10 to 15 min.

Pinch the soft portion of the nares for 10 to 15 min. Applying direct pressure by pinching the nares for 10 to 15 min is effective to control the bleeding of most episodes of epistaxis.

A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the clients legs. The nurse should place a pillow between the clients legs to prevent hip dislocation.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution because the pressure from an artery is greater than that of the line

A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.

Place body weight on the crutches Advance the unaffected leg onto the stair shift weight from the crutches to the unaffected leg and then bring the crutches and the affected leg up to the stair

A nurse is caring for a client who has bilateral pneumonia and an spo2 of 88% the client is dyspneic and productive cough and is using accessory muscles to breathe which of the following actions should the nurse take first

Place the client in a high Fowler's position

A client is admitted to the ER with anxiety loss of muscle coordination and skin is hot and dry the client had been working on the yard prior to coming to the hospital which of the following actions should the nurse anticipate taking first

Place the client on a cooling blanket because these findings indicate the client is at greatest risk for hyperthermia

A client with glaucoma is admitted for surgery the following day. The client is to continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this medication, an appropriate nursing action is which of the following? Instruct the client to blink several times after instillation of the medication. Ask the client to look straight ahead. Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min. Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation.

Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min. Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.

A nurse is planning care for a client who is post-operative following a parathyroidectomy which of the following actions should the nurse identify as the priority

Placed a tracheostomy tray at the bedside in case of Airway obstruction

A client diagnosed with viral encephalitis secondary to West Nile Virus is admitted to the hospital for treatment. When assisting in the development of a nursing care plan, which interventions are consistent with the client's diagnosis? (Select all that apply.) Place the client on respiratory isolation. Monitor vital signs every 4 hr. Assess neurological status every 4 hr. Assess for Brudzinski's sign. Implement seizure precautions.

Placing the client on respiratory isolation is incorrect. West Nile Virus is an arbovirus. It can be transmitted to humans only after a person is bitten by an infected organism such as the tick. The infection cannot be transmitted person-to-person as with viral or bacterial infections. Monitoring vital signs every 4 hr is correct. It is important to monitor vital signs to assess for changes consistent with increased intracranial pressure. Assessing neurological status every 4 hr is correct. Neurological status should be monitored at least every 4 hr or more frequently as the client's status may indicate. The course of encephalitis is unpredictable, so the client must be monitored closely for any signs of deteriorating neurological functioning. Assessing for Brudzinski's sign is correct. Brudzinski's sign is assessed by placing the client on the back and forcibly bending the neck forward. If positive, a reflexive flexion of the knees occurs, indicating meningeal irritation, which is one of the major clinical manifestations of viral encephalitis. Implementing seizure precautions is correct. Due to the inflammatory response of the brain to the arbovirus the client is at risk for seizures. Precautions should be implemented to ensure client safety if a seizure does occur.

A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes? (Select all that apply.) Polyuria Dysphagia Polydipsia Photophobia Neuropathy

Polyuria Polydipsia Neuropathy

Respiratory Diagnostic Procedures: Client positioning for thoracentesis

Position the client sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well supported

A nurse is reviewing the medication history of a client who is to undergo allergy testing the nurse should instruct the client to discontinue which of the following medications before testing

Prednisone because it is a glucocorticoid that can cause the client to have false negative test results they should discontinue antihistamine medications several weeks prior to testing

ECG and Dysrthymia monitoring: Performing 12 lead ECG

Prepare client for 12 lead if prescribed - Position client in supine position with chest exposed - wash skin to remove oils - Attach one electrode to each of the clients extremities by applying electrodes to flat surfaces above the wrist and ankles and the other 6 electrodes to the chest, avoiding chest hair. Instruct client to remain still

A nurse in an emergency department is planning care for a client who has a flail chest on the right side following a motor vehicle crash which of the following actions should the nurse plan to take

Prepare the client for positive pressure ventilation to promote lung expansion and stabilize the pressure within the client's chest then there should also administer analgesics to alleviate pain while breathing to achieve optimal lung reexpansion

A nurse is caring for a client who has undergone a hip arthroplasty. The nurse reminds the client that the purpose of an abduction pillow following arthroplasty is to do which of the following? Raise the bed linens off the client's feet preventing plantar flexion. Keep the client's heels off the bed to prevent pressure ulcers. Position the client off of the operative site while in bed. Prevent dislocation of the hip during position changes or movement.

