dynamic quiz final

Blood transfusion complications: A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis Perfect!

Correct Answer: A. Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. Incorrect Answers: B. A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fevers, chills, headaches, and flushing are indications of a febrile reaction. C. Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of circulatory overload. D. Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting, and diarrhea are indications of sepsis.

COPD nursing interventions: A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis Perfect!

Correct Answer: B. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

Chemotherapy complications: A nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow." Perfect!

Correct Answer: C. "I will inspect my child's mouth every day for sores." A child who has leukemia is at an increased risk of mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations.

Primary hypothyroidism diagnostics/lab values: A nurse is assessing a client who has hypothyroidism and takes levothyroxine. Which of the following findings indicates that the client is experiencing acute levothyroxine overdose? A. Bradycardia B. Cold intolerance C. Tremor D. Hypothermia Perfect!

Correct Answer: C. Tremor Tremors and anxiety are expected findings in acute levothyroxine overdose. These findings are similar to those seen in hyperthyroidism.

COPD nursing interventions: A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

Correct answer D D. Place the client in an upright position

Rifampin: for tb given iv or oral, for 6-9 months, educate to continue to take the full course, orange secretions, monitor ast and alt, n/v, anorexia, diarrhea, c-diff , heartburn, hematuria, acute renal failure, hemoglobinuria, hemolytic anemia, eosinophilia, thrombocytopenia, leukopenia, Stevens-johnson syndrome, TEN, angioedema, anaphylaxis, DRESS, take on empty stomach 1 hr before or 2 hrs after food, stain teeth

TB treatment education:

HIV: A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A. "You can expect a persistent fever and swollen glands." B. "You can expect an elevated white blood cell count." C. "You can expect increased blood pressure and edema." D. "You can expect weight gain."

✔Correct answer A A. "You can expect a persistent fever and swollen glands. Perfect! Correct Answer: A. "You can expect a persistent fever and swollen glands." Clients who have AIDS can have a persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS.

Guaiac stool test: A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following? A. Fecal material in vomit B. Blood in stool C. Infestation of parasites D. Microorganisms in urine

✔Correct answer B B. Blood in stool

Fluid overload: A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

a) Jugular vein distention : The increase in venous pressure due to excessive circulating blood volume results in neck vein distention b) Moist crackles : An indicator of pulmonary edema that can quickly lead to death d) Increased heart rate : fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses

Blood transfusion complications: A nurse is assessing a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

✔Correct answer A A. Chills and flank pain Correct Correct Answer: A. Chills and flank pain Chills and flank pain indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify that the child is having a hemolytic reaction.

Emphysema: A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

✔Correct answer A A. Discuss ways the client can reduce the number of cigarettes smoked per day

hyperkalemia A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

✔Correct answer A A. Elevated ST segments

Emphysema: A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

✔Correct answer A A. Hyperkalemia Correct Answer: A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid.

Hypokalemia A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

✔Correct answer A A. Hypokalemia

Fluid overload: A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein

✔Correct answer A A. Limit fluid intake

ABGs A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? A. Potassium and magnesium B. Calcium and bicarbonate C. Hemoglobin and hematocrit D. Arterial pH and PaCO2 Correct

✔Correct answer A A. Potassium and magnesium

ABGs A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

✔Correct answer A A. Respiratory alkalosis

Emphysema: A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

✔Correct answer A A. Use pursed-lip breathing during periods of dyspnea

Fluid overload: A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

✔Correct answer A A. Weight gain of 1 kg (2.2 lb) in 1 day

HIV: A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should the nurse include the teaching? A. "HIV can be transmitted as soon as a person develops manifestations." B. "HIV can be transmitted to anyone who has had contact with infected blood." C. "HIV is transmitted through the respiratory route via droplets." D. "HIV is transmitted only during the active phase of the virus."

✔Correct answer B B. "HIV can be transmitted to anyone who has had contact with infected blood."

Chemotherapy complications: A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide? A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications is used." B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed." C. "The use of more chemotherapy medications will shorten the time you have to be in treatment." D. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."

✔Correct answer B B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."

Emphysema: A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."

