Exam 3

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

A clients white blood cell count is 7500/mm3. Calculate the expected range for this clients neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3

4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500 x 0.55 = 4125 7500 x 0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.

An emergency department nurse cares for a client who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.) ____ mL/hr

500 mL/hr Because IV pumps deliver in units of milliliters per hour, the pump would have to be set at 500 mL/hr to deliver 3 L (3000 mL) over 6 hours. 6x = 3000 x = 500

A client in the intensive care unit with acute kidney injury (AKI) must maintain a mean arterial pressure (MAP) of 65 mm Hg to promote kidney perfusion. What is the clients MAP if the blood pressure is 98/50 mm Hg? (Record your answer using a whole number.) _____ mm Hg

66 mm Hg MAP = [SBP + (2 × DBP)]/3 MAP = [98 + (2 x 50)]/3 MAP = (98 + 100)/3 MAP = 198/3 MAP = 66

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. CVA tenderness

A, B, DNephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) Acute gout b. Colchicine (Colcrys) Acute gout c. Febuxostat (Uloric) Chronic gout d. Indomethacin (Indocin) Acute gout e. Probenecid (Benemid) Chronic gout

B, C, D, E. Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. BUN: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hgb: 8.2 mg/dL d. WBC count: 12,000/mm3

B. The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

C, D. The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Over-hydration

A, B, C, D. Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Over-hydration is not a common risk factor for shock.

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client

B. By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney. The nurse then should notify the provider immediately. Skin turgor, lung sounds, and weight could give information about the fluid status of the client, but they are not the priority assessment.

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

C. Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the clients usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

A, B, C, D. Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

A, B, C, D. Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Finish the prescribed antibiotic even if you are feeling better. b. Drink at least 3 liters of fluid each day. c. The bruising on your back may take several weeks to resolve. d. Report any blood present in your urine. e. It is normal to experience pain and difficulty urinating.

A, B, C. The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

A, B, C. The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

A, B, C. Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

A, B, D, E. Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.

A, B, D, E. MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

A, B, D, E. The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. c. Adjust your diet to prevent diarrhea. d. Contact your provider if you have visual disturbances. e. Assess your urine for renal stones.

A, B, D. A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

A, B, D. A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. How much water do you drink every day? b. Do you take estrogen replacement therapy? c. Does anyone in your family have a history of cystitis? d. Are you on steroids or other immune-suppressing drugs? e. Do you drink grapefruit juice or orange juice daily?

A, B, D. Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

A, B, D. Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyper-acute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

A. Hyper-acute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

A, B, D. Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the health care provider contacted.

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. c. You will have no risk for infection with PD. d. You have flexible scheduling for the exchanges. e. It takes less time than hemodialysis treatments.

A, B, D. PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence Urine loss with physical exertion b. Urge incontinence Large amount of urine with each occurrence c. Functional incontinence Urine loss results from abnormal detrusor contractions d. Overflow incontinence Constant dribbling of urine e. Reflex incontinence Leakage of urine without lower urinary tract disorder

A, B, D. Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

A nurse reviews a clients laboratory results. Which results from the clients urinalysis should the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive

A, B, D. The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

A, B, D. There are many non-pharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

A nurse plans care for an older adult client. Which interventions should the nurse include in this clients plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the UAP. e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

A, B, E, F. The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse should not delegate any teaching to the UAP, including bladder training instructions. The UAP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash-Systemic lupus erythematosus (SLE) b. Esophageal dysmotility-Systemic sclerosis c. Excess uric acid excretion-Gout d. Footdrop and paresthesias-Osteoarthritis e. Vasculitis causing organ damage-Rheumatoid arthritis

A, B, E. A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this clients dietary teaching? (Select all that apply.) a. Limit your intake of food high in animal protein. b. Read food labels to help minimize your sodium intake. c. Avoid spinach, black tea, and rhubarb. d. Drink white wine or beer instead of red wine. e. Reduce your intake of milk and other dairy products.

A, B, E. Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the clients urine. e. Administer antihypertensive medications.

A, B, E. Prior to a percutaneous kidney biopsy, the client should be NPO for 4 to 6 hours. Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure. There is no need to keep the client on bedrest or assess for blood in the clients urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

A, B, E. The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10, and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The client should begin to notice improvement in control of urine after several weeks of exercising the pelvic muscles.