Prevent dislocation of the hip during position changes or movement. Total hip arthroplasty is a surgical procedure to reconstruct a diseased hip joint. The head of the femur is removed, along with the lining of the acetabulum (hip socket). The head of the femur is replaced with a metal ball and stem, and the acetabulum is replaced with a plastic or metal cup. Following surgery, the client must be on "hip precautions" to prevent dislocation of the new hip joint. The abduction pillow is a wedge-shaped pillow that is placed between the legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body following total hip replacement during position changes or client movement. TQLogicTM The most important step of TQLogic used in answering this question is comprehension and relies on basic nursing knowledge. In examining the critical element of the test question, the issue of the question is the purpose of an abductor pillow following hip arthroplasty. An abduction pillow or splint is used following total hip arthroplasty to prevent adduction beyond the midline of the body and prevent possible dislocation.

While reviewing an admission assessment for a client with an exacerbation of asthma, the nurse learns the client has several food allergies. The most important nursing action in promoting this client's safety is to do which of the following? Place an allergy bracelet on the client's wrist. Provide the dietitian with a list of the client's allergies. Observe the client carefully for signs of anaphylaxis. Have epinephrine available on the clinical unit.

Provide the dietitian with a list of the client's allergies. Providing the dietitian with a list of the client's allergies will most likely prevent the client from being served a tray with a hidden allergen. A hidden allergen may be an ingredient used in the preparation of the meal. This is the highest risk to the client.

Hematologic Diagnostic Procedures: Laboratory findings to report

RBC: 4.2-5.4 and 4.7-6.1 WBC: 5-10,000 Platelets: 150-400,000 Hgb: 12-16 and 14-18 Hct: 37-47% and 42-52% PT: 11-12.5 sec aPPT: 1.5-2 times normal range of 30-40 INR: 2-3 on warfarin

A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following? Remain NPO 6 to 8 hr prior to the EEG. Receive a sedative the night prior to the EEG. Receive a thorough shampoo prior to the EEG. Have no dietary restrictions prior to the test.

Receive a thorough shampoo prior to the EEG. The client's hair must be washed thoroughly prior to the EEG. Hairsprays, oils, and other hair preparations interfere with recording results of the EEG.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

Regular insulin 20 units IV bolus

A client diagnosed with emphysema is being prepared for discharge. Which instruction reinforced by the nurse would be beneficial for improving the client's gas exchange? Reinforcing teaching for the client to use pursed-lip breathing Encouraging the client to limit fluids to 1,500 mL per day Demonstrating the proper technique for chest breathing Reinforcing teaching about home oxygen therapy at 5 L/min

Reinforcing teaching for the client to use pursed-lip breathing Pursed-lip breathing slows expiration, prevents collapse of lung units, and facilitates effective gas exchange.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 min of the infusion.

A provider prescribes a confused and combative client to be placed in a jacket restraint and wrist restraints. To prevent injury to the client, the most important nursing action is which of the following? Remove the restraints and observe the extremities for circulation at least every 2 hr. Explain the reason for the restraints to the client and the client's family. Use a square knot when securing the restraint to the bed frame. Document the use of restraints in the client's chart.

Remove the restraints and observe the extremities for circulation at least every 2 hr. Skin, nerve, and musculoskeletal injuries to the client are a possibility as a result of poor circulation caused by the restraints if they are not removed at intervals for careful observation. This nursing action is also the only option listed that will help prevent injury.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory Paralysis

The client's arterial blood gas (ABG) levels are pH 7.5, pCO2 32, bicarbonate (HCO3) 24. The nurse interprets that the client is in which of the following? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Respiratory alkalosis Arterial blood gases are drawn to determine acid-base balance in the arterial blood. Alkalosis is determined by measuring a high pH. The expected reference range for pH is 7.35 to 7.45. This client measures 7.5. Also, respiratory versus metabolic origin is determined by analyzing the pCO2 measurement. When pCO2 is abnormally high or low, this most often indicates a respiratory origin. Remember that the pCO2 expected reference range is 35 to 45 mm Hg. This client measures 32 mm Hg.