✔Correct answer B B. "Try to drink at least 2 to 3 liters of fluid per day

HIV: A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? A. "Your provider will prescribe a single antiretroviral medication at a time." B. "You should take antiretroviral medications on a routine schedule." C. "You should increase your intake of raw fruits and vegetables while taking antiretroviral medications." D. "Your provider will prescribe antiretroviral therapy to kill the HIV."

✔Correct answer B B. "You should take antiretroviral medications on a routine schedule. Correct Correct Answer: B. "You should take antiretroviral medications on a routine schedule." The nurse should inform the client of the need to take antiretroviral therapy exactly as prescribed and to avoid delaying or skipping any doses, which can result in medication resistance.

Fluid overload: A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? A. Check the client's blood glucose for hypoglycemia B. Check the client's urine specific gravity C. Weigh the client weekly D. Insert an indwelling urinary catheter for the client

✔Correct answer B B. Check the client's urine specific gravity Correct Correct Answer: B. Check the client's urine specific gravity The nurse should check the client's urine specific gravity to assess for fluid volume overload.

Basal skull fracture: A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B.. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

✔Correct answer B B. Clear fluid coming from the nares

Left-sided stroke: A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

✔Correct answer B B. Difficulty with speech Perfect! Correct Answer: B. Difficulty with speech The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication. Incorrect Answers: A. A client who is recovering from a left-hemisphere stroke will demonstrate hemiplegia of the right side of the body because the pyramidal pathway crosses over at the base of the brain. C. A client who is recovering from a right-hemisphere stroke can be impulsive. Clients who are recovering from a left-hemisphere stroke are cautious. D. A client who is recovering from a right-hemisphere stroke can neglect the left side of the body. The client can inadvertently injure an arm or leg since the client cannot feel or see anything on the left side of the body.

(Spinal cord complication): A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction

✔Correct answer B B. Place the client in a high-Fowler's position

Hypokalemia: A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? A. WBC 6,000/mm^3 B. Potassium 3.0 mEq/L C. Clear, pale yellow drainage D. Report of abdominal fullness Correct Correct Answer: B. Potassium 3.0 mEq/L A potassium level of 3.0 mEq/L is below the expected reference range and can cause dysrhythmias. Dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia.

✔Correct answer B B. Potassium 3.0 mEq/L C. Clear, pale yellow drainage

Hypokalemia A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

✔Correct answer B B. Prolonged QT intervals C. Shortened QT interval Correct Correct Answer: B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

COPD nursing interventions: A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

✔Correct answer B B. Promotes carbon dioxide elimination

Emphysema: A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

✔Correct answer B B. Promotes carbon dioxide elimination

(Spinal cord complication): A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS? A. Sensory dysfunction B. Weakness of the distal extremities C. Decreased vision D. Altered temperature regulation - Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

✔Correct answer B B. Weakness of the distal extremities

(Spinal cord complication): A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS? A. Sensory dysfunction B. Weakness of the distal extremities C. Decreased vision D. Altered temperature regulation

✔Correct answer B B. Weakness of the distal extremities

HIV: A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse provide? A. "That is your decision alone." B. "I would if I were you." C. "It sounds like you are unsure what to say to your partner." D. "Your provider is required by law to notify your partner."

✔Correct answer C C. "It sounds like you are unsure what to say to your partne

(Spinal cord complication): A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle placement in her spinal column. Which of the following responses should the nurse offer? A. "Let's not focus on the negative. Let's focus on getting better." B. "Why are you feeling so anxious about this procedure?" C. "The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends." D. "Your doctor is very skilled at this procedure. Everything will be all right."

✔Correct answer C C. "The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends."

Emphysema: A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

✔Correct answer C C. "When I breathe out through pursed lips, my airways don't collapse between breaths."

Basal skull fracture: A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid C. - Rigid skull containing cranial contents D. Brain herniated into the brainstem

✔Correct answer C C. - Rigid skull containing cranial contents Correct Correct Answer: C. Rigid skull containing cranial contents The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP. Incorrect Answers: A. A decrease in cerebral perfusion is a result of increasing ICP, not the cause. This leads to brain tissue ischemia and edema, which can cause death if untreated. B. The leakage of cerebral spinal fluid occurs with a basilar skull fracture, which is an open traumatic injury rather than a closed traumatic injury.