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

A, B, E. Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A, C, D, E. Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

A, C, D, E. Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the clients mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the clients abdomen.

A, C, D. Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

A, C, D. Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

A, C, E. Many clients with AKI are too ill to meet caloric goals and require tube feedings with kidney-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the UAP? (Select all that apply.) a. Apply an abduction pillow to the clients legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

A, C, E. The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min

A. Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The specially trained nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 90 beats/min is normal.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

A, C, E. The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash your hands before and after self-catheterization. b. Use a large-lumen catheter for each catheterization. c. Use lubricant on the tip of the catheter before insertion. d. Self-catheterize at least twice a day or every 12 hours. e. Use sterile gloves and sterile technique for the procedure. f. Maintain a specific schedule for catheterization.

A, C, F. The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

A, C. The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. elevated AST/ALT b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

A, D, E. The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

A, D, E. The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A, D, E. The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating

A, D. The nurse should monitor urine output and contact the provider if urine output decreases or becomes absent. The nurse should also assess for blood in the clients urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present. If bleeding is present, the nurse should urgently contact the provider. Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the client received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the provider.

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

A. A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

A. According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

A. All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

A. All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

A. All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

A. Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the clients dietary habits. b. Inquire about the use of NSAIDs. c. Hold the clients metformin (Glucophage). d. Contact the health care provider immediately.

A. An elevated BUN/creatinine ratio is often indicative of dehydration, urinary obstruction, catabolism, or a high- protein diet. The nurse should inquire about the clients dietary habits. Kidney damage related to NSAID use most likely would manifest with elevations in both BUN and creatinine, but no change in the ratio. The nurse should obtain more assessment data before holding any medications or contacting the provider.

The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

A. Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.

A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

A. Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

A. Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I don't need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.

A. Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider? a. Seafood b. Penicillin c. Bee stings d. Red food dye

A. Clients with seafood allergies often have severe allergic reactions to the standard dyes used during intravenous urography. The other allergies have no impact on the clients safety during an intravenous urography.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

A. High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

After teaching a client with a history of renal calculi, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I should drink at least 3 liters of fluid every day. b. I will eliminate all dairy or sources of calcium from my diet. c. Aspirin and aspirin-containing products can lead to stones. d. The doctor can give me antibiotics at the first sign of a stone.

A. Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

A. Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The NSAID celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

A. Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self- administer the medication. The other options are not appropriate for etanercept.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. I am thrilled that I can continue to eat fast food. b. I will cut out bacon with my eggs every morning. c. My cooking style will change by not adding salt. d. I will probably lose weight by cutting out potato chips.

A. Fast food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.

A. Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

A. For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the clients abdomen. d. Assess the clients diet history.

A. Furosemide (Lasix) is a loop diuretic that helps reduce fluid overload and hypertension in clients with early stages of CKD. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds should be assessed if there is fluid retention, as in heart failure. Palpation of the clients abdomen is not necessary, but the nurse should check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effect of the medication.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I cant be exposed to the sun, I have been using a tanning bed.

A. Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct? a. Inspect the clients distal finger joints. b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes. d. Perform range of motion on the clients wrists.

A. Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. Drink 1 to 2 liters of water each day. b. Have 10 to 12 ounces of juice a day. c. Liver is a good source of iron. d. Never eat hard cheeses or sardines.

A. Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

After teaching a client who has stress incontinence, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will limit my total intake of fluids. b. I must avoid drinking alcoholic beverages. c. I must avoid drinking caffeinated beverages. d. I shall try to lose about 10% of my body weight.

A. Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

A. Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the clients capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

A. Metformin can cause lactic acidosis and renal impairment as the result of an interaction with the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established. The clients health care provider needs to provide alternative therapy for the client until the metformin can be resumed. Keeping the client NPO, checking the clients blood glucose, and administering intravenous fluids should be part of the clients plan of care, but are not the priority, as the examination should not occur while the client is still taking metformin.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.

A. Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

A. Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

A. Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

A. Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Bakers cysts. b. Inspect the clients feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

A. Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.

A. Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

A. Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs. The electrolyte values are not related to the protein- restricted diet.

A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

A. Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies over-hydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the- counter antihistamines. What response by the nurse is most appropriate? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.

A. Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away. The client may or may not need steroids; they may be given either IV or orally.

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this clients risk factors? a. Do you smoke cigarettes? b. Do you use any alcohol? c. Do you use recreational drugs? d. Do you take any prescription drugs?

A. Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

A. The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

A. The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAPs performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female clients and male icon for all male clients. b. Telling the client, This test measures the amount of urine in your bladder. c. Applying ultrasound gel to the scanning head and removing it when finished. d. Taking at least two readings using the aiming icon to place the scanning head.

A. The UAP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. The UAP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

A. The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this clients teaching? a. Use a second form of birth control while on this medication. b. You will experience increased menstrual bleeding while on this drug. c. You may experience an irregular heartbeat while on this drug. d. Watch for blood in your urine while taking this medication.

A. The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg.

A. The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

A. The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

A. The initial action for the nurse is to assess anxiety, coping styles, and the clients acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the clients acceptance of the treatment should come first.

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? Lung sounds: Wheezing a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

A. The nurse has auscultated wheezing in the clients lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the clients culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

A. The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for a while. b. Prepare to administer anti-anxiety medication. c. Raise all four side rails on the client's bed. d. Tell the client everything possible is being done.

A. The nurses presence will be best to reassure this client. Anti-anxiety medication is not warranted as this will lower the client's blood pressure. Using all four side rails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety. Telling a confused client that everything is being done is not the most helpful response.

A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.

A. The nurses priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the clients intake and output. d. Ask to have the laboratory redraw the blood specimen.

A. The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.

A. The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history? a. Have you been taking any aspirin, ibuprofen, or naproxen recently? b. Do you have anyone in your family with renal failure? c. Have you had a diet that is low in protein recently? d. Has a relative had a kidney transplant lately?

A. There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. Do any of your family members have this problem? b. Do you drink any cranberry juice? c. Do you urinate after sexual intercourse? d. Do you experience burning with urination?

A. There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

A. These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication. Administering antiemetics, asking if the client can eat, and obtaining a referral to a specialist all address the clients symptoms but do not lead to the cause of the symptoms.

A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

A. This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the client to drink 2 to 3 liters of water each day. An intravenous line may be ordered later, after the clients degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

A. This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

A. This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

A. This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

A. This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. Avoid large crowds or people who are ill. b. Stay upright for 1 hour after taking this drug. c. This drug may cause your hair to fall out. d. You may double the dose if pain is severe.

A. This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

What action by the peri-operative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the clients white blood cell count. c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively.

A. To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for post-exposure prophylaxis.

A. Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for post-exposure prophylaxis.

A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

A. With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

B, C, D, E. Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

B. Lower blood volume will decrease MAP. The other answers are not accurate.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I can continue to take antacids to relieve heartburn. b. I need to ask for an antibiotic when scheduling a dental appointment. c. I'll need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

B, C, D, E. In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the UAP? (Select all that apply.) a. Assessing the clients fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

B, C, D, E. The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Reports sore throat, runny nose, headache; Red, watery eyes; Posterior pharynx is reddened; Nasal discharge is seen in the back of the throat; Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) WBC count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

B, C, D, E. This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply.) a. A 24-year-old pregnant woman prescribed prenatal vitamins b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose NSAIDs for chronic back pain e. A 75-year-old with COPD who is prescribed an albuterol nebulizer

B, C, D. Many medications can affect kidney function. Clients who take synthetic creatine supplements, metformin, and high-dose or long-term NSAIDs are at risk for kidney dysfunction. Prenatal vitamins and albuterol nebulizers do not place these clients at risk.

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea

B, C, E. Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Feltys syndrome c. Joint deformity d. Low-grade fever e. Weight loss

B, C, E. Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the UAP? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

B, C, E. The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

B, D, E. After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. I need to decrease sodium, cholesterol, and protein in my diet. b. My weight should be maintained at a body mass index of 30. c. Smoking should be stopped as soon as I possibly can. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

B, D, E. Weight should be maintained at a body mass index (BMI) of 22 to 25. A BMI of 30 indicates obesity. The use of nonsteroidal anti-inflammatory drugs such as aspirin should be limited to the lowest time at the lowest dose due to interference with kidney blood flow. The client should drink at least 2 liters of water daily. Diet adjustments should be made by restricting sodium, cholesterol, and protein. Smoking causes constriction of blood vessels and decreases kidney perfusion, so the client should stop smoking.