A nurse is assessing a client following the completion of hemodialysis which of the following findings is the nurses priority to report to the provider

Restlessness because using the Urgent vs. Non-virgin approach to client care the nurse to determine that the priority funding to report to the provider is restlessness which can be an indication of the client is experiencing disequilibrium syndrome which is caused by the rapid removal of electrolytes for the clients blood and can lead to dysrhythmias or seizures other manifestations include nausea vomiting fatigue and headache

A nurse is caring for a client who is eight hours post-operative following a total hip arthroplasty the client is unable to void on the bed pan Which of the following actions should the nurse take first

Scan the bladder with a portable ultrasound the first action should be using the nursing process which is assisting the client scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder

A nurse is providing follow-up care for a client who sustained a compound fracture three weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider

Sedimentation rate. And increased sedimentation rate occurs when a client has any type of inflammatory process such as osteomyelitis

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for Gentamicin which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider

Serum creatinine because a client who has an elevated serum creatinine level should not receive Gentamicin because the medication is nephrotoxic

Hemodialysis and Peritoneal Dialysis: Manifestations of Peritonitis

Severe abdominal pain which worsens with movement

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening?

Shellfish allergy

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate

Pain management: PCA

Small frequent dosing ensure consistent plasma levels Morphine and Dilaudid Let nurse know if the pump doesn't control the pain Client is the only person to push the button

A nurse is providing discharge instructions to a client who has active tuberculosis which of the following information should the nurse include in the instructions

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures after three negative sputum cultures the client is no longer considered infectious

Infection control: Appropriate room assignment

Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag

A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?

Store the medication in its original container

A nurse is caring for a client who has cirrhosis of the liver with esophageal varies. Which of the following activities should the nurse instruct the client to avoid?

Straining to have bowel movements

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy to the nurse should recognize that which of the following complications is associated with long-term mechanical ventilation

Stress ulcers because of elevated levels of hydrochloric acid in the stomach

a nurse is caring for a client following excavation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately

Strider. Using the Urgent vs. Non-urgent approach to client care the nurse should determine that the priority finding a Strider. Strider can indicate and narrowing Airway or possible obstruction caused by edema or laryngeal spasms the nurse should report the finding immediately Implement an intervention

Hepatitis and Cirrhosis: Priority findings to report

Supine position for liver biopsy Report: Hepatitis - Fever - Vomiting - Dark-colored urine - clay colored stools - Jaundice Cirrosis - Cognitive changes - Ascities -Jaundice - Petechiae - Palmar erythema -fruit or musty odor

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for Omeprazole. The nurse should instruct the client that the medication provides Relief by which of the following actions

Suppressing gastric acid production. I love her soul is a proton pump inhibitor it relieves manifestations of gastric ulcers by suppressing gastric acid production

A nurse is assessing a client following IV urography. Which of the following findings is the priority?

Swollen lips

Fluid Imbalances: Clinical manifestations of hypervolemia

Tachycardia bounding pulse hypertension muscle weakness headache ascites orthopnea crackeles distended neck veins

A nurse is caring for a client admitted with a diagnosis of hyperthyroidism caused by an adenoma of the thyroid gland. Twelve hours following the thyroidectomy, which of the following findings should the nurse report to the charge nurse? (Select all that apply.) Tachycardia and hypertension Respiratory rate of 16/min Negative Chvostek's sign Laryngeal stridor and a hoarse voice Positive Trousseau's sign

Tachycardia and hypertension are correct. Tachycardia and hypertension are unexpected findings and may indicate the occurrence of thyroid storm, which can occur after removal of the thyroid gland, especially if the client was in a hyperthyroid state prior to the surgery. Thyrotoxic, or thyroid, storm is a life-threatening condition that develops in cases of thyrotoxicosis (hyperthyroidism) or following acute stress, such as trauma or infection. Onset is sudden with a tachycardia, fever, sweating, restlessness, and tremors. Congestive heart failure and pulmonary edema can develop rapidly and lead to death. A respiratory rate of 16/min is incorrect. This is an expected finding and is within the normal reference range. A negative Chvostek's sign is incorrect. This is an expected finding. A Positive Chvostek's sign (facial muscle spasm after tapping the facial nerve in front of the ear) would be an indication of hypocalcemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired. Laryngeal stridor and a hoarse voice are correct. Laryngeal stridor and a hoarse voice are unexpected findings and may be an indication of swelling in the area of the surgery or damage to the laryngeal nerve. This should be reported to the provider before respiratory distress develops. A positive Trousseau's sign is correct. A Positive Trousseau's sign is an indication of hypocalcemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching?