Emphysema: A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

✔Correct answer C C. Crepitus Correct Correct Answer: C. - Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax.

ABGs: A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication Correct

✔Correct answer C C. Increase the oxygen flow and request an arterial blood gas determination

COPD nursing interventions: A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication

✔Correct answer C C. Increase the oxygen flow and request an arterial blood gas determination

ABGs A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn

✔Correct answer C C. Perform an Allen's test prior to obtaining the specime

ABGs A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

✔Correct answer C C. Respiratory alkalosis

ABGs A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

✔Correct answer C C. Respiratory alkalosis

HIV: A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A. Protective isolation B. Droplet precautions C. Standard precautions D. Airborne precautions

✔Correct answer C C. Standard precautions Correct Answer: C. - Standard precautions Standard precautions should be implemented with every client to prevent the spread of infection transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is spread through blood and bodily fluids, standard precautions are appropriate.

Blood transfusion complications: A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature ✔Correct answer C C. Sudden oliguria D. Decreased respirations

✔Correct answer C C. Sudden oliguria Correct Correct Answer: C. Sudden oliguria The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs.

Digoxin toxicity: A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? A. Suppression of dysrhythmias B. Increased atrioventricular (AV) conductio C. Visual disturbances D. Weight gain

✔Correct answer C C. Visual disturbances

Digoxin toxicity: A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching? A. "I know that blurred vision is expected to happen while I'm taking digoxin." B. "I will measure my urine output each day and document it in my diary." C. "I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute." D. "I will eat fruits and vegetables that have a high potassium content every day."

✔Correct answer D D. "I will eat fruits and vegetables that have a high potassium content every day."

Fluid overload: A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis Perfect

✔Correct answer D D. Diaphoresis Perfect! Correct Answer: D. Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

(Spinal cord complication): A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? A. Irregular cardiac rhythm B. Numbness in the hands C. Muscle cramps D. Facial edema

✔Correct answer D D. Facial edema

(Spinal cord complication): A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? A. Irregular cardiac rhythm B. Numbness in the hands C. Muscle cramps D. Facial edema

✔Correct answer D D. Facial edema

Blood transfusion complications: A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension D.. Low back pain

✔Correct answer D D. Low back pain Correct Correct Answer: D. Low back pain Low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia, and dark urine.

ABGs A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

✔Correct answer D D. Metabolic acidosis

COPD nursing interventions: A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula Perfect!

✔Correct answer D D. Nasal cannula Perfect! Correct Answer: D. Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

HIV: A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions

✔Correct answer D D. Reddish-purple skin lesions Perfect! Correct Answer: D. - Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy.

(Spinal cord complication): A nurse is caring for a client who has cancer involving the lumbar vertebrae and has been prescribed gabapentin. Which of the following therapeutic effects should the nurse identify for the client when taking this medication? A. Reduced cancer-related bone pain B. Decreased anxiety and insomnia C. Decreased inflammatory response to cancer tumors D. Reduced cramping, aching, and burning neuropathic pain

✔Correct answer D D. Reduced cramping, aching, and burning neuropathic pain

Clinical manifestations of right sided stroke: A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplegia

✔Correct answer D D. Right-sided hemiplegia

Complications of subtotal thyroidectomy: A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client? A. Cardiac monitor B. Defibrillator C. Thoracotomy tray D. Tracheostomy tray

✔Correct answer D D. Tracheostomy tray Perfect! Correct Answer: D. Tracheostomy tray Because of the laryngeal edema that is common after a thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk of hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client.