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

B, E. Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

B, E. Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the evening hours.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

B. A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What non-pharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs

B. A humidifier will help relieve many of the clients Sjgrens syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

B. A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

A nurse cares for a client who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? a. Pneumonia b. Dehydration c. Renal failure d. Edema

B. ADH increases tubular permeability to water, leading to absorption of more water into the capillaries. ADH is triggered by a rising extracellular fluid osmolarity, as occurs in dehydration. Pneumonia, renal failure, and edema would not trigger the release of ADH.

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

B. Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

B. Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

A nurse provides health screening for a community health center with a large population of African- American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.

B. All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African- American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

B. All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. You're still taking your diabetic medication, right?

B. All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!

B. All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for hand washing and general hygiene and cleaning purposes.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the UAP to strain the clients urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

B. An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

B. An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

B. Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

B. CRA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take a laxative every night before going to bed. b. I must increase my intake of dietary fiber and fluids. c. I shall only use salt when I am cooking my own food. d. Ill eat white bread to minimize gastrointestinal gas.

B. Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high- fiber diet.

An emergency department nurse assesses a client with kidney trauma and notes that the clients abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products

B. Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the clients vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Peri-orbital edema c. Bloody and cloudy urine d. Enlarged abdomen

B. Peri-orbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

B. Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.

B. Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

B. During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation c. A 64-year-old female with Alzheimers-type senile dementia Bladder training d. A 77-year-old female who has difficulty ambulating Exercise therapy

B. Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Physical therapy and a bedside commode would be appropriate interventions for the client who has difficulty ambulating. Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate.

After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAPs understanding. Which action indicates the UAP needs additional teaching? a. Toileting the client after breakfast b. Changing the clients incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the clients incontinence episodes

B. Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What non-pharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

B. Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.

B. In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

A nurse reviews a female clients laboratory results. Which results from the clients urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color

B. Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings for a female clients urinalysis.

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

B. Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs. Hypertension is common in most clients with CKD, and skin itching increases with calcium-phosphate imbalances, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area. d. It is likely that you have an untreated sexually transmitted disease.

B. Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

B. Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

B. Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesnt give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A nurse reviews the health history of a client with an over-secretion of renin. Which disorder should the nurse correlate with this assessment finding? a. Alzheimers disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis

B. Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimer's disease, diabetes mellitus, or viral hepatitis.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

B. SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.

B. Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first? a. Are you drinking plenty of water? b. What medications are you taking? c. Have you tried laxatives or enemas? d. Has this type of thing ever happened before?

B. Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the clients medication list to determine whether the client is taking an anticholinergic medication. If he or she is taking anticholinergics, the nurse should further assess the clients manifestations to determine if they are related to a simple side effect or an overdose. The other questions are not as helpful to understanding the current situation.

After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take this medication with food and plenty of water. b. I shall keep my appointment at the infusion center each week. c. I'll limit my intake of green leafy vegetables while on this medication. d. I must not take this medication if I have an infection or am feeling ill.

B. Temsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet.

After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I can prevent more damage to my kidneys by managing my blood pressure. b. If I have increased urination at night, I need to drink less fluid during the day. c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.

B. The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this clients teaching? a. Use the toilet when you first feel the urge, rather than at specific intervals. b. Try to consciously hold your urine until the scheduled toileting time. c. Initially try to use the toilet at least every half hour for the first 24 hours. d. The toileting interval can be increased once you have been continent for a week.

B. The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

B. The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

B. The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

B. The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the clients right lower back. Which action should the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

B. The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the clients position will not decrease bleeding.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: WBC count: 8900/mm3 RBC count: 3.2/mm3, Hgb: 9 g/dL Hct: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

B. This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

B. This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the clients cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the clients intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

B. This specific gravity is within the normal range for urine. There is no need to evaluate the clients intake and output, obtain a urine specimen, or increase fluid intake.

A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self- management by teaching what principle of medical management? a. Infusions will be scheduled every 3 to 4 weeks. b. Treatment is aimed at treating specific infections. c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions.

B. Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

B. Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. A little sedation will help you get some rest. b. Depression often accompanies fibromyalgia. c. This drug works in the brain to decrease pain. d. You will have more energy after taking this drug.

C. Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

C, D, E. The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynauds phenomenon. The UAP can adjust the room temperature for the clients comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. BUN of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

C. A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

C. A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10. Which action should the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the pulse rate and blood pressure. d. Examine the color of the clients urine.