Take additional pairs of shoes.

A nurse is providing instruction about traveling for a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip by airplane which of the following should the nurse include in the teaching

Take an additional pair of shoes

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

Take insulin even if you are unable to eat your regular diet.

Osteoporosis: Teaching about self administration of Alendronate

Take with 8oz water in the early morning before eating Remain upright for 30 minutes after taking medication

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia?

The client has to turn her head to see the entire visual field.

a nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider

The client reports back pain the nurse should notify the provider if the client reports back pain which can indicate that the nephrostomy tube is dislodged or clogged

A nurse is teaching a client who has end-stage kidney disease about organ donation which of the following information should the nurse include in the teaching

The client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased

At the start of the night shift, an assistive personnel (AP) brings the nurse a list of client reports. Which client does the nurse need to check first? The client with emphysema who is reporting dyspnea The client with ulcerative colitis who is reporting diarrhea The client with benign prostate hypertrophy (BPH) who is reporting dysuria The client with laryngeal cancer who is reporting dysphagia

The client with emphysema who is reporting dyspnea Using the airway, breathing, and circulation (ABC) priority framework, the nurse should check the client who is having difficulty breathing first. Dyspnea is a common report from clients with emphysema, but the nurse realizes that this is the client with the greatest physiologic risk.

A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following findings should indicate to the nurse that the client is experiencing hypoxia

The clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia

A nurse is assessing a client who has Graves disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

The nurse should identify an outward protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision including focusing on objects as well as pressure on the optic nerve.

Where would you palpate to assess for an inguinal hernia

The nurse should palpate at the right groin area because an inguinal hernia forms of the peritoneum which contains part of the intestine and can protrude into the scrotum in males

A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching

This device can detect when you have an irregular heart rate because it reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

This identifies if the pacemaker cells of my heart are working properly.

A nurse is preparing to assist with the insertion of a non tunneled percutaneous central venous catheter into a client's subclavian vein the nurse should plan to place the client in which of the following positions

Trendelenburg disposition facilitates the insertion of the catheter by dilating the blood vessels of the clients neck and

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)?

Troponin I 8 ng/mL

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretic which of the following information should the nurse include in the teaching

Try to walk at least 3 times per week for exercise because the development of a regular exercise routine can improve outcomes in clients who have heart failure

A client with chronic renal failure is undergoing peritoneal dialysis. Which nursing measure will be helpful in promoting outflow drainage of the dialyzing solution? Turn the client from side to side. Elevate the height of the dialysate bag. Apply manual pressure to the client's lower abdomen. Push the peritoneal catheter in approximately 1 inch further.

Turn the client from side to side. Sometimes the peritoneal catheter is buried in the omentum, which will slow or stop the outflow drainage. If the fluid is not draining properly, it is helpful to move the client from side to side to facilitate removal of peritoneal drainage.

A nurse is caring for a client who is having a seizure which of the following interventions is the nurses priority

Turn the client to the side because the greatest risk to this client is hypoxia from an impaired Airway

A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication?

Urinary retention

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity is 1.045

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use a 30mL syringe

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity which of the following instructions should the nurse include in the plan of care

Used crutches with rubber tips to prevent the client from slipping and decrease the risk of Falls

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) Expressive aphasia Visual spatial deficitis Left hemianopsia Right hemiplegia One-sided neglect

Visual spatial deficits Left hemianopsia One-sided neglect

Following a total gastrectomy, which medication should the nurse anticipate that the client will need to take for the rest of the client's life? Vitamin K Ranitidine (Zantac) Vitamin B12 Metoclopramide (Reglan)