ABGs A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3- 32 mEq/L, PaCO2

✔Correct answer D D. pH 7.49, HCO3- 32 mEq/L, PaCO2

HIV: A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include? (Select all that apply.) A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher C. Change pet litter boxes with disposable gloves D. Consume fresh fruit and raw vegetables E. Avoid digging in the garden

A. Avoid large gatherings of people B. Clean toothbrush by running through the dishwasher E. Avoid digging in the gardenThe nurse should instruct the client to avoid large crowds or gatherings of people, especially if individuals have been ill or exposed to illness; this can place clients who have HIV at risk of infection. The client should clean the toothbrush by running it through the dishwasher. If the client does not have a dishwasher, rinsing the toothbrush with bleach followed by hot water is also effective at destroying bacteria on the toothbrush. The client should avoid digging in the garden because exposure to the dirt, which contains bacteria and organisms, places the client at risk of infection.

Gout nursing interventions/treatment: A nurse is caring for a client who is experiencing an acute gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? A. Colchicine B. Allopurinol C. Probenecid D. Pegloticase

Correct Answer: A. Colchicine The nurse should anticipate a prescription for colchicine because it is the medication of choice for an acute gout attack. The client can experience relief from the attack within hours of receiving this medication. Colchicine can also be prescribed for long-term use to prevent future attacks from occurring. Incorrect Answers: B. Allopurinol is the medication of choice for clients who have chronic tophaceous gout. Allopurinol acts by lowering the uric acid levels in the blood and reducing the development of new tophus formation, which are nodular masses resulting from increased uric acid levels producing uric crystals. However, it is not used to treat an acute gout attack. C. Probenecid is not indicated for a client who is experiencing an acute gout attack. This medication acts by lowering the plasma urate levels and increasing the excretion of uric acid in the urine. This can exacerbate an acute gout attack and is indicated once the acute gout attack is controlled. D. Pegloticase is an intravenous medication used to treat chronic gout that has not responded to the normal treatment. It is not indicated to treat an acute gout attack.

Chemotherapy complications: A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? A. Paresthesia B. Alopecia C. Stomatitis D. Constipation

Correct Answer: A. Paresthesia The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

Primary hypothyroidism diagnostics/lab values: A nurse is preparing to administer levothyroxine to a client who has hypothyroidism. The nurse should identify which of the following laboratory results as supporting the administration of this medication? A. Thyroid-stimulating hormone (TSH) 8 microunits/mL B. Free triiodothyronine (T3) 300 pg/dL C. Free thyroxine (T4) 7 mcg/dL D. Thyroxine-binding globulin 2.3 mg/dL Perfect!

Correct Answer: A. Thyroid-stimulating hormone (TSH) 8 microunits/mL The expected reference range for TSH is 0.3 to 5 microunits/mL. When a client has primary hypothyroidism, the TSH level becomes elevated in an attempt to normalize the thyroid gland's function. When the client has had a therapeutic response to treatment, the TSH level returns to the expected reference range. Incorrect Answers: B. T3 is a hormone the thyroid gland produces. Free T3 is a blood test that helps evaluate thyroid function, primarily to diagnose hyperthyroidism. The expected reference range for free T3 for adults up to the age of 50 is 70 to 205 ng/dL. Over the age of 50, it is 40 to 180 ng/dL. With primary hypothyroidism, the level of T3 decreases. C. T4 is a hormone the thyroid gland produces. Free T4 is a blood test that helps evaluate thyroid function. The expected reference range for T4 is 4 to 12 mcg/dL for adult male clients up to the age of 60. For adult female clients up to the age of 60, it is 5 to 12 mcg/dL. Over the age of 60, it is 5 to 11 mcg/dL. With primary hypothyroidism, the level of T4 decreases. D. Thyroxine-binding globulin is a thyroid hormone protein carrier that helps evaluate clients who have total T3 and T4 levels outside their respective reference ranges. The expected reference range for thyroxine-binding globulin is 1.7 to 3.6 mg/dL.

High ammonia level treatment: A nurse in a community health clinic is assessing a new client who has prescriptions for isoniazid and rifampin. Which of the following disorders should the nurse expect the client to have? A. Tuberculosis B. Hypertension C. Diabetes D. Cirrhosis Perfect!