C. An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage. A change in vital signs can indicate that hemorrhage is occurring. Before other actions, the nurse must assess the clients hemodynamic status.

A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a. Do you want daily weights on this client? b. Will the client be able to return home? c. Can we discontinue the indwelling catheter? d. Should we get another chest x-ray today?

C. An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the UAP after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower side rail on the affected side. d. Remind the client to do quad-setting exercises.

C. Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the side rail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

C. Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the clients previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

A nurse cares for a client who has pyelonephritis. The client states, I am embarrassed to talk about my symptoms. How should the nurse respond? a. I am a professional. Your symptoms will be kept in confidence. b. I understand. Elimination is a private topic and shouldn't be discussed. c. Take your time. It is okay to use words that are familiar to you. d. You seem anxious. Would you like a nurse of the same gender to care for you?

C. Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the clients symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond? a. Test your urine daily for the presence of ketone bodies and proteins. b. Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.

C. Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the clients sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

C. During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate. There is no indication to check the white blood cell count or connect the client to an ECG monitor. The other vital signs are within normal limits.

A nurse teaches a client who is recovering from a urography. Which instruction should the nurse include in this clients discharge teaching? a. Avoid direct contact with your urine for 24 hours until the radioisotope clears. b. You may have some dribbling of urine for several weeks after this procedure. c. Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster. d. Your skin may become slightly yellow from the dye used in this procedure.

C. Dyes used in urography are potentially nephrotoxic. A large fluid intake will help the client eliminate the dye rapidly. Dyes used in urography are not radioactive, the client should not experience any dribbling of urine, and the dye should not change the color of the clients skin.

A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, Is my anemia related to the renal insufficiency? How should the nurse respond? a. Red blood cells produce erythropoietin, which increases blood flow to the kidneys. b. Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density. c. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow. d. Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.

C. Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency. The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

C. Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.

C. Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. I should leave the drainage bag above the level of my abdomen. b. I could flush the tubing with normal saline if the flow stops. c. I should take a stool softener every morning to avoid constipation. d. My diet should have low fiber in it to prevent any irritation.

C. Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

A nurse obtains a sterile urine specimen from a clients Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clamp another section of the tube to create a fixed sample section for retrieval. b. Insert a syringe into the injection port and aspirate the quantity of urine required. c. Clean the injection port cap of the drainage tubing with povidone-iodine solution. d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

C. It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe. The urine sample should be collected directly from the catheter; therefore, a second clamp to create a sample section would not be appropriate. Every sample from the catheter is usable; there is the need to discard the first sample.

A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. d. You are at risk for seizures due to fungal infections.

C. Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

C. Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a smart pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

C. Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

C. Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. Let's ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers.

C. Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice daily.

C. Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative TB skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

C. Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alternative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

C. The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years experience on this floor

C. The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client. The float nurses would not be as knowledgeable about the unit and its clients. The licensed practical nurse may not have the education level of the RN to assess for pericarditis.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L BUN 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

C. The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

A nurse cares for a client with urinary incontinence. The client states, I am so embarrassed. My bladder leaks like a young childs bladder. How should the nurse respond? a. I understand how you feel. I would be mortified. b. Incontinence pads will minimize leaks in public. c. I can teach you strategies to help control your incontinence. d. More women experience incontinence than you might think.

C. The nurse should accept and acknowledge the clients concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the clients concerns with the use of pads or stating statistics about the occurrence of incontinence.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

C. The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

C. The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I wont wash my incision to keep it dry.

C. There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

C. This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

C. With an optimal fluid balance, the client will be more able to eject blood from the left ventricle without increased pressure in the left ventricle and pulmonary vessels. Other ideal goals are oxygen saturations greater than 92%, no auscultated crackles or wheezes, and no demonstrated shortness of breath.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan.

C. With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

C. Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call light, the client presents an appearance as shown below: What action by the nurse takes priority? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these manifestations will go away.

C. The nurse should ensure the clients airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.

A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) Normal value-no connective tissue disease b. Elevated sedimentation rate-Rheumatoid arthritis c. Lowered albumin Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27)-Reiters syndrome or ankylosing spondylitis e. Positive rheumatoid factor-Possible kidney disease

D, E. The HLA-B27 is diagnostic for Reiters syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team.