Vitamin B12 A total gastrectomy blocks the absorption of vitamin B12 from the gastrointestinal tract. Unless this vitamin is supplied by parenteral injection throughout life, the client can develop pernicious anemia.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery the nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider

Warfarin because it is an anticoagulant which increases the client's risk for bleeding and is contraindicated for a client scheduled for I or Central Nervous System since surgery

A nursing assistant asks the nurse what type of precautions are necessary when caring for a client newly diagnosed with tuberculosis. The nurse instructs the nursing assistant to do which of the following? (Select all that apply.) Wash your hands before and after client care. Prepare to move the client to a negative pressure private room. Wear a surgical mask when in the client's room. Wear a gown and gloves when bathing the client. Give the client an impermeable paper bag for used tissues.

Washing your hands before and after client care is correct. Standard precautions should be used with all clients. Standard precautions require that hands be washed before and after all client contact and at any time the hands have been soiled. Preparing to move the client to a negative pressure private room is correct. The client requires a private room that provides at least six exchanges of air per hour. Wearing a surgical mask when in the client's room is incorrect. Staff must wear a specially fitted N95 or particulate respirator mask. A surgical mask does not provide adequate protection. Wearing a gown and gloves when bathing the client is correct. A gown and gloves should be worn when providing personal care and contamination of clothing with pulmonary secretions is possible. Giving the client an impermeable paper bag for used tissues is correct. A paper bag that is impermeable to leakage of its contents should be used for tissues that contain sputum.

ECG and Dysrthymia monitoring: Analyzing ECG

Watch for manifestations of dysrhythmias (chest pain, decreased LOC, SOB) and hypoxia. Remove leads, print ECG report and notify the provider

Electrolyte imbalance: manifestations of hypokalemia

Weak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T waves, ST depression Decreased GI motility, abdominal distension, constipation, n/v, anorexia, polyuria Decreased K (<3.5) ABG: Metabolic alkalosis (pH > 7.45)

A nurse is assisting with the discharge of a client newly diagnosed with diabetes. When reviewing information about proper foot care, which of the following would be appropriate to include? Soak feet every night in warm water. Wear clean cotton socks daily. Walk barefoot at home when possible. Get fitted for shoes in the morning.

Wear clean cotton socks daily. Cotton socks should be worn by clients who are diabetic. They are soft and will wick excess moisture away from the foot.

A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider?

Weight gain

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

White blood cell count of 2000. This white blood cell count is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings

A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management which of the following information should the nurse include in the teaching

You should increase your fiber intake to prevent constipation because opioids slow paracelsus in the gastrointestinal tract which causes constipation

A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

You will not be able to use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension

IV therapy: Performing Venipuncture on an older adult client

a 22-24 gauge catheter is best to use on older adults Tie the tourniquet sparingly and try to avoid veins in the hand

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent Airway which of the following interventions is the priority

applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a high-flow non-rebreather mask to deliver oxygen at 90 to 100%

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer?

calcium carbonate

Blood and blood product transfusions: Monitoring for adverse response to multiple blood transfusions

cute Hemolytic: chills, fever, low back pain, tachycardia, flushing, hypotension Febrile: chiils, fever, flushing, headache Mild Allergic: itching, urticaria and flushing Anaphylactic: wheezing, dyspnea, chest tightness cyanosis and hypotension

A pacu nurse is assessing a client who is post-operative following a right nephrectomy the client's initial vital signs for heart rate 80 permanent blood pressure 130 over 70 respiratory rate 16 and temperature 96.8 which of the following Vital sign changes should alert the nurse the client might be hemorrhaging

heart rate of 110 per minute because one of the first signs of hemorrhage is an increase in the heart rate from the clients Baseline which occurs to compensate for blood

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

muscle atrophy

Peripheral Vascular Diseases: Arterial Revascularization

used for severe claudication and or limb pain at rest - maintain adequate circulation - check pedal and dorsalis pulse -Note color, temperature, sensation and cap refill

Diagnostic and therapeutic procedures for female reproductive disorders: Discharge teaching for abdominal hysterectomy

well balanced diet (high in protein) Hormonal therapy restrict activity for as long as 6 weeks avoid use of tampons look for foul smelling drainage and temp > 100F