Correct Answer: A. Tuberculosis Isoniazid and rifampin are first-line antitubercular medications used to treat active tuberculosis. The medications are used in combination therapy. Incorrect Answers: B. Isoniazid and rifampin are not used to treat hypertension. The nurse should recognize that beta-blockers, diuretics, ACE inhibitors, and calcium channel blockers are used to treat hypertension. C. Isoniazid and rifampin are not used to treat diabetes. The nurse should recognize that insulin therapy and oral antihyperglycemic medications are used to treat diabetes. D. Isoniazid and rifampin are not used to treat cirrhosis. The nurse should recognize that therapy for cirrhosis is often symptomatic and can include beta blockers, lactulose or antibiotics to decrease ammonia levels, vasoactive medications to prevent bleeding, and diuretics to remove ascites.

Clinical manifestations of bladder infections: A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following client statements should the nurse provide further teaching? A. "I drink at least 2 L of fluid per day." B. "I prefer taking tub baths to showering." C. "I urinate before and after sexual relations." D. "I wipe from front to back after urinating." Perfect!

Correct Answer: B. "I prefer taking tub baths to showering." Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk of infection. The nurse should recommend taking showers instead of tub baths. Incorrect Answers: A. Staying well hydrated helps prevent urinary tract infections and bladder wall inflammation. C. Urinating prior to and following sexual intercourse helps prevent urinary tract infections. D. Wiping from front to back helps prevent fecal bacteria from contaminating the urethra and reduces the risk of urinary tract infections.

priority assessments and interventions for burns: A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output Perfect!

Correct Answer: B. Characteristics of the cough and sputum The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway.

High ammonia level treatment: A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? A. Decreased lactate dehydrogenase B. Increased serum albumin C. Decreased serum ammonia D. Increased prothrombin time

Correct Answer: D. Increased prothrombin time Clients who have end-stage liver failure have an inadequate supply of clotting factors and an increased (i.e. prolonged) prothrombin time. Incorrect Answers: A. Lactate dehydrogenase levels increase for a client who has end-stage liver failure, indicating liver cell destruction. B. Serum albumin levels decrease for a client who has end-stage liver failure. C. Serum ammonia levels increase for a client who has end-stage liver failure.

AIDS opportunistic infections: A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions Perfect!

Correct Answer: D. Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy. Incorrect Answers: A. A nonproductive cough accompanied by a fever and shortness of breath are associated with multiple opportunistic respiratory infections that clients who are immunocompromised have a high risk of developing. A nonproductive cough is not a manifestation of Kaposi's sarcoma. B. Blurred vision due to lesions on the retina is not a manifestation of Kaposi's sarcoma. C. The onset of progressive dementia describes AIDS-dementia complex, which can occur as the HIV infection affects the nervous system. Dementia is not a manifestation of Kaposi's sarcoma.

Primary hypothyroidism diagnostics/lab values: A nurse is reviewing the laboratory reports of a client and notes an elevated thyroid-stimulating hormone (TSH) level. Which of the following findings should the nurse expect? A. Bradycardia B. Tremors C. Low-grade fever D. Diaphoresis

Correct Answer: A. Bradycardia An elevated TSH level indicates hypothyroidism, which is characterized by weight gain, bradycardia, cold intolerance, paresthesia, hearing loss, depression, and many other manifestations.

Priority assessments and interventions for burns: A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest

Correct Answer: A. Initiate range-of-motion exercises The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures. Incorrect Answers: B. The nurse should use sterile technique to provide wound care for this client to reduce the risk of infection. C. The nurse should place the client on a high-protein, high-calorie diet to promote wound healing. D. The nurse should encourage the client to ambulate frequently to promote mobility and improve ventilation.

TB treatment education: A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make? A. "Stop taking the isoniazid for 3 days, and the discoloration should go away." B. "Rifampin can turn body fluids orange." C. "I'll make an appointment for you to see the provider this afternoon." D. "Isoniazid can cause bladder irritation." Perfect!

Correct Answer: B. "Rifampin can turn body fluids orange." Rifampin can cause body fluids, such as tears, sweat, saliva, and urine, to turn a reddish-orange color. The nurse should inform the client that this effect does not cause harm. Incorrect Answers: A. Isoniazid does not cause urine or body fluids to turn a reddish-orange color. A client who has active TB should not stop taking prescribed medication. C. There is no indication for the client to see the provider at this time. D. Isoniazid does not cause bladder irritation; however, rifampin can cause hematuria.