D. A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. ACE inhibitor

D. ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney. Antibiotics fight infection, histamine blockers decrease inflammation, and bronchodilators increase the size of the bronchi; none of these medications helps slow the progression of CKD in clients with hypertension.

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

D. All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

D. As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority. DIF: Applying/Application REF: 318

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

D. Both the cefazolin and the vitamins should be held until after the hemodialysis is completed because they would otherwise be removed by the dialysis process.

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond? a. No genetic link is known, so your children are not at increased risk. b. Your sons will develop this disease because it has a sex-linked gene. c. Only if both you and your spouse are carriers of this disease. d. Each of your children has a 50% risk of having ADPKD.

D. Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder.

A client with rheumatoid arthritis (RA) is in the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

D. Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching? a. Since you only have one kidney, a salt and fluid restriction is required. b. Your therapy will include hemodialysis while you recover. c. Medication will be prescribed to control your high blood pressure. d. You need to avoid participating in contact sports like football.

D. Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has TB.

D. Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the UAP. What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

D. For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this clients teaching? a. You must clean around your catheter daily with soap and water. b. Wash the vaginal weights with a 10% bleach solution after each use. c. Operations to repair your bladder are available, and you can consider these. d. Buy slacks with elastic waistbands that are easy to pull down.

D. Functional urinary incontinence occurs as the result of problems not related to the clients bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the client's recent dietary selections. d. Perform a capillary artery glucose assessment.

D. Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the clients dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

D. Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this clients plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

D. In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the clients creatinine level. d. Increase the clients fluid intake.

D. Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the clients fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids.

D. Normal urine osmolality ranges from 300 to 900 mOsm/L. This clients urine is more concentrated, indicating dehydration. The nurse should encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels. Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the clients dehydration or elevate the osmolality.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four side rails up. c. Restrain the clients hands. d. Use an abduction pillow.

D. Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion

D. Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the clients white blood cell count. b. Culture any drainage from the wound. c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes.

D. Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

D. Sjogren's syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjogren's syndrome.

A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol LA) d. Allopurinol (Zyloprim)

D. Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Phenazopyridine is given to clients with urinary tract infections. Propantheline is an anticholinergic. Tolterodine is an anticholinergic with smooth muscle relaxant properties.

The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

D. Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

D. The central line should have a heparin or heparin/saline dwell after hemodialysis treatment. The central line catheter used for dialysis should not be used for blood sampling, monitoring central venous pressures, or giving drugs or fluids.

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, I am anxious about having an ileal conduit. What is it like to have this drainage tube? How should the nurse respond? a. I will ask the provider to prescribe you an anti-anxiety medication. b. Would you like to discuss the procedure with your doctor once more? c. I think it would be nice to not have to worry about finding a bathroom. d. Would you like to speak with someone who has an ileal conduit?

D. The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge. Medications for anxiety will not promote a positive self-image and a positive attitude, nor will discussing the procedure once more with the physician or hearing the nurses opinion.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50pack-year cigarette smoking history

D. The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the clients record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the clients abdomen and vital signs.

D. The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the clients abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a. That feeling will gradually go away as you get used to the treatment. b. You probably need to see a psychiatrist to see if you are depressed. c. Do you need help from social services to discuss financial aid? d. Tell me more about your feelings regarding hemodialysis treatment.

D. The nurse needs to explore the clients feelings in order to help the client cope and enter a phase of acceptance or resignation. It is common for clients to be discouraged because of the dependency of the treatment, especially during the first year. Referrals to a mental health provider or social services are possibilities, but only after exploring the clients feelings first. Telling the client his or her feelings will go away is dismissive of the clients concerns.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion.

D. The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the clients urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the clients pulse.

D. The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

A nurse cares for a client who is having trouble voiding. The client states, I cannot urinate in public places. How should the nurse respond? a. I will turn on the faucet in the bathroom to help stimulate your urination. b. I can recommend a prescription for a diuretic to improve your urine output. c. I'll move you to a room with a private bathroom to increase your comfort. d. I will close the curtain to provide you with as much privacy as possible.

D. The nurse should provide privacy to clients who may be uncomfortable or have issues related to elimination or the urogenital area. Turning on the faucet and administering a diuretic will not address the clients concern. Although moving the client to a private room with a private bathroom would be nice, this is not realistic. The nurse needs to provide as much privacy as possible within the clients current room.

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

D. The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

D. This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

D. Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

D. Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.