TB treatment education: A nurse is caring for a client who has rheumatoid arthritis and a new prescription for etanercept. Which of the following values should the nurse review prior to the administration of the medication? A. Ability to swallow B. Results of last purified protein derivative (PPD) test C. Serum creatinine level D. Blood glucose level

Correct Answer: B. Results of last purified protein derivative (PPD) test The nurse should identify that a client who is taking etanercept is at risk for infections such as tuberculosis (TB). To reduce this risk, the client should be tested for latent TB; if the test is positive, the client should undergo TB treatment before receiving etanercept. During treatment with etanercept, the client should be monitored closely for the development of TB.

Gout nursing interventions/treatment: A nurse is providing teaching for a client who has gout and a prescription for allopurinol. Which of the following statements by the client should indicate to the nurse that the teaching was effective? A. "I should start taking this medication at 800 mg daily." B. "I will have an increased risk for diabetes with this medication." C. "I will increase my fluids to at least 2 liters per day." D. "I should take this medication twice daily." Perfect!

Correct Answer: C. "I will increase my fluids to at least 2 liters per day." The nurse should identify that an adverse effect of allopurinol is renal injury. Therefore, clients are encouraged to drink at least 2,000 mL/day to maintain a urine output of at least 2 L/day. Incorrect Answers: A. The initial dosage for allopurinol begins at 100 mg daily. This dose can be increased every few weeks to control manifestations of gout. The provider can increase this dosage to a maximum of 800 mg/day. B. Allopurinol may cause hypoglycemia in clients who are taking oral hypoglycemic agents. However, this medication is not associated with an increased risk for the development of diabetes mellitus. D. Allopurinol is typically prescribed once daily due to its prolonged half-life.

Clinical manifestations of bladder infections: A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following client statements indicates the need for additional teaching? A. "I will empty my bladder every 4 hours." B. "I will drink 2 L of fluids per day." ✔Correct answer C C. "I will use a vaginal douche daily." D. "I will wear cotton underwear." Perfect!

Correct Answer: C. "I will use a vaginal douche daily." The client should avoid vaginal douches, bubble baths, and any substances that can increase the risk of UTIs. The client should use mild soap and water to wash the perineal area. Incorrect Answers: A. The client should empty her bladder every 4 hours to prevent urinary stasis, which can cause UTIs. B. The client should maintain a daily fluid intake of 2 to 3 L to flush the kidneys and prevent urinary stasis. D. The client should wear loose-fitting cotton (not nylon) underwear to prevent irritation.`

Chemotherapy complications: A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements indicates that the client needs further instructions? A. "I'll keep an antibacterial hand gel in my purse." B. "My partner will have to take care of the cat's litter boxes for a while." C. "I'm planning a large gathering of friends and family for the holidays." D. "I will eat canned fruits and vegetables."

Correct Answer: C. "I'm planning a large gathering of friends and family for the holidays." A client who has neutropenia should avoid exposure to infection, so this statement warrants more teaching. A client who has neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection.

Primary hypothyroidism diagnostics/lab values: A nurse is providing teaching to a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client that which of the following findings is an indication of thyrotoxicosis? A. Weight gain B. Constipation C. Chest pain D. Fatigue Perfect!

Correct Answer: C. Chest pain Thyrotoxicosis can result if a client takes too much levothyroxine. Manifestations include chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis. The client should notify the provider if any of these manifestations are present. Incorrect Answers: A. Clients who have hypothyroidism often lose weight when they take levothyroxine and revert to an average basal metabolic rate. B. Constipation is a common manifestation of hypothyroidism and should subside with effective levothyroxine therapy. D. Fatigue is common with hypothyroidism and can persist until clients taking levothyroxine reach therapeutic levels.

Gout nursing interventions/treatment: A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. The nurse should instruct the client to discontinue taking the medication for which of the following adverse effects? A. Nausea B. Metallic taste C. Fever D. Drowsiness Perfect!

Correct Answer: C. Fever A fever can indicate a potentially fatal hypersensitivity reaction. The client should discontinue allopurinol and notify the provider if a fever or rash develops. Incorrect Answers: A. Mild gastrointestinal adverse effects (e.g. nausea, vomiting, abdominal pain, and diarrhea) can occur with allopurinol. The client should take the medication with food to reduce these effects. B. Metallic taste is a mild adverse effect of allopurinol. The nurse should inform the client that this can occur and not to discontinue the medication. D. Drowsiness is a mild adverse effect of allopurinol. The nurse should inform the client that this can occur and not to discontinue the medication.

Primary hypothyroidism diagnostics/lab values: A nurse is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid-stimulating hormone (TSH) level and a decreased total T3 and T4 level. The nurse should anticipate a prescription for which of the following medications? A. Methimazole B. Somatropin C. Levothyroxine D. Propylthiouracil Perfect!

Correct Answer: C. Levothyroxine Levothyroxine replaces thyroid hormone for a client who has hypothyroidism. Laboratory values for hypothyroidism include an increased TSH level and decreased total T3 and T4 levels. Clinical manifestations of hypothyroidism include fatigue, cold intolerance, and a decreased body temperature and pulse.

High ammonia level treatment: A nurse is monitoring a client who is receiving lactulose for cirrhosis. Which of the following laboratory values related to this medication should indicate to the nurse that the treatment is effective? A. Increased aspartate aminotransferase (AST) B. Decreased alanine aminotransferase (ALT) C. Increased prothrombin time (PT) D. Decreased serum ammonia

Correct Answer: D. Decreased serum ammonia The nurse should identify that lactulose is a laxative that can be used for chronic liver disorders such as cirrhosis. Lactulose improves the client's condition by decreasing ammonia levels through enhancing intestinal secretion of ammonia so that it can be eliminated from the body.

Primary hypothyroidism diagnostics/lab values: A nurse is teaching a client who is taking levothyroxine for hypothyroidism about a new prescription for a calcium supplement. Which of the following pieces of information should the nurse include in the teaching? A. The calcium supplement will enhance the effect of the levothyroxine. B. The calcium supplement will accelerate the metabolism of the levothyroxine. C. Take the medications together at 1700 for the greatest effect. D. Take the calcium supplement 4 hr after taking the levothyroxine. Perfect!

Correct Answer: D. Take the calcium supplement 4 hr after taking the levothyroxine. Levothyroxine should be taken in the morning on an empty stomach, and the calcium supplement should be taken at least 4 hours later. Food or supplements containing iron, magnesium, or zinc also bind to levothyroxine and prevent complete absorption of the medication.

Priority assessments and interventions for burns: A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1°C (102.4°F)

Correct Answer: D. Temperature of 39.1°C (102.4°F) An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.

COPD nursing interventions: A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking Perfect!

Correct Answer: A. Eat high-calorie foods first Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first.

Primary hypothyroidism diagnostics/lab values: A nurse is caring for a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following findings should the nurse identify as an indication that the client requires intervention? A. Heart rate 106/min B. Dry skin C. Oral temperature 36.8°C (98.2°F) D. Lethargy Perfect!

Correct Answer: A. Heart rate 106/min Tachycardia can be a manifestation of hyperthyroidism, possibly due to excessive hormone replacement. The client might require a lower dosage of levothyroxine.

Gout nursing interventions/treatment: A nurse is caring for a client who is experiencing an acute gout attack. The nurse should anticipate a prescription from the provider for which of the following medications? A. Naproxen B. Pegloticase C. Probenecid D. Allopurinol

Correct Answer: A. Naproxen The nurse should anticipate that the provider will prescribe an NSAID such as naproxen. This type of medication is recommended as the first choice of treatment for relieving the manifestations of an acute gout attack.

Gout nursing interventions/treatment: A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone Perfect!

Correct Answer: C. Aspirin Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid interaction between probenecid and salicylate medications.

Clinical manifestations of bladder infections: A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? A. "I'll drink less water so I don't have to catheterize myself too often." B. "I must use sterile technique for each of the catheterizations." C. "I should stop the catheterization when I have removed 150 mL of urine." D. "I will perform intermittent self-catheterization every 2 to 3 hr." Perfect!

Correct Answer: D. "I will perform intermittent self-catheterization every 2 to 3 hr." The client might initially require self-catheterization every 2 to 3 hours, with the frequency eventually increasing to every 4 to 6 hours. A longer interval can result in bladder distention and an increased risk of urinary tract infections.

High ammonia level treatment: A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects? A. Increases blood pressure B. Prevents esophageal bleeding C. Decreases heart rate D. Reduces ammonia levels -

Correct Answer: D. Reduces ammonia levels Lactulose is a laxative that promotes the excretion of ammonia in a client who has hepatic encephalopathy from cirrhosis of the liver.

Gout nursing interventions/treatment: A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply.) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices Correct

Correct Answers: A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine The nurse should inform the client that allopurinol is an antigout medication that reduces uric acid, which helps prevent uric acid stone formation. Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise. Purine increases the risk of uric acid stone formation; organ meats, poultry, fish, red wine, and gravy are high in purine. Incorrect Answers: D. Maintaining an adequate fluid intake of 2 to 3 L per day reduces the risk of stone formation. E. Citrus juices alkalinize the urine, which helps prevent uric acid stone formation.

COPD nursing interventions: A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teaching? A. "I will increase my fluid intake when I eat a meal." B. "I will eat more cold foods at meals rather than hot foods." C. "I will avoid high-fat foods like butter and gravies." D. "I will cook my meals instead of eating convenience foods."

Correct Correct Answer: B. "I will eat more cold foods at meals rather than hot foods." The client should prepare more cold foods to eat because they provide a decreased feeling of fullness compared to hot foods.

TB treatment education: A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? A. "You'll need to take this medication for the rest of your life to prevent recurrence." B. "Your provider will monitor your thyroid function while you are taking this medication." C. "You should take this medication on an empty stomach." D. "You should take this medication with an antacid."

Correct Correct Answer: C. "You should take this medication on an empty stomach." The nurse should instruct the client to take isoniazid on an empty stomach to improve absorption of the medication. To ensure the stomach is empty, the client should take the medication either 1 hour before or 2 hours after a meal.

Clinical manifestation of diabetes insipidus (DI): A nurse is reviewing the medical record of a client who is receiving hydrochlorothiazide (HCTZ). The nurse should expect to find an improvement in which of the following conditions as a result of this medication? A. Gouty arthritis B. Dehydration C. Diabetes insipidus D. Hypokalemia

Correct Correct Answer: C. Diabetes insipidus A thiazide diuretic such as HCTZ is administered to treat diabetes insipidus. Diabetes insipidus is a condition in which there is an overproduction of urine. Thiazides reduce urine production by 30% to 50%.

COPD nursing interventions: A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypne C. Tachycardia D. Diaphoresis

Correct Correct Answer: C. Tachycardia Tachycardia, dyspnea, restlessness, headaches, and increased blood pressure are indications of impending respiratory failure.

hyperkalemia A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals

Correct answer A A. Elevated ST segments

(Spinal cord complication): A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

Correct answer B B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

Basal skull fracture: A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign Perfect! Correct Answer:

Correct answer C C. Dilated pupils C. Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.

Digoxin toxicity: A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia Perfect!

Correct answer C C. Vomiting Correct Answer: C. Vomiting The nurse should identify that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately. Incorrect Answers: A. Irritability is not a manifestation of digoxin toxicity. B. Diaphoresis is not a manifestation of digoxin toxicity. D. Bradycardia

(Spinal cord complication): A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine Correct

Correct answer D - Immobilize the client's cervical spine Correct

Digoxin toxicity: A nurse is caring for a client who has congestive heart failure and is taking digoxin. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first? A. Encourage the client to eat the toast on the breakfast tray B. Administer an antiemetic C. Inform the client's provider d.. Check the client's apical pulse

Correct answer D D. Check the client's apical pulse Correct Correct Answer: D. Check the client's apical pulse Nausea, anorexia, fatigue, visual effects, and cardiac dysrhythmias (often caused by a slow pulse rate) are possible findings in digoxin toxicity.